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Ciçek A, De Temmerman L, De Weweire M, De Backer H, Buyle M, Clement F. Thunderclap headache as a first manifestation of acute disseminated encephalomyelitis: case report and literature review. BMC Neurol 2024; 24:315. [PMID: 39232678 PMCID: PMC11373465 DOI: 10.1186/s12883-024-03803-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 08/12/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Acute Disseminated Encephalomyelitis (ADEM) is an acute demyelinating disorder of the central nervous system, characterize by multiple white matter hyperintensities on T2 MRI. Patients usually present with subacute progressive encephalopathy and polyfocal neurological deficits. Possible treatments are corticosteroids, immunoglobulins and plasma exchange. Full clinical recovery is seen in more than half of the cases. CASE We describe a case of a 62-year-old patient presenting with thunderclap headache as the first symptom, two weeks after an upper respiratory tract infection. The clinical course was complicated by progressive coma and intracranial hypertension mandating external ventricular drainage and sedation. Initial treatment with methylprednisolone was unsuccessful but clinical resolution and radiological regression was achieved after plasma exchanges and cyclophosphamide. CONCLUSION To our knowledge, this is the first reported case of ADEM presenting with thunderclap headache. Intracranial hypertension with the need for invasive neuromonitoring and pressure management is also a very rare complication of ADEM. In this report, we describe the findings of the literature review concerning ADEM, thunderclap headache and intracranial hypertension.
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Affiliation(s)
- Abdulhamid Ciçek
- Department of Neurology, Delta General Hospital, Roeselare, Belgium
- Department of Neurosurgery, Delta General Hospital, Roeselare, Belgium
| | | | - Mieke De Weweire
- Department of Neurology, Delta General Hospital, Roeselare, Belgium
| | - Hilde De Backer
- Department of Neurology, Delta General Hospital, Roeselare, Belgium
| | - Maarten Buyle
- Department of Neurology, Delta General Hospital, Roeselare, Belgium
| | - Frederik Clement
- Department of Neurology, Delta General Hospital, Roeselare, Belgium
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Czeisler BM. Emergent Management of Central Nervous System Demyelinating Disorders. Continuum (Minneap Minn) 2024; 30:781-817. [PMID: 38830071 DOI: 10.1212/con.0000000000001436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article reviews the various conditions that can present with acute and severe central nervous system demyelination, the broad differential diagnosis of these conditions, the most appropriate diagnostic workup, and the acute treatment regimens to be administered to help achieve the best possible patient outcomes. LATEST DEVELOPMENTS The discovery of anti-aquaporin 4 (AQP4) antibodies and anti-myelin oligodendrocyte glycoprotein (MOG) antibodies in the past two decades has revolutionized our understanding of acute demyelinating disorders, their evaluation, and their management. ESSENTIAL POINTS Demyelinating disorders comprise a large category of neurologic disorders seen by practicing neurologists. In the majority of cases, patients with these conditions do not require care in an intensive care unit. However, certain disorders may cause severe demyelination that necessitates intensive care unit admission because of numerous simultaneous multifocal lesions, tumefactive lesions, or lesions in certain brain locations that lead to acute severe neurologic dysfunction. Intensive care may be necessary for the management and prevention of complications for patients who have severely altered mental status, rapidly progressive neurologic worsening, elevated intracranial pressure, severe cerebral edema, status epilepticus, or respiratory failure.
