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April 2020; 10 (2) Research

Worldwide survey of neurologists on approach to autoimmune encephalitis

Aravind Ganesh, Luca Bartolini, Sarah F. Wesley
First published August 13, 2019, DOI: https://doi.org/10.1212/CPJ.0000000000000701
Aravind Ganesh
Department of Clinical Neurosciences (AG), University of Calgary, Canada; Centre for Prevention of Stroke and Dementia (AG), University of Oxford, United Kingdom; Clinical Epilepsy Section (LB), National Institutes of Health, Bethesda, MD; and Department of Neurology (SFW), Yale School of Medicine, New Haven, CT.
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Luca Bartolini
Department of Clinical Neurosciences (AG), University of Calgary, Canada; Centre for Prevention of Stroke and Dementia (AG), University of Oxford, United Kingdom; Clinical Epilepsy Section (LB), National Institutes of Health, Bethesda, MD; and Department of Neurology (SFW), Yale School of Medicine, New Haven, CT.
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Sarah F. Wesley
Department of Clinical Neurosciences (AG), University of Calgary, Canada; Centre for Prevention of Stroke and Dementia (AG), University of Oxford, United Kingdom; Clinical Epilepsy Section (LB), National Institutes of Health, Bethesda, MD; and Department of Neurology (SFW), Yale School of Medicine, New Haven, CT.
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Worldwide survey of neurologists on approach to autoimmune encephalitis
Aravind Ganesh, Luca Bartolini, Sarah F. Wesley
Neurol Clin Pract Apr 2020, 10 (2) 140-148; DOI: 10.1212/CPJ.0000000000000701

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Abstract

Objective To explore practice differences in the diagnosis and management of autoimmune encephalitis (AE), which is complicated by issues with sensitivity/specificity of antibody testing, nonspecific MRI/EEG/CSF findings, and competing differential diagnoses.

Methods We used a worldwide electronic survey with practice-related demographic questions and clinical questions about 2 cases: (1) a 20-year-old woman with a neuropsychiatric presentation strongly suspicious of AE and (2) a 40-year-old man with new temporal lobe seizures and cognitive impairment. Responses among different groups were compared using multivariable logistic regression.

Results We received 1,333 responses from 94 countries; 12.0% identified as neuroimmunologists. Case 1: those treating >5 AE cases per year were more likely to send antibodies in both serum and CSF (adjusted odds ratio [aOR] vs 0 per year: 3.29, 95% CI 1.31–8.28, p = 0.011), pursue empiric immunotherapy (aOR: 2.42, 95% CI 1.33–4.40, p = 0.004), and continue immunotherapy despite no response and negative antibodies at 2 weeks (aOR: 1.65, 95% CI 1.02–2.69, p = 0.043). Case 2: neuroimmunologists were more likely to send antibodies in both serum and CSF (aOR: 1.80, 95% CI 1.12–2.90, p = 0.015). Those seeing >5 AE cases per year (aOR: 1.86, 95% CI 1.22–2.86, p = 0.004) were more likely to start immunotherapy without waiting for antibody results.

Conclusions Our results highlight the heterogeneous management of AE. Neuroimmunologists and those treating more AE cases generally take a more proactive approach to testing and immunotherapy than peers. Results highlight the need for higher-quality cohorts and trials to guide empiric immunotherapy, and evidence-based guidelines aimed at both experts and nonexperts. Because the average AE patient is unlikely to be first seen by a neuroimmunologist, ensuring greater uniformity in our approach to suspected cases is essential to ensure that patients are appropriately managed.

Footnotes

  • Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.

  • Infographic: Npub.org/NCP/pc06-research

  • Explore this topic: Npub.org/NCP/pc6

  • Interactive world map: NPub.org/NCP/map06

  • More Practice Current: NPub.org/NCP/practicecurrent

  • Received March 7, 2019.
  • Accepted May 16, 2019.
  • © 2019 American Academy of Neurology
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