Acute haemorrhagic leucoencephalitis with a prolonged clinical course

Decompressive craniectomy for encephalitis with brain herniation: case report and review of the literature

BACKGROUND

Decompressive craniectomy (DC) has been sporadically used in cases of infectious encephalitis with brain herniation. Like for other indications of DC, evidence is lacking regarding the beneficial or detrimental effects for this pathology.

METHODS

We reviewed all the cases of viral and bacterial encephalitis treated with decompressive craniectomy reported in the literature. We also present one case from our institution. These data were analyzed to determine the relation between clinical and epidemiological variables and outcome in surgically treated patients.

RESULTS

Of 48 patients, 39 (81.25 %) had a favorable functional recovery and 9 (18.75 %) had a negative course. Only two patients (4 %) died after surgical treatment. A statistically significant association was found between diagnosis (viral and bacterial encephalitis) and outcome (GOS) in surgically treated patients. Viral encephalitis, usually caused by herpes simplex virus (HSV), has a more favorable outcome (92.3 % with GOS 4 or 5) than bacterial encephalitis (56.2 % with GOS 4 or 5).

CONCLUSIONS

Based on this literature review, we consider that, due to the specific characteristics of infectious encephalitis, especially in case of viral infection, decompressive craniectomy is probably an effective treatment when brain stem compression threatens the course of the disease. In patients with viral encephalitis, better prognosis can be expected when surgical decompression is used than when only medical treatment is provided.

Encefalomielite acuta disseminata

L’encefalomielite acuta disseminata (EMAD) è una malattia infiammatoria autoimmune che coinvolge il cervello e il midollo spinale. Descritta soprattutto nel bambino, generalmente fa seguito a un episodio infettivo o a una vaccinazione, ma può essere idiopatica. La sua presentazione clinica comprende un’encefalopatia acuta associata a segni e a sintomi neurologici multifocali. La sua diagnosi si basa sulla clinica e sulla risonanza magnetica, che rivela lesioni multifocali della sostanza bianca in ipersegnale T2 mal delimitate, della stessa età, che prendono il gadolinio e possono anche riguardare il talamo e i nuclei della base. Il liquor può mostrare un’iperlinfocitosi con iperproteinorrachia e, a volte, la presenza di bande oligoclonali transitorie. La sua prognosi è piuttosto favorevole, passato l’episodio monofasico, con un trattamento specifico. È quindi fondamentale escludere fino dall’inizio le sue molte diagnosi differenziali. Il trattamento dell’EMAD, di prima scelta, consiste in boli di corticosteroidi endovenosi a forti dosi. In caso di insuccesso bisogna ricorrere agli scambi plasmatici o alle immunoglobuline endovenose. Anche se, di solito, è monofasica, possono verificarsi altri episodi che fanno allora pensare a un’EMAD multifasica. Tuttavia, in alcuni casi queste nuove poussées sono una modalità di esordio di un’autentica sclerosi multipla.

Acute hemorrhagic demyelination in a murine model of multiple sclerosis

Acute hemorrhagic leukoencephalomyelitis (AHLE) is a rare neurological condition characterized by the development of acute hemorrhagic demyelination and high mortality. The pathomechanism of AHLE, as well as potential therapeutic approaches, have remained elusive due to the lack of suitable animal models. We report the first murine model of AHLE using a variation of the Theiler's Murine Encephalitis Virus (TMEV) MS model. During acute TMEV infection, C57BL/6 mice do not normally undergo demyelination. However, when 7 day TMEV infected C57BL/6 mice are intravenously administered the immunodominant CD8 T cell peptide, VP2_121–130, animals develop characteristics of human AHLE based on pathologic, MRI and clinical features including microhemorrhages, increased blood-brain barrier permeability, and demyelination. The animals also develop severe disability as assessed using the rotarod assay. This study demonstrates the development of hemorrhagic demyelination in TMEV infected C57BL/6 mice within 24 hours of inducing this condition through intravenous administration of CD8 T cell restricted peptide. This study is also the first demonstration of rapid demyelination in a TMEV resistant non-demyelinating strain without transgenic alterations or pharmacologically induced immunosuppression.

Acute hemorrhagic leukoencephalitis mimicking herpes simplex encephalitis: case report

Acute hemorrhagic leukoencephalitis (AHLE) is a more severe form of acute disseminated encephalomyelities (ADEM) characterized by a fulminant clinical course and the presence of hemorrhagic necrosis of the white matter. We report the case of a 57-year-old woman who developed delirium following a respiratory infection. Magnetic resonance imaging of the brain disclosed signal abnormalities in the frontal and temporal lobes, usually found in herpes simplex encephalitis (HSE). Gram stain, India ink and acid-fast bacilli staining were all negative in CSF as was a polymerase chain reaction (PCR) for herpes simplex virus. A diagnosis of AHLE was made and the patient was treated with IV methylprednisolone 1g/day for 5 days. Despite treatment, the patient developed several neurological sequelae compatible with the severity of her illness.

Acute hemorrhagic leukoencephalitis in male sibs

Male siblings developed acute hemorrhagic leukoencephalitis (AHL) at age five months and eight months, respectively. This rare condition has not been reported in individuals less than two years of age or with a recurrence in the family. The diagnosis was based on neuropathologic features after ruling out potentially mimicking conditions. Genetic counseling of early onset AHL should include the possibility of recurrence in siblings.