Bilateral thalamic bleed and cerebral venous sinus thrombosis in Japanese encephalitis

Rare Causes of Cerebral Venus Sinus Thrombosis: A Systematic Review

Background: Cerebral venous sinus thrombosis (CVST) is a rare manifestation of thrombosis commonly caused by thrombophilia, hormonal-related factors, non-cerebral malignancy, and hematologic diseases. The aim of this review was to identify and summarize rare CVST cases. Methods: A literature search of the Medline database was performed in November 2022. CVST cases of a common cause were excluded. Demographic and clinical data were extracted. Eligible cases were categorized into inflammatory, primary CNS tumors, post-operative/traumatic, and idiopathic groups to allow statistical group comparisons. Results: 76 cases were analyzed. Idiopathic CVST was most frequently reported followed by inflammatory, post-traumatic/operative and primary CNS tumor causes. The intracranial hemorrhage rate was 23.7% and it was found to increase in the inflammatory group (45.8%). Anticoagulation was used in the majority of cases and it was significantly related to better outcomes. A low rate of anticoagulation use (43.8%) was found among CVST cases in the post-operative/traumatic group. The overall mortality rate was 9.8%. 82.4% of patients showed significant early improvement. Conclusions: Most rare CVST cases were either of idiopathic or inflammatory origin. Interestingly, hemorrhage occurred often he idiopathic CVST cases. A low rate of anticoagulation use in neurosurgical CVST cases after trauma or head surgery was observed.

Cerebral venous thrombosis in COVID-19

BACKGROUND AND AIMS

Initially, novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) was considered primarily a respiratory pathogen. However, with time it has behaved as a virus with the potential to cause multi-system involvement, including neurological manifestations. Cerebral venous sinus thrombosis (CVT) has increasingly been reported in association with coronavirus infectious disease of 2019 (COVID-19). Here, we have shed light upon CVT and its possible mechanisms in the backdrop of the ongoing COVID-19 pandemic.

METHODS

In this review, data were collected from PubMed, EMBASE and Web of Science, until March 30, 2021, using pre-specified searching strategies. The search strategy consisted of a variation of keywords of relevant medical subject headings and keywords, including "COVID-19", "SARS-CoV-2", "coronavirus", and "cerebral venous sinus thrombosis".

RESULTS

COVID-19 has a causal association with a plethora of neurological, neuropsychiatric and psychological effects. CVT has gained particular importance in this regard. The known hypercoagulable state in SARS-CoV-2 infection is thought to be the main mechanism in COVID-19 related CVT. Other plausible mechanisms may include vascular endothelial dysfunction and altered flow dynamics.

CONCLUSIONS

Although there are no specific clinical characteristics, insidious or acute onset headache, seizures, stroke-like, or encephalopathy symptoms in a patient with, or who has suffered COVID-19, should prompt the attending physician to investigate for CVT. The treatment of COVID-19 associated CVT does not differ radically from the therapy of CVT without the infection, i.e. urgent initiation of parenteral unfractionated heparin or low molecular weight heparin followed by conventional or mostly newer oral anticoagulants.

MRI Spectrum of Japanese Encephalitis in Northeast India: A Cross-Sectional Study

Objective  Japanese encephalitis (JE) is an arthropod-borne flavivirus infection having high mortality and morbidity. This study was performed to evaluate the conventional magnetic resonance imaging (MRI) findings in JE and to find out any difference between pediatric and adult JE.

Materials and Methods  This retrospective study was performed on serologically positive 54 JE patients presented to a tertiary care hospital with acute encephalitic symptoms between April 2016 and October 2019. Relevant neurological examination, cerebrospinal fluid analysis, and MRI scan of the brain were performed.

