MR imaging of adult acute infectious encephalitis

Bickerstaff encephalitis in childhood: a review of 74 cases in the literature from 1951 to today

Bickerstaff brainstem encephalitis (BBE) is a rare autoimmune disease characterized by the subacute onset of bilateral external ophthalmoplegia, ataxia, and decreased level of consciousness. BBE is part of a group of rare autoimmune diseases in children that can affect the nervous system at any level. The onset of neurological deficits is often sudden and nonspecific. The diagnosis is based on clinical findings and abnormal findings on cerebrospinal fluid (CSF), electroencephalography (EEG), electromyography (EMG), and magnetic resonance imaging (MRI). BBE is associated with the presence of the antiganglioside antibody, anti-GQ1b and anti-GM1. Intravenous immunoglobulin (IVIg) and plasma exchange are often used as treatments for these patients. We conducted a review on clinical presentation, diagnosis, treatment and outcome of reported cases of BBE. 74 cases are reported in the literature from the first cases described in 1951 to today. The prevalence is unknown while the incidence is higher in males. In 50% of cases, BBE occurs following respiratory or gastrointestinal tract infections. The most frequent initial symptoms were consciousness disturbance, headache, vomiting, diplopia, gait disturbance, dysarthria and fever. During illness course, almost all the patients developed consciousness disturbance, external ophthalmoplegia, and ataxia. Lumbar puncture showed pleocytosis or cytoalbuminological dissociation. Abnormal EEG and MRI studies revealed abnormalities in most cases. Anti-GQ1b antibodies were detected in more than half of the patients; anti-GM1 antibodies were detected in almost 40% of patients. Treatment guidelines are missing. In our analysis, steroids and IVIg were administered alone or in combination; as last option, plasmapheresis was used. BBE has a good prognosis and recovery in childhood is faster than in adulthood; 70% of patients reported no sequelae in our analysis. Future studies need to investigate pathogenesis and possible triggers, and therapeutic possibilities.

Vulnerability of the Hippocampus to Insults: Links to Blood-Brain Barrier Dysfunction

The hippocampus is a critical brain substrate for learning and memory; events that harm the hippocampus can seriously impair mental and behavioral functioning. Hippocampal pathophysiologies have been identified as potential causes and effects of a remarkably diverse array of medical diseases, psychological disorders, and environmental sources of damage. It may be that the hippocampus is more vulnerable than other brain areas to insults that are related to these conditions. One purpose of this review is to assess the vulnerability of the hippocampus to the most prevalent types of insults in multiple biomedical domains (i.e., neuroactive pathogens, neurotoxins, neurological conditions, trauma, aging, neurodegenerative disease, acquired brain injury, mental health conditions, endocrine disorders, developmental disabilities, nutrition) and to evaluate whether these insults affect the hippocampus first and more prominently compared to other brain loci. A second purpose is to consider the role of hippocampal blood-brain barrier (BBB) breakdown in either causing or worsening the harmful effects of each insult. Recent research suggests that the hippocampal BBB is more fragile compared to other brain areas and may also be more prone to the disruption of the transport mechanisms that act to maintain the internal milieu. Moreover, a compromised BBB could be a factor that is common to many different types of insults. Our analysis indicates that the hippocampus is more vulnerable to insults compared to other parts of the brain, and that developing interventions that protect the hippocampal BBB may help to prevent or ameliorate the harmful effects of many insults on memory and cognition.

Encephalitis in HIV-negative immunodeficient patients: a prospective multicentre study, France, 2016 to 2019

BackgroundData on infectious encephalitis in immunodeficient (ID) individuals are scarce. This population may present with atypical clinical symptoms, be infected by uncommon pathogens and develop poor outcomes.AimWe aimed to describe the epidemiology of infectious encephalitis among HIV-negative ID patients.MethodsPatients from the ENCEIF (Etude Nationale de Cohorte des Encéphalites Infectieuses en France) prospective cohort meeting criteria for infectious encephalitis between January 2016 and December 2019 were included. We compared clinical presentation, magnetic resonance imaging (MRI) results, biological results, infection causes and outcome of ID patients with immunocompetent (IC) patients using Pearson's chi-squared test and Student's t-test. We carried out logistic regression to assess the role of immunodeficiency as risk factor for poor outcome.ResultsID patients (n = 58) were older (mean 72 vs 59 years), had higher prevalence of diabetes (26% vs 12%), pre-existing neurological disorders (12% vs 5%) and higher case-fatality rate (23.6% vs 5.6%) compared to IC patients (n = 436). Varicella zoster virus was the primary cause of encephalitis in ID patients (this aetiology was more frequent in ID (25.9%) than in IC patients (11.5%)), with herpes simplex virus second (22.4% in ID patients vs 27.3% in IC patients). Immunodeficiency was an independent risk factor for death or major sequelae (odds ratio: 3.41, 95%CI: 1.70-6.85).ConclusionsVaricella zoster virus is the most frequent cause of infectious encephalitis in ID patients. Immunodeficiency is a major risk factor for poor outcome. ID encephalitis patients should benefit from stringent investigation of cause and early empiric treatment.

