A 62-year-old man presented with confusion, agitation, and pressured, tangential speech after a car accident. Brain MRI showed left-hemispheric cortical ribboning, concerning for encephalitis, seizure, or prion disease (Figure). Four-day EEG showed left-hemispheric slowing but no epileptiform activity. Toxicology and infectious workups were negative. CSF was positive for anti-NMDA receptor antibodies. Oncologic assessments were unrevealing. Patient received 5 days of intravenous methylprednisolone and IVIG with improved attention, ability to follow commands, and engage in appropriate conversation. Anti-NMDA receptor encephalitis often affects young female patients1,2 and often is associated with teratoma. Although often normal, if brain MRI findings are present, lesions are more commonly reported in the medial temporal lobe. This case demonstrates that an acute to subacute change in mental status along with an atypical MRI finding of unilateral cortical ribboning is a possible presentation of anti-NMDA receptor encephalitis. Recognition of this atypical presentation is important for early treatment and maximum functional recovery.⇓
Brain MRI on admission showing apparent diffusion coefficient correlated with diffusion restriction signals in left cortical layers, deep basal ganglia (A, arrows), and hyperintensity in left occipital and hippocampus regions (B, arrows).
Study Funding
The authors report no targeted funding.
Disclosure
The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Acknowledgment
We thank Mr. David F. Schmidt for critical editing of the manuscript for clarity. Mr. David F. Schmidt declined authorship due to limited contribution to the intellectual content.
Appendix Authors
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Submitted and externally peer reviewed. The handling editor was Roy Strowd III, MD, Med, MS.
Teaching slides links.lww.com/WNL/C354.
- Received January 13, 2022.
- Accepted in final form August 22, 2022.
- © 2022 American Academy of Neurology
Letters: Rapid online correspondence
- Reader Response: Teaching NeuroImage: Atypical Unilateral Cortical Ribboning in Anti-N-methyl-D-aspartate Receptor Encephalitis
- Reader Response: Teaching NeuroImage: Atypical Unilateral Cortical Ribboning in Anti-N-methyl-D-aspartate Receptor Encephalitis
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