自身免疫性脑炎远期预后及其危险因素分析
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摘要
目的探讨自身免疫性脑炎患者的远期预后及其影响因素。方法 59例自身免疫性脑炎患者随访1 a,比较患者急性期与随访1 a后的主要症状发生率。采用改良Ranking量表(mRS)评分评估患者神经功能恢复情况,根据末次随访mRS评分分为预后良好组(mRS评分≤2分)51例和预后不佳组(mRS评分>2分)8例,比较2组临床资料,采用多因素logistic回归分析自身免疫性脑炎患者远期预后的影响因素。结果随访1 a后,神经功能完全恢复(mRS评分0分)23例(39.0%),遗留轻度神经功能障碍(mRS评分1～2分)28例(47.4%),遗留中重度神经功能障碍(mRS评分3～5分)3例(5.1%),死亡(mRS评分6分)5例(8.5%);随访1 a后患者癫痫(6.8%)、精神行为异常(33.9%)、认知功能减退(32.2%)发生率明显低于急性期(72.9%、69.5%、71.2%)(P<0.05),且未见癫痫持续状态、意识障碍或不自主运动发生;预后不佳组免疫治疗时机[35.0(18.0,52.0)d]长于预后良好组[13.0(7.0,28.5)d],发病后1、6个月mRS评分[4.00(3.25,4.75)、5.00(3.25,5.75)]均高于预后良好组[2.00(1.00,3.00)、1.00(0,2.00)](P<0.05);发病后1个月mRS评分增高是自身免疫性脑炎患者远期预后不良的独立危险因素(OR=7.228,95%CI:1.845～28.310,P=0.005)。结论自身免疫性脑炎患者预后较好,免疫治疗时机延迟与远期预后不佳有关,急性期后神经功能未恢复提示长期预后不佳。
Objective To explore the long-term prognosis of patients with autoimmune encephalitis(AE) and its influencing factors. Methods Fifty-nine patients with AE were followed up for 1 year to compare the incidences of main symptom in acute stage and in 1-year follow-up. Modified Ranking Scale(mRS) was used to evaluate the neurological function recovery. According to the final mRS score, the patients were divided into 51 patients with mRS score≤2(good prognosis group) and 8 patients with mRS score>2(poor prognosis group). The clinical data were compared between two groups, and the multivariate logistic regression was used to analyze the influencing factors for long-term prognosis of patients with AE. Results The 1-year follow-up result showed complete recovery of neurological function(mRS score: 0) in 23 patients(39.0%), mild neurological impairment(mRS score: 1-2) in 28 patients(47.4%), moderate to severe neurological impairment(mRS score: 3-5) in 3 patients(5.1%), and 5 deaths(8.5%)(mRS score: 6). The incidences of epilepsy(6.8%), mental and behavioral disorders(33.9%) and cognitive deficiency(32.2%) were significantly lower after 1-year follow-up than those in acute period(72.9%, 69.5%, 71.2%)(P<0.05), and no status epilepticus, conscious disturbance or involuntary movement occurred. The time of immunotherapy was significantly longer in poor prognosis group(35.0(18.0, 52.0) d) than that in good prognosis group(13.0(7.0, 28.5) d), and mRS scores were significantly higher in 1 and 6 months after onset(4.00(3.25, 4.75), 5.00(3.25, 5.75)) in poor prognosis group than those in good prognosis group(2.00(1.00, 3.00), 1.00(0, 2.00))(P<0.05). The mRS score in 1 month after onset was an independent risk factor for long-term prognosis of patients with AE(OR=7.228, 95%CI: 1.845-28.310, P=0.005). Conclusion The AE patients have favorable prognosis, and delayed immunotherapy involves in poor prognosis. No recovery of neurologic function after acute phase indicates a poor long-term prognosis.
Objective To explore the long-term prognosis of patients with autoimmune encephalitis(AE) and its influencing factors. Methods Fifty-nine patients with AE were followed up for 1 year to compare the incidences of main symptom in acute stage and in 1-year follow-up. Modified Ranking Scale(mRS) was used to evaluate the neurological function recovery. According to the final mRS score, the patients were divided into 51 patients with mRS score≤2(good prognosis group) and 8 patients with mRS score>2(poor prognosis group). The clinical data were compared between two groups, and the multivariate logistic regression was used to analyze the influencing factors for long-term prognosis of patients with AE. Results The 1-year follow-up result showed complete recovery of neurological function(mRS score: 0) in 23 patients(39.0%), mild neurological impairment(mRS score: 1-2) in 28 patients(47.4%), moderate to severe neurological impairment(mRS score: 3-5) in 3 patients(5.1%), and 5 deaths(8.5%)(mRS score: 6). The incidences of epilepsy(6.8%), mental and behavioral disorders(33.9%) and cognitive deficiency(32.2%) were significantly lower after 1-year follow-up than those in acute period(72.9%, 69.5%, 71.2%)(P<0.05), and no status epilepticus, conscious disturbance or involuntary movement occurred. The time of immunotherapy was significantly longer in poor prognosis group(35.0(18.0, 52.0) d) than that in good prognosis group(13.0(7.0, 28.5) d), and mRS scores were significantly higher in 1 and 6 months after onset(4.00(3.25, 4.75), 5.00(3.25, 5.75)) in poor prognosis group than those in good prognosis group(2.00(1.00, 3.00), 1.00(0, 2.00))(P<0.05). The mRS score in 1 month after onset was an independent risk factor for long-term prognosis of patients with AE(OR=7.228, 95%CI: 1.845-28.310, P=0.005). Conclusion The AE patients have favorable prognosis, and delayed immunotherapy involves in poor prognosis. No recovery of neurologic function after acute phase indicates a poor long-term prognosis.