Magnetic resonance imaging of human variegated squirrel bornavirus 1 (VSBV-1) encephalitis reveals diagnostic pattern indistinguishable from Borna disease virus 1 (BoDV-1) encephalitis but typical for bornaviruses

Human bornavirus encephalitis is an emerging disease caused by the variegated squirrel bornavirus 1 (VSBV-1) and the Borna disease virus 1 (BoDV-1). While characteristic brain magnetic resonance imaging (MRI) changes have been described for BoDV-1 encephalitis, only scarce diagnostic data in VSBV-1 encephalitis exist. We systematically analysed brain MRI scans from all known VSBV-1 encephalitis patients. Initial and follow-up scans demonstrated characteristic T2 hyperintense lesions in the limbic system and the basal ganglia, followed by the brainstem. No involvement of the cerebellar cortex was seen. Deep white matter affection occurred in a later stage of the disease. Strict symmetry of pathologic changes was seen in 62%. T2 hyperintense areas were often associated with low T1 signal intensity and with mass effect. Sinusitis in three patients on the first MRI and an early involvement of the limbic system suggest an olfactory route of VSBV-1 entry. The viral spread could occur per continuitatem to adjacent anatomical brain regions or along specific neural tracts to more distant brain regions. The number and extent of lesions did not correlate with the length of patients' survivals. The overall pattern closely resembles that described for BoDV-1 encephalitis. The exact bornavirus species can thus not be deduced from imaging results alone, and molecular testing and serology should be performed to confirm the causative bornavirus. As VSBV-1 is likely of tropical origin, and MRI investigations are increasingly available globally, imaging techniques might be helpful to facilitate an early presumptive diagnosis of VSBV-1 encephalitis when molecular and/or serological testing is not available.

The Clinical Profile and Prognostic Factors Influencing Mortality in Patients With Acute Encephalitis Syndrome

Introduction Acute encephalitis syndrome (AES) is a significant global public health concern. AES is a disorder characterized by fever and altered mental status, and it is associated with considerable morbidity and mortality. There is a limited amount of existing literature on the clinical profile and prognostic markers that influence mortality in these patients. Our study seeks to comprehend the etiology, clinical characteristics, complications, and prognostic markers that impact mortality among patients with AES.  Methods The study was a prospective observational study conducted over 18 months, involving a sample size of 105 patients. Patients aged 12 years and older, who met the WHO case definition of Acute Encephalitis Syndrome (AES), were consecutively recruited for this study. The patients' details were recorded, including their medical history and physical and clinical examination findings upon admission. The extent of cognitive impairment was evaluated using the Glasgow Coma Scale (GCS). Additionally, the patient's presenting symptoms, any complications experienced during their hospital stay, and the mortality rate were documented. The etiology, MRI results of the brain, laboratory parameters, and the need for assisted ventilation were also recorded. In-hospital characteristics were analyzed using the t-test for continuous variables and the chi-square test for binary variables. The log-rank test was employed to identify the predictors with the most significant independent influence on prognosis. All participants were selected only after obtaining their written informed consent.  Results Most of the patients were in the age group of 21-30. 60% of the patients were male. Advanced age at presentation was associated with an increased risk of mortality (p-value=0.018). All patients presented to the hospital with symptoms of fever and altered sensorium. The most common agent isolated as the etiologic cause was HSV-1, found in 31.4% of the patients. 28.6% of the patients succumbed to death. The leading cause of death was raised intracranial pressure leading to hemorrhage in the brain. There was no significant correlation between the duration of symptoms and the primary outcome of death (p-value=0.498). The requirement for assisted ventilation was shown to increase the risk of death (p-value=0.001). A low GCS score at presentation was associated with a higher mortality rate (p-value=0.048).    Conclusions The factors that predict mortality in AES involve a complex interplay of patient demographics, viral etiology, clinical severity, neuroimaging findings, and the need for assisted ventilation. Integrating these factors into clinical practice would enable healthcare providers to make informed decisions regarding patient management and interventions. As our comprehension of AES continues to develop, forthcoming advancements in diagnostics and therapeutics could refine prognostic assessments further. These developments could open new avenues for enhancing outcomes and diminishing mortality rates in this complex neurological disorder.

Anaplasma phagocytophilum Encephalitis: A Case Report and Literature Review of Neurologic Manifestations of Anaplasmosis

Anaplasma phagocytophilum is an obligate intracellular, Gram-negative pathogen, causative agent of Human Granulocytic Anaplasmosis (HGA). HGA usually manifests as a non-specific febrile illness, accompanied by evidence of leucopenia, thrombocytopenia, and an alteration in liver enzymes. Neurologic manifestations of anaplasmosis are rare and rarely reported. We describe a 62-year-old man who developed encephalitis due to an Anaplasma phagocytophilum infection. The patient favorably responded to intravenous doxycycline and recovered without neurological sequela. In the tick endemic area, clinicians should have a high index of suspicion for tick-borne diseases in patients presenting with neurological deficits. A prompt diagnosis and treatment lead to improvements in morbidity and mortality.