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Nguyen L, Miles DK, Harder L, Singh S, Whittemore BA, Greenberg BM, Wang CX. Increased Intracranial Pressure in Pediatric Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200174. [PMID: 37918972 PMCID: PMC10621892 DOI: 10.1212/nxi.0000000000200174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/28/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Elevated intracranial pressure (ICP) in myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) has been largely unexplored. The objectives of this study were to determine the frequency of increased ICP in MOGAD and its association with disease course and outcomes and to highlight cases requiring medical and/or surgical management of increased ICP. METHODS In this retrospective, single-center cohort study, we examined the clinical and paraclinical data from the initial presentation and follow-up data of children diagnosed with MOGAD. In those with opening pressure (OP) measurements, univariate analyses were used to evaluate factors associated with increased ICP, which was defined as OP > 28 cm H2O. We also present a case series of patients with or without OP measurement who required medical and/or surgical management of increased ICP. RESULTS Of 86 children with MOGAD, 43 (50.0%) had an OP recorded and 7 (8.1%) required ICP management. In those with OP recorded, the median (interquartile range) OP for the different MOGAD phenotypes were: 30.0 (22.8-41.6) (acute disseminated encephalomyelitis, ADEM), 20.5 (16.1-23.6) (optic neuritis), 17.0 (17.0-22.5) (myelitis), and 19.5 (16.5-29.3) (other) cm H20. Overall, 20.9% had increased ICP based on an OP > 28 cm H2O, of whom 77.8% presented with ADEM. In a subgroup analysis of those presenting with ADEM, those with an elevated ICP had longer hospital stay (p = 0.007) and neurologic disability (defined as modified Rankin Scale >1) (p = 0.049). In those with or without OP recorded, 7 (6 with ADEM, one with cerebral cortical encephalitis) required ICP-directed therapies. Findings on brain MRI in these 7 children revealed extensive disease burden with bilateral cerebral involvement and evidence of restricted diffusion. While neuropsychological data in this small subset revealed significant variability, all sustained identifiable deficits after discharge, including attention-deficit hyperactivity disorders and language and learning disorders. DISCUSSION In pediatric MOGAD, increased OP and ADEM at initial presentation were associated with longer hospital stays and greater long-term morbidity. Although invasive ICP monitoring has not been specifically advocated in the management of MOGAD, it is important to recognize signs and symptoms of increased ICP in these patients and consider ICP monitoring and management strategies based on clinical and radiologic findings, especially in those presenting with ADEM and with OP > 28 cm H2O.
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Affiliation(s)
- Linda Nguyen
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas.
| | - Darryl K Miles
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas
| | - Lana Harder
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas
| | - Sumit Singh
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas
| | - Brett A Whittemore
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas
| | - Benjamin M Greenberg
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas
| | - Cynthia X Wang
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas
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Fainberg NA, Silver MR, Arena JD, Landzberg EI, Banwell B, Gambrah-Lyles C, Kirschen MP, Madsen PJ, McLendon L, Narula S, Tucker AM, Huh JW, Kienzle MF. Invasive Multimodality Neuromonitoring to Manage Cerebral Edema in Pediatric Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease. Crit Care Explor 2023; 5:e1003. [PMID: 37929184 PMCID: PMC10624473 DOI: 10.1097/cce.0000000000001003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an inflammatory disorder of the CNS with a variety of clinical manifestations, including cerebral edema. Case Summary A 7-year-old boy presented with headaches, nausea, and somnolence. He was found to have cerebral edema that progressed to brainstem herniation. Invasive multimodality neuromonitoring was initiated to guide management of intracranial hypertension and cerebral hypoxia while he received empiric therapies for neuroinflammation. Workup revealed serum myelin oligodendrocyte glycoprotein antibodies. He survived with a favorable neurologic outcome. Conclusion We describe a child who presented with cerebral edema and was ultimately diagnosed with MOGAD. Much of his management was guided using data from invasive multimodality neuromonitoring. Invasive multimodality neuromonitoring may have utility in managing life-threatening cerebral edema due to neuroinflammation.
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Affiliation(s)
- Nina A Fainberg
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Maya R Silver
- Division of Child Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - John D Arena
- Division of Neurosurgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Elizabeth I Landzberg
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Brenda Banwell
- Division of Child Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Claudia Gambrah-Lyles
- Division of Child Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew P Kirschen
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Division of Child Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Peter J Madsen
- Division of Neurosurgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Loren McLendon
- Division of Child and Adolescent Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL
- Division of Pediatric Neurology, Nemours Children's Health, Jacksonville, FL
| | - Sona Narula
- Division of Child Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alexander M Tucker
- Division of Neurosurgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jimmy W Huh
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Martha F Kienzle
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Azab MA. Neurosurgical intervention in an unusual case of extensive acute disseminated encephalomyelitis - A case report and literature review. Surg Neurol Int 2023; 14:176. [PMID: 37292401 PMCID: PMC10246339 DOI: 10.25259/sni_367_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/03/2023] [Indexed: 06/10/2023] Open
Abstract
Background The clinical presentations of demyelinating diseases are variable and can range from mild symptoms to fulminant presentations. Acute disseminated encephalomyelitis is one of those diseases which usually follow an infection or vaccination. Case Description We report a case of extensive acute demyelinating encephalomyelitis (ADEM) with massive brain swelling. A 45-year-old female presented to the emergency room with status epilepticus. Patient has no history of any associated medical problems. Glasgow coma scale (GCS) was 15/15. CT brain was normal. Lumbar puncture was done and cerebrospinal fluid showed pleocytosis and increased protein content. About 2 days after admission, the conscious level rapidly deteriorated and GCS was 3/15, with the right pupil fully dilated and unreactive to light. Computed tomography and magnetic resonance imaging brain were done. We performed an urgent decompressive craniectomy as a life-saving procedure. Histopathological examination was suggestive of ADEM. Conclusion Few cases of ADEM with brain swelling were reported, but there is no solid consensus about the appropriate management of these cases. Decompressive hemicraniectomy is a possible choice, but further research is needed to evaluate the proper timing, and indication of surgery.
