title: Bi-insular cortical involvement in anti-NMDA-receptor encephalitis - a case report.
abstract: BACKGROUND
  Anti-NMDA-receptor encephalitis is an immune-mediated inflammatory disorder of the central nervous system. Brain MRI is unremarkable in at least 50% of patients and highly variable in the remaining patients with signal abnormalities in different brain regions. Only scarce reports exist on other imaging modalities.
  
  
  METHODS
  A 31-year-old woman sub-acutely developed psychosis, behavioural changes, amnesia, alternating states of agitation and mutism, fever and epileptic seizures. Clinically suspected diagnosis of anti-NMDA-receptor encephalitis was confirmed by the detection of anti-NMDA receptor antibodies in CSF and serum. During the acute phase, brain MRI abnormalities were found in both insular cortices and hippocampi, whereas F(18)-FDG-PET showed hypermetabolism bilaterally in insular and prefrontal cortex. After resection of the underlying ovarian teratoma and with multimodal immunotherapy the patient substantially improved reaching a modified Rankin Scale score of 2 after 3 months. At follow-up, both hippocampi were still affected on MRI, whereas insular cortex appeared normal; however, both regions showed prominent glucose hypometabolism.
  
  
  CONCLUSIONS
  Here, we report bi-insular cortical abnormalities on MRI and F(18)-FDG-PET in a patient with anti-NMDA-receptor encephalitis during the acute phase and after clinical improvement.
authors: Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria. harald.hegen@i-med.ac.at.
authors: Harald
authors: http://orcid.org/0000-0002-2833-6337
authors: H
authors: Hegen
authors: Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria.
authors: Christian
authors: C
authors: Uprimny
authors: Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria.
authors: Astrid
authors: A
authors: Grams
authors: Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria.
authors: Irene
authors: I
authors: Virgolini
authors: Neuroimmunology Laboratory, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
authors: Melanie
authors: M
authors: Ramberger
authors: Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
authors: Ronny
authors: R
authors: Beer
authors: Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
authors: Raimund
authors: R
authors: Helbok
authors: Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
authors: Bettina
authors: B
authors: Pfausler
authors: Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
authors: Erich
authors: E
authors: Schmutzhard
mesh_terms: D000328:Adult; D060426:Anti-N-Methyl-D-Aspartate Receptor Encephalitis / Q000000981:diagnostic imaging* / Q000276:immunology; D000906:Antibodies / Q000097:blood / Q000134:cerebrospinal fluid; D002540:Cerebral Cortex / Q000000981:diagnostic imaging*; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods; D005260:Female; D019788:Fluorodeoxyglucose F18; D005500:Follow-Up Studies; D006624:Hippocampus / Q000000981:diagnostic imaging; D006801:Humans; D007167:Immunotherapy / Q000379:methods; D016202:N-Methylaspartate / Q000276:immunology; D010051:Ovarian Neoplasms / Q000175:diagnosis / Q000628:therapy; D049268:Positron-Emission Tomography / Q000379:methods; D017397:Prefrontal Cortex / Q000000981:diagnostic imaging; D013724:Teratoma / Q000175:diagnosis / Q000628:therapy; D051598:Whole Body Imaging / Q000379:methods
chemical_list: D000906:Antibodies; D019788:Fluorodeoxyglucose F18; D016202:N-Methylaspartate
keywords: Autoimmune encephalitis; Case report; Frontal lobe; Hippocampus; Insular cortex; MRI; Medial temporal lobe; NMDA receptor; PET