Can we forecast poor outcome in herpes simplex and varicella zoster encephalitis? A narrative review

Herpes simplex virus (HSV) and varicella zoster virus (VZV) are among the most commonly diagnosed infectious causes of sporadic encephalitis worldwide. Despite treatment, mortality and morbidity rates remain high, especially for HSV encephalitis. This review is intended to provide an overview of the existing scientific literature on this topic from the perspective of a clinician who is confronted with serious decisions about continuation or withdrawal of therapeutic interventions. We performed a literature review searching two databases and included 55 studies in the review. These studies documented or investigated specifically outcome and predictive parameters of outcome of HSV and/or VZV encephalitis. Two reviewers independently screened and reviewed full-text articles meeting the inclusion criteria. Key data were extracted and presented as a narrative summary. Both, HSV and VZV encephalitis have mortality rates between 5 and 20% and complete recovery rates range from 14 to 43% for HSV and 33 to 49% for VZV encephalitis. Prognostic factors for both VZV and HSV encephalitis are older age and comorbidity, as well as severity of disease and extent of magnetic resonance imaging (MRI) lesions on admission, and delay in treatment initiation for HSV encephalitis. Although numerous studies are available, the main limiting factors are the inconsistent patient selection and case definitions as well as the non-standardised outcome measures, which hampers the comparability of the studies. Therefore, larger and standardised observational studies applying validated case definitions and outcome measures including quality of life assessment are required to provide solid evidence to answer the research question.

Empirical intravenous aciclovir therapy in a suspected case of acute encephalitis

Herpes simplex encephalitis is the most common cause of sporadic viral encephalitis worldwide but presents as a diagnostic challenge at many settings due to its non-specific symptoms, which can be easily mistaken for systemic infection or metabolic encephalopathy. It has diverse range of presentations from fever, altered sensorium, nausea, vomiting, meningismus to seizures, neurological deficits and coma in advanced stages. It is associated with significant morbidity and mortality if treatment is delayed or inadequate. We here discuss a case of Herpes simplex virus (HSV) encephalitis which rapidly progressed to result in irreversible neurological insult due to delayed diagnosis and treatment.

Pneumonia and Meningoencephalitis Due to Varicella-zoster Virus Reinfection and Epstein-Barr Virus Reactivation in a Patient with Rheumatoid Arthritis

A 72-year-old woman with rheumatoid arthritis was treated with methotrexate (MTX) and iguratimod. Upon examination of a liver tumor, blisters due to varicella-zoster virus (VZV) infection were observed. Despite oral administration of valacyclovir, she developed varicella pneumonia and meningoencephalitis. A VZV antibody test revealed reinfection. The liver tumor shrank after discontinuance of MTX, and polymerase chain reaction revealed the reactivation of the Epstein-Barr virus (EBV). Therefore, we were unable to deny MTX-associated lymphoproliferative disorder (MTX-LPD). This is the first case of a complication of pneumonia and meningoencephalitis due to VZV reinfection and EBV reactivation.

Brainstem lesions: MRI review of standard morphological sequences

MRI signal changes in the brainstem are observed in a multitude of disorders including vascular diseases, neoplastic lesions, degenerative diseases, inflammatory disorders, metabolic diseases, infections, and trauma. In some diseases, brainstem involvement is typical and sometimes isolated, while in other diseases, brainstem lesions are only observed occasionally in the presence of other typical extra-brainstem abnormalities. In this review, we will discuss the MRI characteristics of brainstem lesions observed in different disorders associated with frequent and less frequent brainstem involvement. Identification of the origin of the brainstem lesion depends on the exact localisation of the lesion(s) inside the brainstem, the presence and the characteristics of associated lesions seen outside the brainstem, the signal changes on different MRI sequences, the evolution over time of the radiological abnormalities, the history and clinical state of the patient, and other radiological and non-radiological examinations.

HSV-Encephalitis Resembling Acute Cerebral Infarction in a Patient With Atrial Fibrillation: Beware of Stroke Mimics

INTRODUCTION

Herpes simplex virus-1 (HSV-1) encephalitis, the most common and potentially life-threatening type of encephalitis, may rarely present as a stroke mimic. Prompt diagnosis is of paramount importance for the timely initiation of antiviral treatment and to avert intravenous thrombolysis.

CASE REPORT

A 60-year-old man with a history of lone paroxysmal atrial fibrillation without prior antithrombotic treatment was admitted due to mild gait unsteadiness and intermittent dysarthria of acute onset. On admission, the patient was afebrile, whereas neurological examination revealed only a mild pronator drift on the left. Brain magnetic resonance imaging (MRI) showed an extensive right temporo-occipital and thalamic lesion with restricted diffusion and 3 small-sized hemorrhagic foci. Brain MR-angiography did not show large vessel stenosis or occlusion. On the basis of careful observation and the depiction of several imaging discrepancies, such as early vasogenic edema and hemorrhagic transformation, as well as uncus involvement, but also the lack of significant neurological deficits despite the size of the brain lesion we suspected viral encephalitis which was confirmed by the detection of HSV-1 DNA in the cerebrospinal fluid.