引文
[1] 中华医学会神经病学分会.中国自身免疫性脑炎诊治专家共识[J].中华神经科杂志,2017,50(2):91-98.
[2] 徐文灯,贺菲菲,叶静.抗N-甲基-D-天冬氨酸受体脑炎51例的预后分析[J].中华神经科杂志,2017,50(2):99-102.
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[4] HERKEN J,PRüSS H.Red flags:clinical signs for identifying autoimmune encephalitis in psychiatric patients[J].Front Psychiatry,2017,8(5):25.
[5] FINKE C,KOPP U A,PRüSS H,et al.Cognitive deficits following anti-NMDA receptor encephalitis[J].J Neurol Neurosurg Psychiatry,2012,83(2):195-198.
[6] 龚帆,俞晓飞.抗N-甲基-D-天冬氨酸受体脑炎研究新进展[J].中华神经医学杂志,2014,13(5):537-540.
[7] GUO Y H,KUAN T S,HSIEH P C,et al.Rehabilitation for a child with recalcitrant anti-N-methyl-d-aspartate receptor encephalitis:case report and literature review[J].Neuropsych Dis Treat,2014,10:2263-2267.
[8] PRüβ H.Pathophysiology and prognostic factors of autoimmune encephalitis[J].Fortschr Neurol Psychiatr,2016,84(5):264-270.
[9] 王文富,汪洪,刘枢晓,等.癫痫持续状态27例诊治分析[J].中华实用诊断与治疗杂志,2012,26(2):186-188.
[10] TITULAER M J,MCCRACKEN L,GABILONDO I,et al.Late-onset anti-NMDA receptor encephalitis[J].Neurology,2013,81(12):1058-1063.
[11] TITULAER M J,MCCRACKEN L,GABILONDO I,et al.Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis:an observational cohort study[J].Lancet Neurol,2013,12(2):157-165.
[12] 张婧,赵文博,武力勇.富亮氨酸胶质瘤失活1蛋白A自身抗体相关边缘性脑炎6例临床分析[J].中华实用诊断与治疗杂志,2015,29(10):995-996.
[13] 吴萱,李智文,朱纪婷,等.自身免疫性脑炎14例临床特点分析[J].中国神经精神疾病杂志,2017,43(8):504-508.
[2] 徐文灯,贺菲菲,叶静.抗N-甲基-D-天冬氨酸受体脑炎51例的预后分析[J].中华神经科杂志,2017,50(2):99-102.
[3] GRAUS F,TITULAER M J,BALU R,et al.A clinical approach to diagnosis of autoimmune encephalitis[J].Lancet Neurol,2016,15(4):391-404.
[4] HERKEN J,PRüSS H.Red flags:clinical signs for identifying autoimmune encephalitis in psychiatric patients[J].Front Psychiatry,2017,8(5):25.
[5] FINKE C,KOPP U A,PRüSS H,et al.Cognitive deficits following anti-NMDA receptor encephalitis[J].J Neurol Neurosurg Psychiatry,2012,83(2):195-198.
[6] 龚帆,俞晓飞.抗N-甲基-D-天冬氨酸受体脑炎研究新进展[J].中华神经医学杂志,2014,13(5):537-540.
[7] GUO Y H,KUAN T S,HSIEH P C,et al.Rehabilitation for a child with recalcitrant anti-N-methyl-d-aspartate receptor encephalitis:case report and literature review[J].Neuropsych Dis Treat,2014,10:2263-2267.
[8] PRüβ H.Pathophysiology and prognostic factors of autoimmune encephalitis[J].Fortschr Neurol Psychiatr,2016,84(5):264-270.
[9] 王文富,汪洪,刘枢晓,等.癫痫持续状态27例诊治分析[J].中华实用诊断与治疗杂志,2012,26(2):186-188.
[10] TITULAER M J,MCCRACKEN L,GABILONDO I,et al.Late-onset anti-NMDA receptor encephalitis[J].Neurology,2013,81(12):1058-1063.
[11] TITULAER M J,MCCRACKEN L,GABILONDO I,et al.Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis:an observational cohort study[J].Lancet Neurol,2013,12(2):157-165.
[12] 张婧,赵文博,武力勇.富亮氨酸胶质瘤失活1蛋白A自身抗体相关边缘性脑炎6例临床分析[J].中华实用诊断与治疗杂志,2015,29(10):995-996.
[13] 吴萱,李智文,朱纪婷,等.自身免疫性脑炎14例临床特点分析[J].中国神经精神疾病杂志,2017,43(8):504-508.