Subacute sclerosing panencephalitis. Imaging and clinical correlation

The Rare Case Presentation of Adult-Onset Fulminant Subacute Sclerosing Panencephalitis in a 24-Year-Old Male

Subacute sclerosing panencephalitis (SSPE) is a late effect of measles in children. Its features include seizures, a gradual loss of physical and cognitive function, and finally death. Despite the absence of a definitive cure for this disorder, a regimen combining intrathecal interferon-α (IFN-α) and daily oral isoprinosine has demonstrated effectiveness. We present the case of a 24-year-old male with spastic seizure epilepsy. He exhibited progressive weakness, frequent postural instability, and recurrent generalized tonic-clonic seizures. Increased measles antibody concentrations in the cerebrospinal fluid (CSF), prominent amplitude spikes on the electroencephalogram (EEG), and heightened fluid-attenuated inversion recovery (FLAIR) signals on brain magnetic resonance imaging (MRI) suggested a diagnosis of SSPE.

A Rare Case of Subacute Sclerosing Panencephalitis Presenting As Generalized Seizure

Subacute sclerosing panencephalitis (SSPE) is a late complication of childhood measles. It is characterized by a progressive decline in cognitive and motor functions, seizures, and eventually death. Although a combination of intrathecal interferon alpha (IFN-α) and daily oral isoprinosine has been reported to have a good outcome, there is no cure for this condition.  We present a case of a 16-year-old male with SSPE who presented with progressive weakness, frequent loss of postural control, multiple episodes of generalized tonic-clonic seizures, and urinary incontinence. On exploration of his history, he had measles at the age of two months. Investigation showed increased serum measles antibody titer, high amplitude spikes in electroencephalogram (EEG), and high fluid-attenuated inversion recovery (FLAIR) signals on MRI of the brain consistent with probable SSPE. He was managed symptomatically until his condition got worse and he eventually passed away.

Subacute Sclerosing Panencephalitis of the Brainstem as a Clinical Entity

Subacute sclerosing panencephalitis (SSPE) is a rare progressive neurological disorder of early adolescence caused by persistent infection of the measles virus, which remains prevalent worldwide despite an effective vaccine. SSPE is a devastating disease with a characteristic clinical course in subcortical white matter; however, atypical presentations of brainstem involvement may be seen in rare cases. This review summarizes reports to date on brainstem involvement in SSPE, including the clinical course of disease, neuroimaging presentations, and guidelines for treatment. A comprehensive literature search was performed for English-language publications with keywords “subacute sclerosing panencephalitis” and “brainstem” using the National Library of Medicine PubMed database (March 1981–September 2017). Eleven articles focusing on SSPE of the brainstem were included. Predominant brainstem involvement remains uncharacteristic of SSPE, which may lead to misdiagnosis and poor outcome. A number of case reports have demonstrated brainstem involvement associated with other intracranial lesions commonly presenting in later SSPE stages (III and IV). However, brainstem lesions can appear in all stages, independent of higher cortical structures. The varied clinical presentations complicate diagnosis from a neuroimaging perspective. SSPE of the brainstem is a rare but important clinical entity. It may present like canonical SSPE or with unique clinical features such as absence seizures and pronounced ataxia. While SSPE generally progresses to the brainstem, it can also begin with a primary focus of infection in the brainstem. Awareness of varied SSPE presentations can aid in early diagnosis as well as guide management and treatment.

Subacute Sclerosing Panencephalitis Presenting with Unilateral Periodic Myoclonic Jerks

Background:

Subacute sclerosing panencephalitis (SSPE) is a rare complication of measles virus infection. The disease is characterized by behavioural abnormalities, intellectual deterioration, motor weakness, and generalized myoclonic jerks progressing to coma and death in one to two years in 80% of the cases. The myoclonic jerks are associated with characteristic generalized slow periodic complexes on electroencephalography (EEG). The symptoms and signs of SSPE are frequently quite variable. The clinical course is equally variable and difficult to predict. The characteristic periodic myoclonus can rarely occur unilaterally particularly in the early stages of the disease. As well, the periodic EEG complexes have been reported unilaterally in up to 3% of cases.

Case Report:

A 12-year-old boy, who was seen at a later stage with atypical manifestation of myoclonic body jerks confined entirely unilaterally, combined with contralateral periodic EEG complexes. One could assume clinically that the more diseased hemisphere was responsible for generating the jerks. However, brain magnetic resonance imaging revealed asymmetric hemispheric changes suggesting that the less neurologically damaged hemisphere is responsible for generating the unilateral myoclonic jerks. This has led to the interpretation that the more severely damaged hemisphere has lost the neuronal connectivity required to generate these periodic myoclonic jerks.

