Anti-NMDA receptor encephalitis outcomes in a population-based cohort

Prior studies of anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) may have overestimated poor long-term outcomes and relapse rates and underestimated mortality because they were conducted in referral centers. Our objective was to evaluate these outcomes in a population-based cohort.

We performed a retrospective study of patients with new-onset anti-NMDARE between 2009 and 2022 from the population-based membership of Kaiser Permanente Southern California. All covariates and outcomes were obtained from electronic health records through December 31, 2024.

Seventy-two patients with NMDARE (n = 49, 68% 2014-2022) were identified; of whom 65.3% were female, the median age was 24.5 years, and only 8.3% identified as white, non-Hispanic. First-line immunotherapy was initiated early (median 19 days from symptom onset) and 46 (63.8%) received second-line therapy with rituximab alone (n = 32) or in combination with cyclophosphamide (n = 13). After a median follow-up of 4.7 years (IQR 2.9-9.0), favorable outcomes (modified Rankin Scale ≤ 2) improved from 22% at hospital discharge to 84.5% at the most recent follow-up. Relapses were uncommon (4.1%). Overall mortality declined from 17.4% in 2009-2013 to 4.1% in 2014-2022. Initiation of rituximab within 2 months of symptom onset, increased from 63.6% in 2009-2013 to 82.9% in 2014-2022.

In this population-based cohort of new-onset NMDARE patients, the risk of relapses was lower and long-term functional outcomes were better than previously reported. Mortality was high before 2014 and declined significantly thereafter, paralleling the increase in rapid escalation to rituximab in patients with inadequate responses to first-line treatments.