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Affiliation(s)
- Mohammed A Azab
- Corresponding author: Mohammed A Azab, Department of Biomedical Sciences, Boise State University, Boise, United States.
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Liminga G, Grabowska A, Pétursdóttir D, Cesarini KG, Rostami E, Ehrstedt C. Acute disseminated encephalomyelitis with delayed onset and feasibility of the Miethke shunt and sensor reservoir system: a case report. Childs Nerv Syst 2021; 37:3891-3895. [PMID: 34136944 PMCID: PMC8604833 DOI: 10.1007/s00381-021-05188-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/25/2021] [Indexed: 11/30/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is an immune-mediated demyelinating central nervous system disorder with predilection for early childhood. Delayed onset of ADEM is rare, and herein we present a previously healthy 5-year-old boy, with an unusual clinical course of ADEM with high intracranial pressure (ICP) and acute visual loss that was at first diagnosed as idiopathic intracranial hypertension without papilledema (IIHWOP). The boy underwent acute neurosurgical intervention with ventriculoperitoneal (VP) shunt using Miethke valve and sensor reservoir system and received high-dose steroid treatment with symptom relieve within days. This is the first case report using this system in such a young child, and we find it feasible and valuable also in younger children when VP shunt with ICP measurement is indicated.
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Affiliation(s)
- Gunnar Liminga
- Department of Women’s and Children’s Health, Uppsala University , Uppsala, Sweden
| | - Anna Grabowska
- Department of Surgical Sciences, Radiology, Uppsala University, Uppsala, Sweden
| | | | | | - Elham Rostami
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden ,Department of Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Christoffer Ehrstedt
- Department of Women's and Children's Health, Uppsala University , Uppsala, Sweden.
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Algahtani H, Shirah B, Alassiri A, Algahtani S. Decompressive craniectomy as a lifesaving intervention for acute disseminated encephalomyelitis (ADEM). Mult Scler Relat Disord 2020; 47:102612. [PMID: 33161197 DOI: 10.1016/j.msard.2020.102612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/31/2020] [Accepted: 11/01/2020] [Indexed: 11/17/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM), is an immune-mediated demyelinating disease of the central nervous system that commonly affects children and young adults of both sexes. Hyperacute variants of ADEM represent 2% of cases and are associated with rapid progression of symptoms, malignant brain edema, and high mortality rates. We report a case of a young woman presenting with a hyperacute storming course of few days who was managed with pulse steroid therapy and emergency craniectomy with an excellent outcome. We believe that our patient's acute clinical deterioration and findings on neuroimaging warranted prompt neurosurgery. Although treatment with immunomodulatory medications was commenced, the severity of her condition indicated that only surgical intervention was likely to be lifesaving. We recommend immediate neurosurgical consultation to consider prompt decompressive craniectomy in hyperacute variants with significant brain swelling. Multidisciplinary care including neurologist, neuroradiologist, neurosurgeon, neuropathologist, and neurointensivist is the only way to achieve success and improve survival in patients presenting with hyperacute ADEM.
