Acute encephalopathies

/encephalitis

Prof Deepthi Samarage

 Presenting features
Acute
 reduction in level of consciousness
 seizures
 fever, vomiting, lethargy, and headache.
 abnormal behavior
Sub acute /chronic
 personality or behaviour changes
 deterioration in cognitive functioning,
 developmental regression
 Causes of encepalitis/encephalopathy

 Infections
• Encephalitis-/Menigo encephalitis
Viral – direct invasion
– Herpes Simplex Virus ( HSV)
– Japanese encephalitis ( JE)
– Entero viruses
• Intra cerebral abscess
• Viral – Post infectious –
• ADEM-
Varicella & Measles, EBV
Other rare organisms
• Mycoplasma, borrelia
• Bacterial – meningo encephalitis
 Presenting features
Sub acute /chronic
 personality or behaviour changes
 deterioration in cognitive functioning,
 developmental regression

SSPE – following measles

 Causes of encepalitis/encephalopathy

 Trauma
• Accidental
• Non-accidental
 Intracranial h’age
 Toxins
• Drugs
• Heavy metal poisoning- Pb
 Causes of encepalitis/encephalopathy

 Metabolic
• Liver failure
• Uraemia
• Hyper/hypoglycaemia
 Hypertensive enecphalopathy
 Reye syndrome- hyperammonaemia+ fatty liver
 Autoimmune encephalitis
– N-methyl-D-aspartate receptor antibody encephalitis
 Causes of encepalitis/encephalopathy

 Seizure related
• Status epilepticus
• Epileptic encephalopathy
 Malignancy
• Primary brain tumour
• Metastatic disease
It is important to obtain a detail history
detail history
 child's pre-existing neurological status
 development
 past medical history
 birth history.
 timing and nature of the deterioration,
 any recent febrile illnesses,
 symptoms of headache, vomiting and/or diarrhoea and a history
of seizures
 drug/toxin ingestion
 social history – NAI
 Household exposure to pb
 Immunization status
 Examination

Initial assesment
A- Air way
B- Breathing
C- Circulation
D- Disability – neurological status
E- Exposure- purpuric rash
 Examination

Neurological status
Rapid assessment – AVPU
A- Alert
V-Voice
P-Reponds to pain
U unresponsive
 Neurological status

More detail – Glasgow Coma Scale Children 1-15

 Eye opening- 1-4

 Best Motor responses 1-6

 Best verbal response 1-5

 Examination

Other signs

 Pupils – pin point opitates/ pontine lesions

dilated anticholinergic drugs/OP
poisoning
unilateral- tumors/herniation
Small or pinpoint
reactive pupils

?
Bilateral fixed
dilated pupils
Third nerve
lesion

Unilateral dilated
pupil
Small or pinpoint
reactive pupils

Bilateral fixed
dilated pupils
Third nerve
lesion

Unilateral dilated
pupil
Small or pinpoint
reactive pupils

?
Bilateral fixed
dilated pupils Narcotic /
organophosphate
ingestions

Unilateral dilated
pupil Third nerve
lesion
Small or pinpoint
reactive pupils

Bilateral fixed
dilated pupils Narcotic /
organophosphate
ingestions

Unilateral dilated
pupil Third nerve
lesion
Small or pinpoint
Narcotic /
reactive pupils
organophosphate
ingestions

?
Bilateral fixed
dilated pupils
Hypothermia

Unilateral dilated
pupil Third nerve
lesion
Small or pinpoint
Narcotic /
reactive pupils
organophosphate
ingestions

Bilateral fixed
dilated pupils
Hypothermia

Unilateral dilated
pupil Third nerve
lesion
Small or pinpoint
Narcotic /
reactive pupils
organophosphate
ingestions

?
Bilateral fixed
dilated pupils Hypothermia
Tentorial
herniation

Unilateral dilated
pupil Third nerve
lesion
Small or pinpoint
Narcotic /
reactive pupils
organophosphate
ingestions

Anticholinergic drugs

?
Bilateral fixed
dilated pupils Hypothermia
Tentorial
herniation

Unilateral dilated
pupil Third nerve
lesion
 Examination

Evidence for increased ICP

 Abnormal breathing
 Decorticate posture
 Decerbrate posture
 Bradycardia
 Hyper/hypotension
 papiloedema
abnormal postures
 Examination

Other signs
 Detail neurological examination – cranial nerve palsies ,
long tract signs, focal neurological signs
 Hepatomegaly
 Jaundice
 Investigations
 Capillary glucose and blood glucose
 Blood gas
 Urea and electrolytes
 Liver function tests
 Ammonia
 Full blood count and film
 Blood cultures
 Blood for virology
 Plasma to save (1–2 ml)
 Urine dipstick
 Urine to save (10 ml)
 CSF
 EEG
• generalised or focal slowing.
• focal changes and periodic lateralizing
epileptiform discharges in
herpes simplex virus encephalitis.
tumours
• Neuroimaging may be required if the child does not improve
as expected.

• CT pre/post contrast can diagnose complications of meningitis

(eg, hydrocephalus, abscess, infarction)

• In suspected encephalitis MRI is more sensitive.

 Treat the treatable

 Cefotaxime - If bacterial meningitis /

meningoencephalitis is suspected

 Acyclovir for herpes encephalitis

– presence of focal convulsions/focal neurological
– EEG changes focal
– MRI changes focal necrotic encehalitis
– CSF – presence of red cells in an untraumatic LP
 Treat the treatable
 Hypoglycaemia

 Hyperglycaemia/ DKA

 Poisoning – antidotes
 Treatment
 neuroprotective strategies
 nursing with head in midline
 elevate the head 20°
 maintaining normocapnea.
 maintaing normothermia

 treatment of raised intracranial pressure

hypertonic saline is more effective than mannitol
3% Nacl 3-5 ml/Kg

 Fluid restriction
 Treatment

Other measures
 Control seizures

 Nutrition / fluid / electrolyte / acid base balance,

normoglycaemia

 Monitoring- GSCS

 Nursing an unconscious child

 Prognosis

Variable

• May have complete recovery if mild

• May have severe neurological sequels such as

cerebral palsy , epilepsy, development delay

• May be fatal