CONCLUSION

HSV-encephalitis might occasionally result in the development of unilateral brain MRI lesions with extensive cytotoxic edema, resembling an acute ischemic stroke. Therefore, HSV-encephalitis must be considered in the differential diagnosis of acute ischemic stroke with atypical presentation. The presence of a significant dissociation between the brain MRI lesion volume and the neurological deficits, as well as certain brain MRI imaging discrepancies might serve as "red flags" to extend the diagnostic workup.

Glial Fibrillary Acidic Protein Autoimmunity: A French Cohort Study

Background and Objectives

To report the clinical, biological, and imaging features and clinical course of a French cohort of patients with glial fibrillary acidic protein (GFAP) autoantibodies.

Methods

We retrospectively included all patients who tested positive for GFAP antibodies in the CSF by immunohistochemistry and confirmed by cell-based assay using cells expressing human GFAPα since 2017 from 2 French referral centers.

Results

We identified 46 patients with GFAP antibodies. Median age at onset was 43 years, and 65% were men. Infectious prodromal symptoms were found in 82%. Other autoimmune diseases were found in 22% of patients, and coexisting neural autoantibodies in 11%. Tumors were present in 24%, and T-cell dysfunction in 23%. The most frequent presentation was subacute meningoencephalitis (85%), with cerebellar dysfunction in 57% of cases. Other clinical presentations included myelitis (30%) and visual (35%) and peripheral nervous system involvement (24%). MRI showed perivascular radial enhancement in 32%, periventricular T2 hyperintensity in 41%, brainstem involvement in 31%, leptomeningeal enhancement in 26%, and reversible splenial lesions in 4 cases. A total of 33 of 40 patients had a monophasic course, associated with a good outcome at last follow-up (Rankin Score ≤2: 89%), despite a severe clinical presentation. Adult and pediatric features are similar. Thirty-two patients were treated with immunotherapy. A total of 11/22 patients showed negative conversion of GFAP antibodies.

Discussion

GFAP autoimmunity is mainly associated with acute/subacute meningoencephalomyelitis with prodromal symptoms, for which tumors and T-cell dysfunction are frequent triggers. The majority of patients followed a monophasic course with a good outcome.

Neuroradiology of infectious diseases

PURPOSE OF REVIEW

Early diagnosis of central nervous system (CNS) infections is crucial given high morbidity and mortality. Neuroimaging in CNS infections is widely used to aid in the diagnosis, treatment and to assess the response to antibiotic and neurosurgical interventions.

RECENT FINDINGS

The Infectious Diseases Society of America (IDSA) guidelines have clear recommendations for obtaining a computerized tomography of the head (CTH) prior to lumbar puncture (LP) in suspected meningitis. In the absence of indications for imaging or in aseptic meningitis, cranial imaging is of low utility. In contrast, cranial imaging is of utmost importance in the setting of encephalitis, bacterial meningitis, ventriculitis, bacterial brain abscess, subdural empyema, epidural abscess, neurobrucellosis, neurocysticercosis, and CNS tuberculosis that can aid clinicians with the differential diagnosis, source of infection (e.g., otitis, sinusitis), assessing complications of meningitis (e.g., hydrocephalus, venous sinus thrombosis, strokes), need for neurosurgical interventions and to monitor for the response of therapy. Novel imaging techniques such as fast imaging employing steady-state acquisition (FIESTA), susceptibility-weighted imaging (SWI), and chemical exchange saturation transfer (CEST) contrast are briefly discussed.

SUMMARY

Though the radiological findings in CNS infections are vast, certain patterns along with clinical clues from history and examination often pave the way to early diagnosis. This review reiterates the importance of obtaining cranial imaging when necessary, and the various radiological presentations of commonly encountered CNS infections.

Rhombencephalitis due to Listeria monocytogenes infection with GQ1b antibody positivity and multiple intracranial hemorrhage: a case report and literature review

Listeria monocytogenes is a Gram-positive facultative intracellular bacterium that causes central nervous system infection. We report a case of rhombencephalitis caused by L. monocytogenes infection, which mimicked Bickerstaff’s brainstem encephalitis, and GQ1b antibody positivity and multiple intracranial foci were observed. A 68-year-old male patient presented with a nonspecific prodrome of faintness, forehead tightness, and walking instability. This was followed by progressive cranial nerve palsies, limb weakness, cerebellar signs, hyperpyrexia, and impaired consciousness. Brain imaging showed multiple abnormal brainstem and cerebellar signals that were accompanied by blood infiltration without any lesion enhancement. Serum GQ1b antibody positivity led to an initial diagnosis of Bickerstaff’s brainstem encephalitis, which was treated with immunosuppressive therapy with limited efficacy. A pathogen examination helped confirm L. monocytogenes infection. A combination of meropenem and trimethoprim-sulfamethoxazole therapy was applied and the patient recovered without sequelae. The symptoms and imaging of Listeria rhombencephalitis are nonspecific. Accurate diagnosis and prompt treatment of this condition are essential. Whether Listeria infection triggers an autoimmune response remains unclear.