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Affiliation(s)
- Hussein Algahtani
- King Abdulaziz Medical City / King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.
| | - Bader Shirah
- King Abdullah International Medical Research Center / King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ali Alassiri
- King Abdulaziz Medical City / King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Shah AS, Yahanda AT, Loftspring MC, Osbun JW. Acute disseminated encephalomyelitis associated with a novel paraneoplastic process in hepatic epithelial hemangioendothelioma: A case report. Clin Neurol Neurosurg 2020; 194:105903. [PMID: 32447206 DOI: 10.1016/j.clineuro.2020.105903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 05/03/2020] [Accepted: 05/06/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Amar S Shah
- Department of Neurosurgery, Washington University School of Medicine, 660 South Euclid Ave, St. Louis, MO, 63110, USA.
| | - Alexander T Yahanda
- Department of Neurosurgery, Washington University School of Medicine, 660 South Euclid Ave, St. Louis, MO, 63110, USA.
| | - Matthew C Loftspring
- Department of Neurology Washington University School of Medicine, 660 South Euclid Ave, St. Louis, MO, 63110, USA.
| | - Joshua W Osbun
- Department of Neurosurgery, Washington University School of Medicine, 660 South Euclid Ave, St. Louis, MO, 63110, USA.
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Liu M, Zhong J. Mechanism underlying cranial nerve rhizopathy. Med Hypotheses 2020; 142:109801. [PMID: 32413700 DOI: 10.1016/j.mehy.2020.109801] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/09/2020] [Accepted: 05/02/2020] [Indexed: 12/27/2022]
Abstract
The cranial nerve rhizophathy, commonly presented with trigeminal neuralgia (TN) or hemifacial spasm (HFS), is a sort of hyperexcitability disorders with higher incidence in senior Asian. In this paper, a novel hypothesis on the pathogenesis is proposed and with which some clinical phenomena are explained. In those with crowded cerebellopontine angle in anatomy, the cranial nerve root and surrounding vessel are getting closer and closer to each other with aging and finally the neurovascular conflict happens. As the interfacial friction associated with pulse, the nerve incurs demyelination. Since this pathological change develops to a certain degree, some transmembrane proteins emerge from the nerve due to a series of signaling pathway mediated by inflammatory cytokines. Among them, voltage-gated (Nav1.3) and mechanosensitive (Piezo2) ion channels may play the important role. With pulsatile compressions, the Piezo2 drives the resting potential toward depolarization forming a state of subthreshold membrane potential oscillation. Under this condition, just an appropriate pressure can make the membrane potential easy to reach threshold and activate the sodium channel, eventually generating conductible action potentials from the axon. When these ectopic action potentials propagate to the central nerve system, an illusion of sharp pain is perceived; while to the nerve-muscle junctions, an attack of irregular muscle constriction occurs. This hypothesis can well explain the symptomatic manifestation of paroxysmal attacks aroused by emotions. When we get nervous or excited, our heart rate and blood pressure alter correspondingly, which may give rise to "a just right pressure" - with specific frequency, amplitude and angle - impacting the suffered nerve to reach the threshold of impulse ignition. After a successful microvascular decompression surgery, the trigger is gone (there is no compression anymore) and the symptom is alleviated. While the postoperative recurrence could be attributable to Teflon granuloma development if had been placed improperly - for this nerve root has been susceptible no matter to arteries or to neoplasms. Besides, it may illustrate the clinical phenomenon that secondary TN or HFS cases are seldom caused by schwannoma: with a proliferative sheath, the nerve root is actually insulated. By contrast, not all neurovascular contacts can lead to the onset: it demands an exclusive extent of demyelination firstly.
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Affiliation(s)
- Mingxing Liu
- Dept. Neurosurgery, QingDao Municipal Hospital, No.1 Jiaozhou Rd., Qingdao 266000, China.
| | - Jun Zhong
- Dept. Neurosurgery, XinHua Hospital, Shanghai JiaoTong University School of Medicine, 1665 KongJiang Rd., Shanghai 200092, China.