Conclusion:

Subacute sclerosing panencephalitis may have asymmetric hemispheric involvement, not only early, but also in the advanced stages of the disease, which can result in unilateral periodic myoclonic jerks.

Initial clinical and radiological findings in patients with SSPE: are they predictive of neurological outcome after 6 months of follow-up?

Subacute sclerosing panencephalitis (SSPE) is a progressive, devastating neurologic disorder caused by mutant measles virus. In this study we evaluated the prognostic value of neuroimaging abnormalities in SSPE. Thirty consecutive patients with SSPE were included. Diagnosis of SSPE was based on the criteria described by Dyken. Patients were followed for 6 months. Neuroimaging studies were performed at inclusion and after 6 months. Regression or progression of the disease was defined as a change of one, or more than one, stage in Jabbour's staging system. Degree of disability was assessed using the modified Rankin scale (mRS) score. Neuroimaging abnormalities were seen in 27 patients. Dominant imaging abnormalities were cerebral atrophy, white matter signal changes, cortical grey matter abnormalities and signal change in the basal ganglia. After 6 months of follow-up, 18 (60%) patients had a poor outcome (mRS score: 3-6); one patient died. The remaining 12 patients (40%) had a stabilized clinical condition (mRS score: 0-2). On univariate analysis, predictors of death or disability were: poor mRS score at baseline (p = 0.003) and Jabbour's clinical stage III (p = 0.019). None of the neuroimaging abnormalities were associated with a poor prognosis or clinical deterioration (p > 0.05). We conclude that we did not observe any association between cerebral neuroimaging at baseline and neurological outcome after 6 months in patients with SSPE.

Two cases of subacute sclerosing panencephalitis associated with brainstem involvement

The most commonly involved areas in subacute sclerosing panencephalitis (SSPE) are periventricular and subcortical white matter. The basal ganglia, cerebellum, spinal cord and corpus callosum are less commonly involved. Brainstem involvement is rare and usually accompanied by other intracranial lesions. In this article, we report two cases of SSPE associated with brainstem involvement. The first case a 9-year-old girl had the typical symptom of SSPE. Magnetic resonance imaging (MRI) of the brain revealed a focal lesion 2 x 2.5 cm a diameter in the pons. The second case was a 6-year-old girl. On admission, MRI of the brain was normal. During 6th month of follow-up, T2-weighted MRI showed a hyperintense lesion in the pons and pedincule of cerebellum. On account of these cases we would like to stress that brainstem involvement may be seen in patients with SSPE; therefore, these patients should be monitored for this disorder.

Sequential 3-D MRI frontal volume changes in subacute sclerosing panencephalitis

In patients with subacute sclerosing panencephalitis, clinical stages defined according to Jabbour correlate strongly with frontal lobe dysfunctions. Non-quantitative radiologic investigations in these patients have confirmed cerebral atrophy without identifying predominantly affected regions. We addressed this issue over an 8-year-old boy's course using volumetry based on three-dimensional T1-weighted gradient echo magnetic resonance imaging. Seven normal 6-12-year-old subjects served as controls. Whole-brain volume declined as Jabbour stage advanced from I to III. Frontal lobe volume and frontal-to-whole-brain volume ratios fell significantly as clinical stage progressed. Thus, cerebral atrophy in this SSPE patient was predominantly frontal, and paralleled clinical progression.

Clinical and epidemiological characteristics of subacute sclerosing panencephalitis in Bulgaria during the past 25 years (1978-2002)

The aims of the present study are to establish the subacute sclerosing panencephalitis (SSPE) incidence in Bulgaria for the 25-year period 1978-2002; to analyze the SSPE incidence prior to, and in the period of, routine measles immunization; and, to analyze the clinical characteristics of SSPE. SSPE was diagnosed in a total of 40 children; 28 of were diagnosed between 1978 and 1984, and 12 between 1995 and 2002. Thirty-eight cases (95%) were non-immunized and have had an early measles infection (mean age 16 months). The SSPE onset occurred primarily between 8 and 11 years of age (52.5%) with a mean latent period of about 7 years after the measles infection. After the 10-year disease-free period (1985-1994), the SSPE incidence increased between 1995 and 2002 because of the 1991-1992 measles epidemic. During the period 1995-2002 children with earlier measles infection and earlier SSPE onset predominated, compared to the period 1978-1984. The initial clinical manifestations included intellectual deterioration in 35%, extrapyramidal hyperkinesias in 29%, epileptic seizures in 15%, hemiparesis in 10%, and visual disturbances in 10% of the cases. Nine children (22.5%) demonstrated an atypical onset. A rapidly progressive course was observed in 4 children (10%) and a chronic progressive course with pseudoremissions over 2 years-in 8 cases (20%). Our analysis of the SSPE incidence in Bulgaria for the 25-year period (1978-2002) supports the importance of early measles infection as a crucial risk factor for this persistent neuroinfection. Moreover, it confirms the role of routine measles immunization in SSPE prevention.

