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Presentation at PNU 2014
Citation preview
DIAGNOSTIC APPROACH TO ACUTE ENCEPHALOPATHY
IN CHILDREN
Dr Heng Hock SinPaediatric Neurologist
Sabah Women & Children’s Hospital
Paediatric Neurology Update 2014
Encephalopathy
A syndrome of global brain dysfunction
Definition [International Pediatric MS study Group 2007]: Behavioral change: confusion, excessive irritability
Alteration in consciousness: lethargy, coma
Acute or insidious onset
Encephalopathy
Full consciousness Death
Restless
Agitated
Confused
Delirious
Lethargic
Drowsy
Stuporous
Comatose
*Glasgow Coma Scale
Causes of Acute Encephalopathy
Davies E et.al. Encephalopathy in
children: an approach to assessment and
management. Arch Dis Child. 2012
May;97(5):452-8.
doi: 10.1136/adc.2011.300998. Epub
2011 Dec 27
Causes of Acute Encephalopathy
CNS infection /Para-infection
Autoimmune
Metabolic / Toxins
Seizure related
Hypertensive
Trauma / Haemorrhage
Hypoxic-ischaemic
Tumour / Malignancy
Hydrocephalus / Other causes of raised ICP
Acute Encephalopathy in Children
An important paediatric emergency
Involves children of any age
Previously normal children, or children with pre-existing neurological impairment
Acute Encephalopathy in Children
Associated with significant mortality & long-term morbidity in survivors
Good assessment with appropriate investigations identify treatable causes
minimize neurological impairment
Acute Encephalopathy
Wide range of differential diagnoses
long list of possible investigations
Clinical Assessment
History
Physical examination
Investigations
History
Timing & nature of the encepahlopathy
Associated symptoms
Fever, vomiting, loss of appetite
Headache, seizures
Current / recent febrile illness
In some cases, the cause is obvious
e.g. Acute renal / liver failure, DM, following head trauma or hypoxic event
History
Pre-existing medical / neurological condition
Developmental history
Travel, contact with animals / insects
Drug / toxin ingestion
Family history
Neurological / metabolic disorder; vascular / bleeding disorder
Parental consanguinity
Early / unexplained childhood deaths
Social history: Non-accidental injury
Examination
Opportunistic examination & observation
Vital signs: HR, BP, RR, SpO2, temperature
Mental state, communication, behaviour, orientation, memory e.t.c.
Examination
Neurological examination:
Focal neurological deficit
Motor & sensory
Cranial nerves & limbs
Eyes: nystagmus, ophthalmoplegia, pupils, fundoscopy
Abnormal movement
Examination of other systems
Investigations
Initial investigations
Blood glucose
Blood gases
Urea & electrolytes
LFT
Ammnonia
FBC & blood picture
Urine FEME
Prompt identification of treatable cause
Investigations
Further tests should be tailored to the differential diagnoses
Lumbar puncture: CNS infections
Neuro-imaging (Ultrasound, CT, MRI)
CNS infections / Para-infection
Suggestive features:
Fever , headache
Meningism
Focal neurological deficits
Seizures
Primary source of infection
Pneumonia (bacteria, mycoplasma, TB), purpuric rash (meningococcemia), mucosal herpetic lesions, cyanotic heart dis. (brain abscess)
CNS infection: Investigations
FBC, CRP, ESR
Blood culture
Viral study (blood, throat, urine, stool)
TB work-up
CSF: ME, sugar, protein, C&S, virology, TB, fungus
CNS infection: Neuro-imaging
CT with contrast: Bacterial meningitis: Subdural effusion, meningeal enhancement, abscess formation
CT with contrast: Brain abscess with ring enhancement
Neuro-imaging: TB meningitis
Plain CT: Hydrocephalus CT with contrast: Basal enhancement
Neuro-imaging: Herpes Encephalitis
MRI (T2): Bilateral asymmetric temporal, insular & basifrontal hyper-intensity
Neuro-imaging: Acute Disseminated Encephalomyelitis (ADEM)
MRI, T2 (Lt), FLAIR (Rt): Multiple hyper-intense foci involving the white matter & deep grey matter
Neuro-imaging: Acute NecrotisingEncephalopathy of Childhood (ANEC)
MRI (T2, FLAIR, DWI):Bilaterally symmetric signal change in the thalami
Neuro-imaging: Infantile Bilateral Striatal Necrosis (IBSN)
Plain CT: Bilaterally symmetric hypodensity of the caudate nuclei & putamen with mass effect
Autoimmune Encephalitis & Immune Related Encephalopathy
NMDA-receptor antibody encephalitis, limbic encephalitis, Hashimoto’s encephalopathy, CNS lupus e.t.c.
