Superior diagnostic performance of reduced-FOV DWI versus conventional DWI MRI in anti-NMDAR encephalitis
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LETTER TO THE EDITOR
Superior diagnostic performance of reduced-FOV DWI versus conventional DWI MRI in anti-NMDAR encephalitis Salvatore Monaco 1
&
Sara Mariotto 1 & Anna Bolzan 1 & Sergio Ferrari 1 & Franco Alessandrini 2
Received: 28 May 2020 / Accepted: 5 October 2020 # Fondazione Società Italiana di Neurologia 2020
Dear Sirs, Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an antibody-mediated neuroinflammatory disorder characterized by an early onset of depression, visual and auditory hallucinations, abnormal sexual and eating behaviors, thought disorder, and disorganized speech in nearly 90% of patients [1]; additional symptoms may include schizoaffective reactions with predominance of manic features. At variance with other psychotic disorders, anti-NMDAR encephalitis usually presents with complex and polymorphic psychiatric manifestations, is not preceded by premorbid and prodromal stages, and is characterized by refractoriness and intolerance to neuroleptics. Nevertheless, approximately half of the patients are admitted to a psychiatric ward [2, 3]. At early disease stages, anti-NMDAR encephalitis is characterized by intrathecal inflammation and absence of MRI abnormalities in more than one-half of patients, with the other half showing nonspecific increased corticalsubcortical FLAIR or T2-weighted signals, nonspecific withe matter changes, and absence of structural abnormalities [4, 5]. Strikingly, the lack of MRI abnormalities is of diagnostic value in patients with a clinical picture suggestive of anti-NMDAR encephalitis [5]. The above conventional MRI features are at variance with the involvement of the hippocampus observed at early stage with functional connectivity studies and at later stages of disease with multimodal structural imaging [6, 7]. Taken together, the predominance of early psychiatric
* Salvatore Monaco [email protected] 1
Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, Department of Neuroradiology, University of Verona, AOUI, Verona, Italy
2
Department of Neuroradiology, AOUI, Verona, Italy
symptoms in anti-NMDAR encephalitis frequently leads to misdiagnosis [2, 8], and, in addition, the absence of abnormalities by conventional MRI can prevent or delay additional paraclinical tests [9]. We herein describe a patient with anti-NMDAR encephalitis, in whom unequivocal DWI changes in the hippocampi were detected only by non-conventional MRI. A 28-year-old male with an unremarkable medical history presented with fever and spells of right arm paresthesias, followed by left foot hypoesthesia and hypogeusia. Two weeks later, he manifested disinhibited behavior, confusion, and agitation that prompted a psychiatric hospitalization. A toxicological screening yielded negative results and a brain CT was unremarkable. During a 5-week observation, he presented disorganized thinking, abnormal speech content, verbigeration, and auditory hallucinations, all symptoms favoring a diagnosis of idiopathic psychosis. However, symptoms did not improve a
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