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Orbach R, Schneebaum Sender N, Lubetzky R, Fattal-Valevski A. Increased Intracranial Pressure in Acute Disseminated Encephalomyelitis. J Child Neurol 2019; 34:99-103. [PMID: 30477374 DOI: 10.1177/0883073818811541] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the intracranial pressure in pediatric acute disseminated encephalomyelitis using spinal tap opening pressure on lumbar puncture, which is routinely performed as part of suspected acute disseminated encephalomyelitis workup. Compared to other cerebrospinal fluid parameters such as cell count, protein concentration, and presence of oligoclonal bands, cerebrospinal fluid opening pressure is infrequently recorded. METHODS A retrospective chart review of demographic, clinical, and laboratory data of children diagnosed with acute disseminated encephalomyelitis admitted to a tertiary referral hospital between 2005 and 2016. RESULTS Of the 36 children diagnosed with acute disseminated encephalomyelitis, 24 had the cerebrospinal fluid opening pressure documented in their records. The mean cerebrospinal fluid opening pressure was 27.6±12.6 cmH2O, range 9-55 cmH2O (95% confidence interval 21.9-33.6). Cerebrospinal fluid opening pressure in the acute disseminated encephalomyelitis group was statistically significantly higher ( P = .0013, 95% confidence interval 4.2-15.0) than the accepted upper limit in this age group (18 cmH2O). In 10 of 24 patients (42%), the opening pressure was above 28 cmH2O. CONCLUSIONS Increased opening pressure was the most frequent cerebrospinal fluid abnormal finding in our cohort, which suggests a potential role of increased intracranial pressure in the acute disseminated encephalomyelitis pathophysiological disease mechanism. In certain cases, the opening pressure value could have monitoring and therapeutic implications, and therefore its measurement is highlighted by this study.
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Affiliation(s)
- Rotem Orbach
- 1 Pediatrics Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,2 Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Nira Schneebaum Sender
- 3 Pediatric Neurology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ronit Lubetzky
- 1 Pediatrics Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,2 Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Aviva Fattal-Valevski
- 2 Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel.,3 Pediatric Neurology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Honeybul S, Ho KM, Gillett GR. Reconsidering the role of decompressive craniectomy for neurological emergencies. J Crit Care 2017; 39:185-189. [PMID: 28285834 DOI: 10.1016/j.jcrc.2017.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/14/2017] [Accepted: 03/06/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE There is little doubt that decompressive craniectomy can reduce mortality. However, there is concern that any reduction in mortality comes at an increase in the number of survivors with severe neurological disability. METHOD Over the past decade there have been several randomised controlled trials comparing surgical decompression with standard medical therapy in the context of ischaemic stroke and severe traumatic brain injury. The results of each trial are evaluated. RESULTS There is now unequivocal evidence that a decompressive craniectomy reduces mortality in the context of "malignant" middle infarction and following severe traumatic brain injury. However, it has only been possible to demonstrate an improvement in outcome by categorizing a mRS of 4 and upper severe disability as favourable outcome. This is contentious and an alternative interpretation is that surgical decompression reduces mortality but exposes a patient to a greater risk of survival with severe disability. CONCLUSION It would appear unlikely that further randomised controlled trials will be possible given the significant reduction in mortality achieved by surgical decompression. It may be that observational cohort studies and outcome prediction models may provide data to determine those patients most likely to benefit from surgical decompression.
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Affiliation(s)
- S Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Western Australia, Australia.
| | - K M Ho
- Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Australia
| | - G R Gillett
- Dunedin Hospital and Otago Bioethics Centre, University of Otago, Dunedin, New Zealand
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12
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The diagnosis and surgical treatment of central brain herniations caused by traumatic bifrontal contusions. J Craniofac Surg 2014; 25:2105-8. [PMID: 25304144 DOI: 10.1097/scs.0000000000001050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
The objective of this study was to investigate the diagnosis and surgical treatment of central brain herniations caused by traumatic bifrontal contusions. A total of 63 patients (45 men and 18 women; mean age of 43 years with a range from 20 to 72 years) who suffered from traumatic bifrontal contusions between January 2007 and December 2012 were inspected. The clinical and imaging results were studied for all patients, and we found that swelling of the mesencephalon and a downward shift of the bilateral red nucleus were significant signs of central brain herniation in the image of magnetic resonance imaging. All patients were given a simultaneous bilateral craniotomy for balanced decompressive surgery. The Glasgow Outcome Scale was used to monitor the patients during the follow-up period, which lasted from 6 to 52 months with a mean of 22 months. At the termination of the follow-up period, the following Glasgow Outcome Scale scores were obtained: 14 patients scored 5 points, 22 patients scored 4 points, 7 patients scored 3 points, 13 patients scored 2 points, and 7 patients scored 1 point. Therefore, our study suggested that an early magnetic resonance imaging scan could result in a more timely diagnosis of central brain herniation, and simultaneous bilateral craniotomy was found to be one of the best treatments for central brain herniation to improve patient outcomes.