Subacute sclerosing panencephalitis presenting with hemiparesis in childhood: case report

Subacute sclerosing panencephalitis is a chronic and fatal disease of the central nervous system. Most patients present with progressive psychointellectual disturbances. A 14-month-old girl was admitted to our hospital because of left-sided hemiparesis. During hospitalization, focal and generalized seizures occurred. The electroencephalogram (EEG) revealed that periodic lateralized discharges consisted of polyspike and high-voltage slow waves in the left hemisphere. The clinical and EEG findings and positive serology of measles in the cerebrospinal fluid were consistent with subacute sclerosing panencephalitis. In conclusion, we suggest that subacute sclerosing panencephalitis be considered in the differential diagnosis of focal neurologic signs in infants.

Subacute sclerosing panencephalitis with atypical onset: clinical, computed tomographic, and magnetic resonance imaging correlations

Clinical, computed tomographic (CT), and magnetic resonance imaging (MRI) correlations of subacute sclerosing panencephalitis with an atypical onset are presented in three children. In all three patients, the disease began similarly, with unilateral neurologic deficit followed by gnosis, praxis, and memory dysfunction corresponding to massive one-sided lesions. The first patient demonstrated right frontal-lobe syndrome and polymorphic extrapyramidal hyperkinesias; MRI showed a large high-signal lesion in the right frontal lobe, while CT was normal. The second patient displayed a disease onset with left-sided hemiparkinsonism and involuntary movements correlating to the MRI finding, ie, a massive rightsided occipitotemporoparietal subcortical lesion. An acute, stroke-like episode represented the first symptom in the third child. CT visualized cerebral, mainly left-sided cortical atrophy. In all three children, CT and MRI revealed significantly progressing brain atrophy at the disease's latest stages. We discuss the role of MRI in detecting early pathologic changes in children with subacute sclerosing panencephalitis.

The value of serial auditory brainstem response in patients with subacute sclerosing panencephalitis

A total of 98 serial auditory brainstem responses from 17 patients (11 boys and 6 girls) with subacute sclerosing panencephalitis were compared with their clinical course and stages. These patients were exposed to measles early in life (at 1.8 +/- 1.4 years old) with the average onset of the disease at 8.8 +/- 0.7 years of age. The main abnormalities of their auditory brainstem responses were a prolongation of waves I, III, and V, and of the I to V interpeak interval. Wave V thresholds were also elevated. These effects on the auditory brainstem responses started 1 to 2 years after onset of neurologic signs. I to V interpeak latency became prolonged with the progress of clinical stages, especially in Jabbour's clinically advanced stage IV. In two patients with an acute progressive type of subacute sclerosing panencephalitis, very rapid deterioration with a distorted wave pattern of later components was observed. These findings suggest rostrocaudal progression in the central nervous system of both long-term and fulminant cases.

Fulminating subacute sclerosing panencephalitis: case report and literature review

We describe a young urban boy with atypically fulminant subacute sclerosing panencephalitis (SSPE). He had measles at 3 years of age despite receiving measles immunization in infancy. The literature describing acute SSPE is reviewed and summarized. This report reiterates the need to include SSPE as a diagnostic possibility in acute encephalopathic processes. The dismal prognosis of SSPE further emphasizes the need for measles vaccination and revaccination of all children who are initially immunized at an age of less than 15 months.

Subacute sclerosing panencephalitis and acquired immunodeficiency syndrome: role of electroencephalography and magnetic resonance imaging

Subacute sclerosing panencephalitis (SSPE) had largely disappeared from the United States because of nearly universal measles vaccination, but it has reemerged in children infected with human immunodeficiency virus (HIV). Two children with SSPE are described. The first was HIV positive and presented with seizures and encephalopathy at the age of 21 months. The second developed myoclonus and dementia at age 4 years; she was not infected with HIV, but her mother had acquired immunodeficiency syndrome. Magnetic resonance imaging findings were nonspecific and could have been compatible with HIV encephalopathy. Electroencephalography was characteristic of SSPE, showing high-voltage, periodic slow-wave complexes and background slowing. The diagnosis of SSPE was confirmed by brain biopsy or high measles antibody titers in the cerebrospinal fluid.