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Pitt Niehusmann, MD; Josep Dalmau, MD, PhD; Christian Rudlowski, MD; Angela Vincent, FRCPath; Christian E. Elger, FRCP; Jeffrey E. Rossi, BA; Christian G. Bien, MD

Arch Neurol. 2009;66(4):458-464.

Background  In women younger than 45 years, a new form of encephalitis associated with ovarian teratoma and presenting with seizures and psychiatric symptoms has been described. Most patients have antibodies to NR1/NR2 heteromers of the N-methyl-D-aspartate receptor (NMDAR).

Objective  To assess the frequency and significance of antibodies to NMDAR in otherwise unexplained new-onset epilepsies in young women.

Design  Prospective cohort study.

Setting  University department of epileptology.

Patients  From January 1, 2005, to June 30, 2007, we identified 19 female patients aged 15 to 45 years with unexplained new-onset epilepsy. In addition, we studied 61 cerebrospinal fluid–serum sample pairs from patients with other cryptogenic epilepsies and 11 cerebrospinal fluid–serum sample pairs from surgically treated patients with epilepsy with no evident encephalitic abnormalities.

Main Outcome Measures  Antibodies to NMDAR and characteristics of affected patients.

Results  Five of the 19 patients had antibodies against NMDAR. These patients had diffuse cerebral dysfunction and seizure origins. Psychiatric symptoms and pleocytosis were significantly associated with this group of patients. The disease course was episodic, in part relapsing-remitting, with full recoveries either spontaneously or after corticosteroid or intravenous immunoglobulin treatments. Only 1 patient had a neoplasm (multiple neuroendocrine tumors that included the ovaries) identified to date. In the control series, one 22-year-old man with a cryptogenic, severely encephalopathic seizure disorder was NMDAR antibody positive, and he also recovered fully.

Conclusions  Anti-NMDAR encephalitis accounts for a relevant proportion of otherwise unexplained new-onset epilepsies. Patients harboring NMDAR antibodies usually have prominent psychiatric symptoms and pleocytosis, and they may develop hypoventilation. Anti-NMDAR encephalitis is not always paraneoplastic.

Author Affiliations: Departments of Epileptology (Drs Niehusmann, Elger, and Bien) and Gynecology (Dr Rudlowski), University of Bonn, Bonn, Germany; Department of Neurology, University of Pennsylvania, Philadelphia (Dr Dalmau and Mr Rossi); and Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, England (Dr Vincent).

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