related to increased GABAergic activity in the brain. As it is unrealistic to have a patient with a long-term therapy to propofol, the authors suggest that propofol could be used as a bridge therapy to a more permanent intervention in patients with SPS. Immunotherapy Rituximab Rituximab is a genetically engineered monoclonal antibody directed against CD20, which causes a sustained depletion of B cells and has demonstrated promising results in several autoimmune neurological diseases. Tacrolimus Tacrolimus belongs to the same class of medication as cyclosporine (calcineurin inhibitor) but is more potent. Tacrolimus inhibits the activity of T cells by decreasing the levels of IL-2. leading to a reduction of activation of B cells to produce antibodies. A small (n=2) study in 2013 showed that patients treated with tacrolimus and additional immunotherapies, after four weeks, reported improvement in their symptoms and a reduction of antibody titers. T helper cells. If the T helper cells can conduct their function, there will be less activation of B cells to produce antibodies. Intravenous Immunoglobulin (IVIG)Therapy Intravenous immune globulin has been found to be a "well-tolerated and effective" therapy. Intravenous immunoglobin is the best second-line treatment for SPS. It often decreases stiffness and improves quality of life and startle reflex. It is generally safe, but there are possible serious side effects, and it is expensive. The European Federation of Neurological Societies suggests it be used when disabled patients do not respond well to diazepam and baclofen. Plasma Exchange (Plasmapheresis) Therapy Plasma exchange, or plasmapheresis, has been shown to benefit patients who do not respond to first-line therapy, specifically beneficial for patients with anti-GAD65 positive SPS. Other Therapies Botulinum toxin has been used to treat SPS, but it does not appear to have long-term benefits and has potential serious side effects. In paraneoplastic cases, tumors must be managed in order for the condition to be contained. Opiates are sometimes used to treat severe pain, but they may exacerbate symptoms. Hematopoietic stem cell transplantation (HSCT) with high intensity conditioning protocol has been performed in a few cases with severe anti-GAD positive SPS, resulting in clinical remission. In carefully selected cases of severe, treatment refractory SPS, HSCT may be an effective therapeutic option. Prognosis The progression of SPS depends on whether it is a typical or abnormal form of the condition and the presence of comorbidities. Early recognition and neurological treatment can limit its progression. SPS is generally responsive