Metronidazole-induced encephalopathy

We report the clinical, neuropsychological, and neuroimaging findings of two patients of diffuse encephalopathy associated with the use of metronidazole. Both patients showed characteristic abnormalities on magnetic resonance imaging (MRI) with diffusion weighted imaging (DWI) and recovered incompletely after the discontinuation of metronidazole. We also suggest that MRI with DWI may be useful in the diagnosis of metronidazole-induced encephalopathy, and that they have a role in the prediction of prognosis.     

Dialysis encephalopathy: a review

Dialysis encephalopathy (DE) is a distinct neuropsychiatric syndrome typically occurring in patients undergoing longterm hemodialysis. It is characterized by electroencephalographic abnormalities in association with disturbances of speech, cognition, movement, affect, or behavior. Previously thought to be relentlessly progressive, recent evidence linking the illness to aluminum overload has led to advances in prevention and treatment. Early diagnosis aids in the reversal or amelioration of the syndrome and can be of immense value to the patient, the family and involved health personnel. The general features of the syndrome, etiologic considerations, differential diagnosis and treatment are discussed. Three case studies are included to illustrate salient features of the syndrome.     

Binswanger's encephalopathy: a review

Summary Binswanger's encephalopathy is reviewed in respect to history, computed tomography, magnetic resonance imaging, epidemiology, pathology, clinical picture, laboratory findings, differential diagnosis, and treatment. The various viewpoints on the pathogenesis of the process are discussed, in particular the role of ischemia, vascular disease, high blood pressure, lacunar infarction, hypoxia, edema, and hydrocephalus. The white matter hypomyelination of congophilic angiopathy and Alzheimer's disease should provide clues. A unifying hypothesis has not been attained.Abbreviations AD Alzheimer's disease - BE Binswanger's encephalopathy - BP blood pressure - CA congophilic angiopathy - CSF cerebrospinal fluid - CT computed tomography - EEG electroencephalography - HU Hounsfield units - ISL incidental subcortical lesions - LD low density - MR magnetic resonance imaging - NPH normal pressure hydrocephalus - PV periventricular - PVH periventricular hyperintensity in MR, including capping and rimming - PVLD periventricular low density in CT - PVWM periventricular white matter - TIA transient ischemic attack - UBOs unidentified bright objects - U fibers arcuate fibers - WM white matter - WMHF white matter hyperintense foci in MR - WMLD white matter low density     

Hashimoto's encephalopathy: systematic review of the literature and an additional case

Hashimoto's encephalopathy, first described in 1966, is still problematic in terms of its pathophysiology, diagnosis, and treatment. The syndrome is more common in women, and is associated with autoimmune antithyroid antibodies. Presentation varies considerably; there may be episodes of cerebral ischemia, seizure, or psychosis, or there may be depression, cognitive decline, and periods of fluctuating consciousness. Because the symptoms respond so well to immunosuppressive treatment, prompt diagnosis and management are important. Here, the authors present a representative case report, along with a comprehensive review of current literature.     

Posterior reversible encephalopathy syndrome: a review

Encephalopathy due to reversible cerebral edema is an important cause of neurologic morbidity accompanying many disorders. Although controversy remains concerning the pathophysiologic trigger, the mechanism of this disorder ultimately depends on failure of the blood-brain barrier to maintain the compartmentalization of intravascular fluid. This failure of the blood-brain barrier depends primarily on the capillary hydrostatic pressure, under the influence of the systemic blood pressure, and on the integrity of the structures that make up the blood-brain barrier, most importantly the vascular endothelium, under the influence of various diseases and toxic medications. Although typical clinical contexts and presentations have been well defined, many patients have atypical features that pose a diagnostic challenge. Therefore, awareness of this clinical variability is important for prompt diagnosis. This review discusses the history and pathophysiology of posterior reversible encephalopathy syndrome and then addresses its clinical diagnosis and management.     

Metronidazole-induced encephalopathy and inferior olivary hypertrophy: lesion analysis with diffusion-weighted imaging and apparent diffusion coefficient maps

BACKGROUND: Although several cases of metronidazole-induced encephalopathy have been reported, to our knowledge, there is no previous report of brain changes in anterior commissure, basal ganglia, cerebellar white matter, and inferior olivary nuclei on magnetic resonance images. The precise mechanisms of action of metronidazole-induced encephalopathy have not been determined. OBJECTIVES: To report a unique case of metronidazole-induced encephalopathy extensively involving multiple lesions and to determine the precise mechanism of action of metronidazole-induced encephalopathy. SETTING: University hospital.Patient A 74-year-old woman hospitalized with complaints of progressive dysarthria, dysphagia, and gait disturbance 3 months after the initiation of metronidazole therapy.Intervention Brain magnetic resonance imaging and discontinuation of metronidazole therapy.Main Outcome Measure We observed changes of multiple lesions found on magnetic resonance imaging and analyzed apparent diffusion coefficient map values. RESULTS: Initial fluid-attenuated inversion recovery brain magnetic resonance images showed high signal intensities in diffuse subcortical white matter, anterior commissure, splenium, basal ganglia, midbrain, cerebellar white matter, and bilateral inferior olivary nuclei. These lesions were resolved after discontinuation of metronidazole therapy. However, the lesions in the inferior olivary nuclei were not resolved; rather they became hypertrophic. Apparent diffusion coefficient map values in the symptom period decreased and were normalized after discontinuation of metronidazole therapy. CONCLUSIONS: We describe a patient with metronidazole-induced encephalopathy involving reversible lesions in the anterior commissure, basal ganglia, and cerebellar white matter, which have not been reported previously. We observed inferior olivary hypertrophy, believed to be the result of lesions in the midbrain and cerebellar white matter rather than the result of lesions induced by metronidazole therapy. By using diffusion-weighted imaging and apparent diffusion coefficient maps, we found that metronidazole-induced encephalopathy might be caused by cytotoxic edema.     