Results  Fifty-four JE patients ( n = 31 males and n = 23 females) having 32 pediatric and 22 adult JE were included in the study sample. Group 1 JE ( n = 16) patients had encephalitic symptoms with duration less than 15 days up to the day of MRI scan and group 2 JE ( n = 38) had symptoms more than 15 days. Group 1 JE had mean apparent diffusion coefficient (ADC) value of 0.563 ± 0.109 (standard deviation [SD]) × 10 ^–3 mm ² /sec and group 2 JE had 1.095 ± 0.206 (SD) × 10 ^–3 mm ² /sec. The mean ADC value of pediatric JE was 0.907 ± 0.336 (SD) × 10 ^–3 mm ² /sec and adult JE was 0.982 ± 0.253 (SD) × 10 ^–3 mm ² /sec.

Conclusion  The majority of the JE patient shows abnormal signal alterations in bilateral thalami and substantia nigra. Diffusion-weighted imaging with ADC mapping helps in evaluating the stage of the JE. No statistical significance of the various conventional MRI findings was found between the pediatric JE and adult JE.

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.

Severe Japanese encephalitis with multiple intracranial hemorrhages: A case report

RATIONALE

Intracranial hemorrhage occurs infrequently in Japanese encephalitis (JE), and even less frequently with hemorrhage occurring twice. In this report, we describe the clinical features and outcomes of a patient with confirmed JE combined with hemorrhage twice.

PATIENT CONCERNS

The patient, a 71-year-old Asian woman, was admitted to the hospital with symptoms of hemiplegia following fever and diarrhea. Soon her condition worsened and a decreased level of consciousness, respiratory failure, and paralysis of extremities occurred.The brain diffusion-weighted imaging sequence showed suspicious abnormal signals in bilateral thalami. Japanese encephalitis virus immunoglobulin M antibody was detected in her serum and cerebrospinal fluid samples, so the patient was diagnosed with JE. During treatment, her condition became aggravated and the brain computed tomography (CT) scan showed multiple lobar hemorrhages. One month later, the multiple lobar hemorrhages occurred again, as observed by a brain CT scan.

DIAGNOSIS

JE with multiple intracranial hemorrhages.

INTERVENTIONS

The patient was treated comprehensively, including surgery, lowering her intracranial pressure and ventilator-assisted breathing.

OUTCOMES

One month later, the patient underwent another surgical procedure for intracranial hemorrhage and suffered a serious neurological disorder.

LESSONS

Severe intracranial hemorrhage may occur in elderly patients with JE, especially in those with poor vascular condition. Therefore, when treating such patients, great caution, as well as early detection and prevention, should be taken in case of the occurrence of severe intracranial hemorrhage.

MR imaging of adult acute infectious encephalitis

BACKGROUND

Imaging is a key tool for the diagnosis of acute encephalitis. Brain CT scan must be urgently performed to rule out a brain lesion with mass effect that would contraindicate lumbar puncture. Brain MRI is less accessible than CT scan, but can provide crucial information with patients presenting with acute encephalitis.

METHOD

We performed a literature review on PubMed on April 1, 2015 with the search terms "MRI" and "encephalitis".

RESULTS

We first described the various brain MRI abnormalities associated with each pathogen of acute encephalitis (HSV, VZV, other viral agents targeting immunocompromised patients or travelers; tuberculosis, listeriosis, other less frequent bacterial agents). Then, we identified specific patterns of brain MRI abnomalies that may suggest a particular pathogen. Limbic encephalitis is highly suggestive of HSV; it also occurs less frequently in encephalitis due to HHV6, syphillis, Whipple's disease and HIV primary infection. Rhombencephalitis is suggestive of tuberculosis and listeriosis. Acute ischemic lesions can occur in patients presenting with severe bacterial encephalitis, tuberculosis, VZV encephalitis, syphilis, and fungal infections.

CONCLUSION

Brain MRI plays a crucial role in the diagnosis of acute encephalitis. It detects brain signal changes that reinforce the clinical suspicion of encephalitis, especially when the causative agent is not identified by lumbar puncture; it can suggest a particular pathogen based on the pattern of brain abnormalities and it rules out important differential diagnosis (vascular, tumoral or inflammatory causes).