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Spencer D, Vela-Duarte D, Sandrian M, Bonwit AW, Schnitzler E, Prabhu VC. Fulminant acute disseminated encephalomyelitis in renal transplant patient treated by decompressive craniectomy: a case report. ACTA ACUST UNITED AC 2014. [DOI: 10.7243/2052-6946-2-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013; 27:979-91. [DOI: 10.3109/02699052.2013.794974] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
OPINION STATEMENT Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease, characterized by an acute onset of polyfocal central nervous system (CNS) deficits, including encephalopathy, demonstrating multifocal lesions on MRI. ADEM is typically a monophasic disorder, but recurrent and multiphasic courses have been described. Furthermore, an ADEM presentation has been reported in neuromyelitis optica (NMO) and multiple sclerosis (MS), particularly in younger children. CNS infections, other autoimmune diseases, and neurometabolic disorders may mimic ADEM at manifestation. There is no single test confirming the diagnosis of ADEM, and diagnosis is based upon a combination of clinical and radiologic features and exclusion of diseases that resemble ADEM. Therefore, a broad workup including infectious, immunologic, and metabolic tests, as well as a systematic follow-up including MRI, is indicated to establish an accurate diagnosis as a prerequisite for an optimized treatment approach. There is a lack of evidence-based, prospective clinical trial data for the management of ADEM. Empiric antibacterial and antiviral treatment is standard of care until an infectious disease process is ruled out. Based on the presumed autoimmune etiology of ADEM, the common treatment approach consists of intravenous methylprednisolone at a dosage of 20 to 30 mg/kg per day (maximum 1 g/day) for 3 to 5 days, followed by an oral corticosteroid taper of 4 to 6 weeks. In case of insufficient response or contraindications to corticosteroids, intravenous immunoglobulin G (IVIG) at a dosage of 2 g/kg divided over 2 to 5 days is a therapeutic option. For severe or life-threatening cases of ADEM, plasmapheresis should be considered early in the disease course. Decompressive craniectomy has been reported as a life-saving measure for ADEM patients with intracranial hypertension. There is a lack of specific recommendations for the long-term management of recurrent and multiphasic ADEM. In children with relapsing demyelinating events, the diagnosis of a chronic autoimmune CNS disease like MS or NMO should be considered.
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Affiliation(s)
- Daniela Pohl
- Department of Neurology, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada,
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Pérez-Bovet J, Garcia-Armengol R, Buxó-Pujolràs M, Lorite-Díaz N, Narváez-Martínez Y, Caro-Cardera JL, Rimbau-Muñoz J, Joly-Torta MC, Castellví-Joan M, Martín-Ferrer S. Decompressive craniectomy for encephalitis with brain herniation: case report and review of the literature. Acta Neurochir (Wien) 2012; 154:1717-24. [PMID: 22543444 DOI: 10.1007/s00701-012-1323-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 03/07/2012] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Jordi Pérez-Bovet
- Neurosurgery Department, Universitary Hospital Dr. Josep Trueta, Carretera de França S/N, 17007, Girona, Girona, Spain.