Septic shock due to Escherichia coli meningoencephalitis treated with immunoglobulin-M-enriched immunoglobulin preparation as adjuvant therapy: a case report

BACKGROUND

Gram-negative bacteria are an uncommon etiology of spontaneous community-acquired adult meningitis and meningoencephalitis. Escherichia coli is a Gram-negative bacterium that is normally present in the intestinal microbial pool. Some Escherichia coli strains can cause diseases in humans and animals, with both intestinal and extraintestinal manifestations (extraintestinal pathogenic Escherichia coli) such as urinary tract infections, bacteremia with sepsis, and, more rarely, meningitis. Meningitis continues to be an important cause of mortality throughout the world, despite progress in antimicrobial chemotherapy and supportive therapy. The mortality rate fluctuates between 15% and 40%, and about 50% of the survivors report neurological sequelae. The majority of Escherichia coli meningitis cases develop as a result of hematogenous spread, with higher degrees of bacteremia also being related to worse prognosis. Cases presenting with impaired consciousness (that is, coma) are also reported to have poorer outcomes.

CASE PRESENTATION

We describe the case of a 48-year-old caucasian woman with meningoencephalitis, with a marked alteration of consciousness on admission, and septic shock secondary to pyelonephritis caused by Escherichia coli, treated with targeted antimicrobial therapy and immunoglobulin-M-enriched immunoglobulin (Pentaglobin) preparation as adjuvant therapy.

CONCLUSION

Despite the dramatic presentation of the patient on admission, the conflicting data on the use of immunoglobulins in septic shock, and the lack of evidence regarding their use in adult Escherichia coli meningoencephalitis, we obtained a remarkable improvement of her clinical condition, accompanied by partial resolution of her neurological deficits.

Conventional and advanced imaging throughout the cycle of care of gliomas

Although imaging of gliomas has evolved tremendously over the last decades, published techniques and protocols are not always implemented into clinical practice. Furthermore, most of the published literature focuses on specific timepoints in glioma management. This article reviews the current literature on conventional and advanced imaging techniques and chronologically outlines their practical relevance for the clinical management of gliomas throughout the cycle of care. Relevant articles were located through the Pubmed/Medline database and included in this review. Interpretation of conventional and advanced imaging techniques is crucial along the entire process of glioma care, from diagnosis to follow-up. In addition to the described currently existing techniques, we expect deep learning or machine learning approaches to assist each step of glioma management through tumor segmentation, radiogenomics, prognostication, and characterization of pseudoprogression. Thorough knowledge of the specific performance, possibilities, and limitations of each imaging modality is key for their adequate use in glioma management.

Correlative Magnetic Resonance Imaging and Histopathology in Small Ruminant Listeria Rhombencephalitis

Background: Listeria rhombencephalitis, infection of the brainstem with Listeria monocytogenes, occurs mainly in humans and farmed ruminants and is associated with high fatality rates. Small ruminants (goats and sheep) are a large animal model due to neuropathological similarities. The purpose of this study was to define magnetic resonance imaging (MRI) features of listeria rhombencephalitis in naturally infected small ruminants and correlate them with histopathology. Secondly, the purpose of this study was to compare the results with MRI findings reported in humans.

Methods: Twenty small ruminants (13 sheep and 7 goats) with listeria rhombencephalitis were prospectively enrolled and underwent in vivo MRI of the brain, including T2-weighted, fluid attenuation inversion recovery, and T1-weighted sequences pre- and post-contrast administration and postmortem histopathology. In MRI, lesions were characterized by location, extent, border definition, signal intensity, and contrast enhancement. In histopathology, the location, cell type, severity, and chronicity of inflammatory infiltrates and signs of vascular damage were recorded. In addition, histopathologic slides were matched to MRIs, and histopathologic and MRI features were compared.

Results: Asymmetric T2-hyperintense lesions in the brainstem were observed in all animals and corresponded to the location and pattern of inflammatory infiltrates in histopathology. Contrast enhancement in the brainstem was observed in 10 animals and was associated with vessel wall damage and perivascular fibrin accumulation in 8 of 10 animals. MRI underestimated the extension into rostral brain parts and the involvement of trigeminal ganglia and meninges.

Conclusion: Asymmetric T2-hyperintense lesions in the brainstem with or without contrast enhancement can be established as criteria for the diagnosis of listeria rhombencephalitis in small ruminants. Brainstem lesions were similar to human listeria rhombencephalitis in terms of signal intensity and location. Different from humans, contrast enhancement was a rare finding, and abscessation was not observed.