Suggestive features:
Prolonged course & fluctuating symptoms
unresponsive to anti-microbial drugs
No infectious agent identified
Specific movement disorders
Underlying immune disorder
Autoimmune Encephalitis & Immune Related Encephalopathy
Investigations:
Work-up for vasculitic disorders
Blood or CSF for specific neuronal antibodies:
Anti-NMDA receptor antibody
Anti-VGKC antibody e.t.c
Thyroid function, anti-thyroid antibodies
Intracranial Haemorrhage
Traumatic
Accidental
Non-accidental: Child abuse (Shaken baby syndrome)
Spontaneous
Vascular malformation
Bleeding disorder
Trauma / Intracranial Haemorrhage
Suggestive features:
History of head trauma
Sudden onset of encephalopathy ( + seizure) in a well child
Signs of acute blood loss: Pallor, tachycardia
History or family history of bleeding disorder
Non-accidental injury
Inconsistent / suspicious history, other suspicious body injuries, retinal haemorrhage, e.t.c.
Trauma / Intracranial Haemorrhage
Blocod count (platelet), coagulation profile
Neuro-imaging
Metabolic Disorders
Broad category of conditions
Suggestive features
History of development delay / regression, growth failure, epilepsy
Relapsing acute encephalopathy / septic-like episodes
Multi-organ impairment
Consanguineous parents, significant family history
Metabolic Disorders
Investigations
*Initial investigations
Metabolic work-up
Neuro-imaging, MR spectoscopy
MRI. Leigh syndrome: Bilateral symmetrical T2 high signal in caudate nuclei /putamen and white matter
Neuro-imaging: MELAS syndrome
(A) CT: Basal ganglia calcification. (B & C) MRI T2: Hyperintense lesion in the left temporo-parieto-occipital regions. (D) MRS: High lactate peak
Tumour / CNS Malignancy
Suggestive features
Signs & symptoms of raised ICP
Focal neurological deficit
Seizures
Extra-cranial primary malignancy
Neuro-imaging: 1st line investigation
Medulloblastoma Gliablastoma multiforme
Diffuse Intrinsic Brainstem Glioma
Acute Encephalopathy in Children
Case Illustration
Case 1
7 year old boy, previously well
Headache & lethargic for 3 days blurred vision, confusion, followed by status epilepticus
Intubated in district hospital, seizure was aborted with iv diazepam
Case 1
On arrival, sedated; pupils-equal & reactive; fundus- N; no focal neuro deficit
Noted hypertension but no bradycardia
Brain CT: Mild cerebral oedema
Wean off sedation but the child remained encephalopathic; Persistent hypertension
Case 1
Urine ME: RBC 5+
ASOT 800
Diagnosis:
Hypertensive encephalopathy secondary to
post-streptococcus acute gromerulo-nephritis (AGN)
Case 1
Brain MRI
Posterior Reversible Encephalopathy Syndrome
Case 2
11 yr old girl
Learning disability with history of recurrent stroke-like episodes & epilepsy
Diagnosed Mitochondrial Encephalopathy Lactic Acidosis Stroke-like episodes (MELAS) syndrome at 9 yr old, confirmed by gene mutation study
Case 2
Able to talk & walk independently
Activities of daily living: need supervision with some assistance
On anti-epileptic drug, occasional breakthrough seizures
Case 2
Presented with:
More frequent seizures, 1-2 episodes / day, for 3 days
Lost her verbal skills, not interactive
Poor head control, needed assistance in walking
Drooling of saliva
Urinary incontinence
Unable to eat
Case 3
Video EEG: Non-convulsive status epilepticus
Conclusions
Acute encephalopathy in children is an emergency with wide range of differential diagnoses; significant morbidity & mortality
A systematic approach is essential for early & accurate diagnosis to ensure appropriate & timely treatment
Thank You