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VanLandingham M, Hanigan W, Vedanarayanan V, Fratkin J. An uncommon illness with a rare presentation: neurosurgical management of ADEM with tumefactive demyelination in children. Childs Nerv Syst 2010; 26:655-61. [PMID: 19949803 DOI: 10.1007/s00381-009-1045-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE This study determined the statewide incidence and prevalence of acute disseminated encephalomyelitis (ADEM) and examined the course of three pediatric patients treated for tumefactive demyelination (TD) at the Blair E. Batson Children's Hospital. METHODS Analyses of ICD-9-CM code hospital records and clinical database were conducted. RESULTS From 2001 through 2007 the incidence in pediatric patients under 20 years was 0.4/100,000/year, with a prevalence of 8.6/100,000 during 2008. Three patients presented with TD. Case 1 had a 3-week history of ataxia and diplopia; case 2 presented with a sudden onset of coma, while the third child had a 4-month history of increasing lethargy and clumsiness in all extremities. Cerebrospinal fluid examinations were nondiagnostic. MRI examinations revealed asymmetric T2/fluid-attenuated inversion recovery hyperintensity within the pons (case 1), a large heterogenously enhancing temporal lobe mass, with extensive edema (case 2), and multiple small brain lesions with occasional ring enhancement (case 3). In case 1, intralesional MR spectroscopy demonstrated changes consistent with ADEM. Case 2 required intracranial monitoring, and medical treatment to control elevated ICP. Cases 2 and 3 underwent cortical biopsies that revealed ADEM. All three patients improved with corticosteroid therapy. At a minimum of 15 months follow-up, cases 1 and 2 showed resolution of deficits and MRI lesions, while the third patient demonstrated additional MRI lesions and increasing paraparesis. CONCLUSIONS These cases demonstrate that appropriate neuroradiological evaluation, treatment of acutely elevated ICP, and brain biopsy can play critical roles in the management of children with undiagnosed ADEM and TD.
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Affiliation(s)
- Matthew VanLandingham
- Department of Neurosurgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505, USA
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Sonneville R, Klein I, de Broucker T, Wolff M. Post-infectious encephalitis in adults: diagnosis and management. J Infect 2009; 58:321-8. [PMID: 19368974 PMCID: PMC7125543 DOI: 10.1016/j.jinf.2009.02.011] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2008] [Revised: 02/18/2009] [Accepted: 02/22/2009] [Indexed: 11/25/2022]
Abstract
Many important central nervous system (CNS) syndromes can develop following microbial infections. The most severe forms of post-infectious encephalitis include acute disseminated encephalomyelitis (ADEM), acute hemorrhagic leukoencephalitis and Bickerstaff's brainstem encephalitis. ADEM is an inflammatory demyelinating disorder of the CNS. It typically follows a minor infection with a 2–30 days latency period and is thought to be immune-mediated. It is clinically characterized by the acute onset of focal neurological signs and encephalopathy. Patients can require intensive care unit admission because of coma, seizures or tetraplegia. Cerebrospinal fluid analysis usually shows lymphocytic pleocytosis but, unlike viral or bacterial encephalitis, no evidence of direct CNS infection is found. There are no biologic markers of the disease and cerebral magnetic resonance imaging is essential to diagnosis, detecting diffuse or multifocal asymmetrical lesions throughout the white matter on T2- and FLAIR-weighted sequences. High-dose intravenous steroids are accepted as first-line therapy and beneficial effects of plasma exchanges and intravenous immunoglobulins have also been reported. Outcome of ADEM is usually favorable but recurrent or multiphasic forms have been described.
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Affiliation(s)
- R Sonneville
- Department of Critical Care Medicine and Infectious Diseases, Bichat-Claude Bernard Hospital, Université Paris 7, 46 Rue Henri Huchard, 75877 Paris Cedex 18, France.
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Abstract
L’encéphalomyélite aiguë disséminée, acute disseminated encephalomyelitis, (ADEM), est une maladie inflammatoire démyélinisante du système nerveux central (SNC). Également appelée encéphalite post-infectieuse, elle est liée à un mécanisme auto-immun et s’installe typiquement dans les suites d’une infection après un intervalle libre de deux à 30 jours. L’ADEM est caractérisée cliniquement par un tableau d’encéphalopathie aiguë avec signes neurologiques multifocaux. Les patients peuvent nécessiter une admission en réanimation du fait de troubles de la conscience, de crises convulsives ou d’une tétraplégie. L’analyse du liquide céphalorachidien peut montrer une méningite lymphocytaire, mais on ne retrouve pas d’infection évolutive du SNC. Il n’existe pas de marqueur spécifique de la maladie et l’imagerie par résonance magnétique cérébrale est essentielle au diagnostic, permettant de mettre en évidence des lésions multifocales de la substance blanche du SNC sur les séquences T2 et FLAIR. Le traitement de l’ADEM est basé sur les corticoïdes fortes doses, éventuellement associés aux immunoglobulines polyvalentes ou aux échanges plasmatiques. Le pronostic est généralement favorable sous traitement, des récurrences peuvent néanmoins survenir dans l’évolution.
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