Adults with severe Japanese encephalitis: a retrospective analysis of 9 cases in Linyi, China

Objective

Japanese encephalitis (JE) is a critical problem of public health worldwide; however, there is limited data about the clinical features and indicators of outcome in adults with severe Japanese encephalitis.

Methods

The clinical manifestations and laboratory study on brain neuroimaging of patients with severe JE were statistically analyzed retrospectively. All patients were followed up for 6 months after discharge. The patients were grouped into good outcome and poor outcome according to the results of the follow-up.

Results

This retrospective study consists of 9 adults with severe JE, including 5 cases with poor outcome, defined as the modified Rankin Scale (mRS) scores of greater than or equal to 4 points, and remained ventilator dependent. Typical clinical manifestations of JE include fever (100%), altered consciousness (100%), headache (66.7%), flaccid weakness (66.7%), and status epilepticus (44.4%). Serological examination revealed that a higher percentage of neutrophils and a lower percentage of lymphocytes at admission may be associated with a poor outcome. Abnormal neuroimaging of the thalamus (85.7%), hippocampal (71.4%), midbrain (28.6%), and basal ganglia (14.3%) was found. 42.9% of patients left severe irreversible disability, and the most prominent were mental symptoms (71.4%) and memory or understanding disorder (57.1%).

Conclusion

Our data suggest that respiratory failure is one of the important causes of early death. Serologic examination, coma, and status epilepticus may indicate a poor outcome for severe JE. Additionally, the hippocampus is the second most common lesion in the adults with severe JE. A large-scale clinical trial is required to further confirm these conclusions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10072-020-04867-8.

[Fast MRI sequences for clarification of acute neurological symptoms]

CLINICAL/METHODICAL ISSUE

Neurological symptoms account for approximately 30% of emergency room (ER) visits. Clinical outcome often relies on a timely diagnosis and treatment initiation. Clinical imaging requirements are fast availability and high diagnostic value.

STANDARD RADIOLOGICAL METHODS

Availability and quality of magnetic resonance imaging (MRI) in emergency rooms outside of core hours are limited compared to computed tomography (CT). Common reasons are infrastructural accessibility (hospitals using outpatient radiology centers), a lack of experienced and qualified staff and high patient compliance requirements. However, in a neurological emergency setting, MRI may show relevant advantages over CT in certain areas, such as diagnosis of stroke.

METHODOLOGICAL INNOVATIONS

Advances in MRI technology have led to shorter exam times and robust motion reduction strategies. Common fast sequences and time reduction techniques for imaging of neurological emergencies are presented in this article.

ACHIEVEMENTS

Recommendations for specific sequences or techniques depend on the institute's MRI hardware and software components. If available, parallel imaging is highly recommended for imaging of neurological emergencies.

PRACTICAL RECOMMENDATIONS

Imaging of neurological emergencies requires fast, significant and motion insensitive standard acquisitions. Additional sequences should be acquired dependent on clinical and standard protocol imaging findings. An MRI emergency protocol is introduced for the most common neurologic emergencies including recommendations for fast MRI sequences and techniques for imaging time reduction.

Herpes simplex virus encephalitis update

PURPOSE OF REVIEW

HSV is the most frequently identified cause of infectious encephalitis, in Western countries. This article is an update on the topic based on a review of recent studies from 2017 to 2018.

RECENT FINDINGS

Acyclovir is still the first line treatment, and no new drugs are currently available for clinical use. The major considerations for HSV encephalitis are as follows: point one, clinical evaluation remains the most important factor, as though CSF HSV PCR has a good sensitivity, in a small proportion of patients the initial testing might be negative. MRI brain is the first line imaging test, and mesial temporal lobe involvement and other typical findings are important for diagnosis; point 2, there should be emphasis on sequela, short-term, and long-term outcomes, and not just case fatality rated in future studies and clinical management. Auto-immune encephalitis can be triggered by HSV, and should be considered in patients who are not responding to treatment; point 3, future studies should be on better management of sequela, and better treatment regimens including those targeting the immune response.

SUMMARY

Autoimmune encephalitis is a clearly identified complication of HSV encephalitis. Inflammatory mechanisms are linked to the clinical presentation as well as severity and poor outcome. Initial corticosteroid therapy has to be evaluated in order to prevent complications.

Meningitis and encephalitis management in the ICU

PURPOSE OF REVIEW

Management of patients with meningitis and encephalitis oftentimes requires ICU level of care. This article is an update on management for meningitis and encephalitis with focus on clinical care in the ICU. Information provided is based on a review of recent studies with focus on studies since 2017.

RECENT FINDINGS

Advances in diagnostic and treatment approach for different pathogens are presented. Nosocomial meningitis now constitutes a major part of brain infections seen in ICUs in the developed world. Advances in ICU care of central nervous system (CNS) infections include application of newer diagnostic methods, improved understanding and delivery of antibiotics to the CNS, infection prevention for nosocomial infections, and application of neuromonitoring where indicated.

