Memory dysfunction and psychiatric outcomes in anti-NMDA receptor encephalitis are linked to altered structural brain complexity

Introduction: Most patients with anti-N-methyl-D-aspartate receptor encephalitis (NMDARE) experience long-term neuropsychiatric sequelae despite immunotherapy. However, how these residual symptoms relate to structural brain changes in the post-acute phase remains unclear. Recently, fractal dimensionality (FD) has emerged as a sensitive imaging marker of structural brain complexity in related conditions but has not been explored in autoimmune encephalitis.

Methods: This cross-sectional study combined clinical, cognitive, and neuroimaging analyses in 70 patients with post-acute NMDARE (median time from onset: 22 months), and 70 healthy controls matched for age (t=-0.57, p=0.57) and sex (χ2=0, p=1). High-resolution T1-weighted magnetic resonance imaging (MRI) data were analyzed with FreeSurfer and computational fractal analysis. Clinical outcomes were assessed with the modified Rankin Scale (mRS) and Clinical Assessment Scale in Autoimmune Encephalitis (CASE). Psychiatric manifestations underwent phenotypical analyses, and memory performance was assessed with standardized neuropsychological tests.

Results: Patients with NMDARE were severely affected at peak illness but showed substantial overall improvement in the post-acute stage (median mRS at peak=5, post-acute=1, z=-7.2, p<0.001; median CASE at peak=11, post-acute=1, z=-7.2, p<0.001). However, 67% of patients showed residual CASE symptoms, with memory dysfunction (61%) and psychiatric symptoms (36%) representing the most prevalent domains. Therein, psychiatric symptoms showed a phenotypical shift from a ‘schizophrenia-like’ phenotype at peak illness to an affective phenotype in the post-acute stage. Neuroimaging uncovered a characteristic pattern of reduced structural brain complexity, including the hippocampus bilaterally and a fronto-cingulo-temporal cluster in cortical gray matter and cerebral white matter. Importantly, normative modeling revealed that patients with residual symptoms showed stronger alterations of brain complexity than those without (psychiatric: t=-2.65, p=0.010; memory: t=-3.98, p<0.001; both vs. no symptoms: t=-5.46, p<0.001). Similarly, patients with stronger alterations of brain complexity showed lower scores of visuospatial and verbal memory (all pFDR<0.015).

Discussion: Post-acute NMDARE is characterized by systematic reductions in structural brain complexity, consistently involving previously implicated regions while identifying changes in the cingulate cortex as a new morphological correlate. These changes are linked to residual psychiatric symptoms and memory dysfunction, highlighting FD as a promising new imaging marker of long-term outcomes. Our findings suggest that current treatment strategies may be insufficient to fully address the residual symptom burden after the acute phase of NMDARE.