自身免疫性脑炎脑电图及诱发电位特点——附8例病例报告

Electroencephalograph and evoked potential characteristics of autoimmune encephalitis——8 cases report

目的了解自身免疫性脑炎患者的脑电图(EEG)和诱发电位改变,以提高临床早期诊断和治疗。方法收集2014年6月18日—2016年6月18日在四川省人民医院神经内科8例自身免性脑炎患者临床资料,所有患者的血液和脑脊液标本均送北京协和医院神经内科实验室做相关抗体的测定;患者至少做2次以上常规EEG和(或)视频脑电图(VEEG),1次以上脑干诱发电位(Auditory brainstem response,ABR)、上肢体感诱发电位(Somatosensory evoked potential,上肢SEP)、下肢体感诱发电位(下肢SEP)、视觉诱发电位(Visual evoked potential,VEP)的检查。患者出院后对其临床症状、EEG进行随访,对诱发电位有异常的患者进行关注。结果患者的临床表现精神行为异常、癫痫发作、记忆力减退、发热头痛、严重者意识障碍和通气功能下降;8例患者中5例为抗NMDA-R脑炎,2例为抗GABAB-R脑炎,1例是两者均为阳性。抗NMDA-R脑炎的EEG:2例患者病程早期(10 d)出现β波,中期(20 d)出现δ波,在此波上叠加快波,呈现δ刷,2例患者病情重,住院时间长,头颅核磁共振(MRI)阴性,治疗以激素冲击,丙种球蛋白,其中1例使用血浆置换疗法,临床预后良好;另2例可见散在的尖波和尖慢波,病情好转,EEG也有好转;1例EEG为正常,使用激素冲击治疗,临床预后好。抗GABAB-R脑炎:1例以慢波为主,治疗以激素冲击和丙种球蛋白,治疗后EEG恢复正常,临床预后好;另1例表现α波泛化,尤其在额区也出现α波,患者放弃治疗。抗NMDA-R和GABABR均为阳性患者,EEG表现慢波,病情好转,EEG好转。体感诱发电位检测中大部分未见异常,部分患者出现异常:波幅的改变,潜伏期轻度延长,异常患者出院3个月后随访,结果均为正常。结论不同类型自身免疫性脑炎的EEG表现不尽一致,不同的病程阶段有相应的改变,EEG可作为疾病预后的指标。早期EEG有快波出现且临床疑诊脑炎时,应及时筛查血与脑脊液的NMDA-R抗体;EEG出现α波泛化,需注意GABAB-R抗体的筛查。部分患者诱发电位改变在波幅和潜伏期轻度延长,出院3个月复查大部分恢复正常。由于病例数较少,诱发电位在自身免疫性脑炎患者中的改变需进一步研究。

Objective To explore changes on Electroencephalograph( EEG) and Evoked Potential( EP) changes in autoimmune encephalitis. Methods Eight cases with autoimmune encephalitis from Sichuan people's hospital during July 18 th 2014 to July 18 th 2016 were recruited. The inclusion criteria included:(1) The blood and cerebral spinal fluid( CSF) of patients were sent to Neurology Lab of Peking Union Medical College Hospital for autoimmunerelated antibody analysis and confirmed as autoimmune encephalitis.(2) Patient had done at least 2 or more times of routine EEG or video EEG( VEEG). 1 or more times of auditory brainstem response( ABR),Visual evoked potential( VEP) and Somatosensory evoked potential( SEP) for both upper and lower limbs.(3) Patients had classical clinical manifestation of autoimmune encephalitis as abnormal psychomotor behaviors,seizures,memory loss,fever,headache,and even disturbance of consciousness or decreased ventilate function. Resulst Of 8 patients in this study,5 were anti NMDA-R encephalitis,2 were anti GABABR encephalitis, and 1 was positive for both antibodies. The EEG profile of 5 anti NMDA-R encephalitis: 2 of them had β wave in early stage( about10 th day) and δ wave with fast wave even appeared as δ brush in middle stage( about 20 th day). They all had severe symptoms and long hospitalization but negative MRI. Another 2 of them could be seen sparsely distributed sharp wave and sharp-slow wave in their EEG. Their EEG gradually turned to normal when their symptoms gradually disappeared. The last one had normal EEG during the whole disease course. The EEG profile of anti GABAB-R encephalitis as following. 1 was dominant by slow wave and EEG went normal after effective treatment and the other showed generalized α wave especially α wave in frontal region. The latter patient withdraw treatment. For the only 1 both antibodies positive patient,EEG showed slow wave and it turned to normal when symptoms disappeared. EP showed some abnormalities with wave amplitude and latency changes in some patients. EP( SEP、VEP) turned to normal when symptoms disappeared. Conclusion The EEG present differently in different types of autoimmune encephalitis and change with stages of disease. EEG may be used as an indicator for prognosis as well. When EEG shows fast wave with the history of patient points to encephalitis,blood and CSF antibodies for NMDA-R should be checked routinely.Generalized αwave on EEG should also be an indicator for checking GABAB-R. More researches should be done for EP changes in autoimmune encephalitis for our study was based on a small patient number.