SUMMARY

Advances in diagnostics and therapeutic approach to CNS infections are continually made. For intensivists, focus on neuromonitoring and brain resuscitation in critically ill patients with CNS infections may present a path to enhance preservation of brain function and improve outcomes. VIDEO ABSTRACT: http://links.lww.com/COCC/A22.

Manifestaciones clínicas del síndrome de Ramsay-Hunt en una serie de 20 casos

Introducción y objetivo: la experiencia clínica nos ha mostrado las distintas formas de presentación y la variabilidad sintomatológica que puede revelar el síndrome de Ramsay-Hunt o herpes zóster ótico. Las descripciones que ofrece la literatura nos han servido para corroborar los hallazgos de un conjunto de pacientes, cuyas características y evolución hemos ido reuniendo en el tiempo. Dada la importancia del tratamiento precoz, el objetivo de este trabajo ha consistido en realizar una exposición estructurada de este complejo síndrome con sus diversas manifestaciones. Método: estudio retrospectivo. Resultados: 20 pacientes ejemplifican los diferentes aspectos de este proceso. Discusión: se trata de una patología infrecuente, con una tríada sintomática patognomónica que consiste en otalgia, erupción vesicular y parálisis facial. Sin embargo, este síndrome no siempre se expresa de forma completa ni con la aparición de los síntomas en el orden indicado, añadiéndose con frecuencia otros cocleovestibulares. La posibilidad de que la infección se propague de forma centrífuga y centrípeta facilita el que se afecten otros nervios sensitivos y motores, ocasionando una polineuropatía craneal (herpes zóster cefálico) y raquídea o incluso, con mucha menor frecuencia, la aparición de una meningoencefalitis. No conocemos con precisión los mecanismos por los que progresa este proceso ni los factores desencadenantes, aunque en ocasiones les haya predisponentes. Establecer un diagnóstico es fundamental para iniciar el tratamiento, cuya precocidad facilita la resolución del proceso. Conclusiones: siendo la sospecha clínica la principal herramienta de un diagnóstico precoz, nos ha parecido de interés realizar esta revisión, dada la infrecuencia del herpes zóster ótico.

Therapeutic difficulties in vegetative epileptic seizures as a sign of acute viral encephalitis: case presentation

Acute encephalitis is a severe pathology represented by the inflammation of the brain parenchyma associated with neurological dysfunction. The etiology is predominantly viral or autoimmune, with different therapeutic approach. The typical manifestations include fever, epileptic seizures and neurological focal signs. The treatment consists in specific drug therapies regarding the etiology and rehabilitation therapies in case of incomplete recovery. We present a case of a 43-year-old woman with occipital cephalalgia and dizziness, associated with vesperal high blood pressure levels at the same hour daily. The brain MRI described possible acute encephalitis, with FLAIR and T2 hypersignal area on right parietal region and diffusion restriction. The lumbar puncture revealed no modifications and the EEG recordings showed irritative patterns. The acyclovir intravenous treatment and an antiepileptic drug were initiated. The repeated MRI revealed laminar necrosis which explained the vegetative epileptic seizures manifested with high blood pressure. The clinical status of the patient majorly improved due to specific treatment including rehabilitation interventions. Key words: acute viral encephalitis, vegetative epileptic seizures, laminar necrosis, cephalalgia, rehabilitation,

Brainstem and Cerebellar Involvement in Ramsay Hunt Syndrome

We present a case of a 62-year-old Caucasian male with laryngeal cancer and Ramsay Hunt Syndrome otherwise known as herpes zoster oticus due to reactivation of the varicella zoster virus. Classic findings include the triad of ipsilateral facial paralysis, otic pain, and herpetic lesions in the sensory supply of the facial nerve. The common pathogenesis is associated with anterograde axonal reactivation of the varicella zoster virus in the geniculate ganglion. Unique features of our case include retrograde transaxonal spread of the varicella-zoster virus from the geniculate ganglion into the brainstem and cerebellum including involvement of the abducens nucleus, facial nucleus, middle cerebral peduncle, and inferior cerebellar peduncle. This presented as left facial paralysis, left sixth nerve palsy, horizontal diplopia to the left lateral gaze, profound truncal ataxia, and left-sided dysmetria. Clinical awareness that Ramsay Hunt syndrome may also involve the brainstem and cerebellum is critical in evaluating the clinical neurologic findings and expanding the diagnostic workup to include brain magnetic resonance imaging and cerebrospinal fluid analysis, including varicella zoster polymerase chain reaction. Encephalitis requires longer duration administration of high-dose intravenous acyclovir in conjunction with steroids. Delays in treatment are often associated with unsatisfactory outcomes with extensive residual deficits.