Neuropsychiatric sequelae of portal-systemic encephalopathy: a review

Portal-systemic encephalopathy (PSE) is a common condition affecting individuals with chronic hepatic dysfunction. The clinical presentation of PSE often mimics a number of psychiatric disorders and, as discussed in the text, complicates the treatment of persons who suffer from both liver dysfunction and psychiatric illness. This review of the literature addresses the etiology, natural history and treatment of PSE. Special attention is devoted to clarifying the cognitive and affective manifestations of chronic low grade PSE.     

Advances in dialysis encephalopathy research: a review

Dialysis encephalopathy (DE) is a progressive, fatal disease with a high mortality rate. Understanding the causes of this disease and the efforts to prevent and treat it would help improve the prognosis and quality of life of affected patients. This paper reviews the etiology, clinical features, methods of examining accessory features, diagnosis, treatment, and prevention of DE. We found that DE is likely to be related to aluminum poisoning. The clinical manifestations of DE include language disorders, mental and behavioral disorders, cognitive decline, and movement disorders. Electroencephalogram (EEG) findings mainly consist of an abundance of low waves, intermittent bilateral synchronous high-amplitude spikes, and ridge waves. Assessing the clinical features and obtaining an EEG are of great value in diagnosis, and DE is treated by both reducing aluminum intake and increasing aluminum excretion. Deferoxamine (DFO) is an effective treatment for DE.     

Epileptogenic drugs: a systematic review

A wide range of substances, including drugs and illicit compounds, increase the risk of epileptic seizures. In this systematic review, the authors address the issue of the epileptogenic potential of marketed drugs, with the aims of providing criteria for the assessment of the cause-effect relationship between drug exposure and the risk of seizures; and to identify the compounds better fulfilling the requirements of an epileptogenic drug. Finding a correlation between drug exposure and occurrence of seizures does not necessarily establish a causal association. In light of the available evidence, even with these limitations, some conclusive remarks can be made on the epileptogenic potential of some active principles. Drugs with high epileptogenic potential include meperidine, sevoflurane, clozapine, phenothiazines and cyclosporine. Drugs with intermediate epileptogenic potential include propofol, maprotiline, tricyclic antidepressants and chlorambucil. Drugs with low epileptogenic potential include fluorquinolones, carbapenems, bupropion and iodinated contrast media. Drugs with minimal or inconclusive epileptogenic potential include interferon alpha.     

Intrasellar cysticercosis: a systematic review

The objective of this study was to review patients with intrasellar cysticercosis to outline the features of this form of neurocysticercosis. A MEDLINE and manual search of patients with intrasellar cysticercosis were done. Abstracted data included clinical manifestations, neuroimaging findings, therapy, and outcome. Twenty-three patients were reviewed. Ophthalmological disturbances, including diminution of visual acuity and visual field defects following a chiasmatic pattern, were recorded in 67 % of cases. Endocrine abnormalities were found in 56 % of patients (panhypopituitarism, hyperprolactinemia, diabetes insipidus, and isolated hypothyroidism). In addition, some patients complained of seizures or chronic headaches. Neuroimaging studies showed lesions confined to the sellar region in 47 % of cases. The remaining patients also had subarachnoid cysts associated or not with hydrocephalus, parenchymal brain cysts, or parenchymal brain calcifications. Thirteen patients underwent surgical resection of the sellar cyst through a craniotomy in nine cases and by the transsphenoidal approach in four. Visual acuity or visual field defects improved in only two of these patients. Five patients were treated with cysticidal drugs without improvement. Intrasellar cysticercosis is rare and probably under-recognized. Clinical manifestations resemble those caused by pituitary tumors, cysts, or other granulomatous lesions. Neuroimaging findings are of more value when intrasellar cysts are associated with other forms of neurocysticercosis, such as basal subarachnoid cysts or hydrocephalus. Prompt surgical resection is mandatory to reduce the risk of permanent loss of visual function. There seems to be no role for cysticidal drug therapy in these cases.     

Hashimoto encephalopathy: literature review

Hashimoto encephalopathy (HE) presents as an encephalopathy without central nervous system infection or tumor. HE is associated with autoimmune thyroiditis and is thus considered to be an autoimmune disorder. The prevalence of HE is low, but death and status epilepticus have been reported. HE manifests with a wide range of symptoms that include behavioral changes and confusion. Elevated thyroid antibodies are present in the majority of cases and are required for the diagnosis of HE. Normal brain MRI findings are found in the majority of patients diagnosed with HE. The most consistent CSF abnormality noted in HE patients is the presence of elevated protein. Most HE patients respond well to steroid therapy. Clinical improvements are also observed with IV immunoglobulin and plasmapheresis. In conclusion, it is now generally accepted that the diagnosis of HE must include encephalopathy characterized by cognitive impairment associated with psychiatric features, such as hallucinations, delusions, and paranoia. Autoimmune encephalitis and prion disease should be considered in the differential diagnosis due to the similarity of the clinical features of these conditions to those of HE.     

Alcohol-induced autonomic dysfunction: a systematic review

Clinical Autonomic Research - Autonomic dysfunction is a known consequence of chronic and excessive alcohol consumption. The aim of this systematic review was to characterise this phenomenon,...