The neurocritical care of tuberculous meningitis

Tuberculous meningitis is the most severe form of tuberculosis and often causes critical illness with high mortality. Two primary management objectives are reducing intracranial pressure, and optimising cerebral perfusion, while killing the bacteria and controlling intracerebral inflammation. However, the evidence base guiding the care of critically ill patients with tuberculous meningitis is poor and many patients do not have access to neurocritical care units. Invasive intracranial pressure monitoring is often unavailable and although new non-invasive monitoring techniques show promise, further evidence for their use is required. Optimal management regimens of neurological complications (eg, hydrocephalus and paradoxical reactions) and of hyponatraemia, which frequently accompanies tuberculous meningitis, remain to be elucidated. Advances in the field of tuberculous meningitis predominantly focus on diagnosis, inflammatory processes, and antituberculosis chemotherapy. However, clinical trials are required to provide robust evidence guiding the most effective supportive, therapeutic, and neurosurgical interventions for tuberculous meningitis that will improve morbidity and mortality.

Imaging in Lyme neuroborreliosis

Abstract

Lyme neuroborreliosis (LNB) is a tick-borne spirochetal infection with a broad spectrum of imaging pathology. For individuals who live in or have travelled to areas where ticks reside, LNB should be considered among differential diagnoses when clinical manifestations from the nervous system occur. Radiculitis, meningitis and facial palsy are commonly encountered, while peripheral neuropathy, myelitis, meningoencephalitis and cerebral vasculitis are rarer manifestations of LNB. Cerebrospinal fluid (CSF) analysis and serology are key investigations in patient workup. The primary role of imaging is to rule out other reasons for the neurological symptoms. It is therefore important to know the diversity of possible imaging findings from the infection itself. There may be no imaging abnormality, or findings suggestive of neuritis, meningitis, myelitis, encephalitis or vasculitis. White matter lesions are not a prominent feature of LNB. Insight into LNB clinical presentation, laboratory test methods and spectrum of imaging pathology will aid in the multidisciplinary interaction that often is imperative to achieve an efficient patient workup and arrive at a correct diagnosis. This article can educate those engaged in imaging of the nervous system and serve as a comprehensive tool in clinical cases.

Key Points

• Diagnostic criteria for LNB emphasise exclusion of an alternative cause to the clinical symptoms.

• MRI makes a crucial contribution in the diagnosis and follow-up of LNB.

• MRI may have normal findings, or show neuritis, meningitis, myelitis, encephalitis or vasculitis.

• White matter lesions are not a prominent feature of LNB.

Acute encephalitis - diagnosis and management

Encephalitis, inflammation of the brain, is most commonly caused by a viral infection (especially herpes simplex virus [HSV] type 1 in the UK) although autoimmune causes, such as N-methyl D-aspartate receptor (NMDAR) antibody encephalitis, are increasingly recognised. Most patients present with a change in consciousness level and may have fever, seizures, movement disorder or focal neurological deficits. Diagnosis hinges crucially on lumbar puncture and cerebrospinal fluid (CSF) examination, but imaging and electroencephalography (EEG) may also be helpful. Treatment of HSV encephalitis with aciclovir dramatically improves outcome, but the optimal management of autoimmune encephalitis is still uncertain. Many patients with encephalitis are left with residual physical or neuropsychological deficits which require long-term multidisciplinary management. Here we review assessment of patients with suspected encephalitis, general aspects of management and areas of ongoing research.

Cytokines Interleukin 4 (IL-4) and Interleukin 10 (IL-10) Gene Polymorphisms as Potential Host Susceptibility Factors in Virus-Induced Encephalitis

Background

This study aimed to analyze and explore the relationship between the cytokines IL-4 and IL-10 in relation to gene polymorphism and their respective effects on the susceptibility to virus-induced encephalitis.

Material/Methods

From January 2012 to June 2013, 112 patients with virus-induced encephalitis (the case group and 109 healthy individuals (the control group) were recruited for the purposes of this study. The functional variations that IL-4 and IL-10 genes exhibit were detected through the use of a function analysis and selection tool for single-nucleotide polymorphisms (FASTSNP). The genotypes of IL-4 were rs2227283 and IL-4 rs2227288, and the genotypes of IL-10 were rs1800871 and IL-10 rs1800872. These genotypes were respectively assessed using direct sequencing.

Results

IL-4 rs2227283 and IL-10 rs1800871 have no correlation in with risk of virus-induced encephalitis (both P>0.05)

GA and AA genotypes were related to IL-4 rs2227288 and GT, while TT and GT + TT genotypes were related to IL-10 rs1800872. These were highlighted as being risk factors in virus-induced encephalitis (all P<0.05). However, the duration of fever, white blood cell (WBC) count, C-reactive protein (CRP), neutrophils, and lymphocytes and monocytes of virus-induced encephalitis patients with IL-4 rs2227288 and IL-10 rs1800872 all displayed significant differences (all P<0.05). Frequencies of GAGT and CAGT haplotypes were evaluated and deemed to be of statistical significance and subsequently were highlighted as being risk factors in virus-induced encephalitis (all P<0.05).

Conclusions

IL-4 rs2227288 and IL-10 rs1800872 may contribute to an increased risk for virus-induced encephalitis. Through use of direct sequencing, we showed that genotypes of IL-4 rs2227288 and IL-10 rs1800872 may have particular host susceptibility to virus-induced encephalitis.