09 ENCEPHALOPA

THY
BASJIRUDDIN A.
Faculty of Medicine, Andalas University

Anak laki-laki, 12 thn, datang ke IGD dengan kejangkejang, kesadaran menurun, gelisah. Anak ini kejang beberapa kali dan ditemukan di gudang rumahnya yang gelap karena listrik mati, waktu itu muntah 3 kali. Pemeriksaan: acral cyanosis, nystagmus. TD 100/60 mmHg, HR 110 x/mnt, suhu 36,8 C

Encephalopathy is a term for any diffuse disease of the brain, that alters brain function or structure It can refer to a wide variety of :
degenerative brain disorders different etiologies prognoses implications

Types
Many types of encephalopathy : Hypertensive encephalopathy : arising from
acutely increase blood pressure

Hypoxic encephalopathy : severely reduced

oxygen delivery to the brain

Hepatic encephalopathy : arising from advanced

cirrhosis of the liver

Causes
Uremic encephalopathy : arising from high levels
of toxins normally cleared by the kidneys (rare, where dialysis is readily available) Toxic-metabolic encephalopathy : a catch-all for brain dysfunction caused by infection, organ failure, or intoxication Wernickes encephalopathy: arising from thiamine defficiency (alcoholism)

Hashimotos encephalopathy: arising from an

acute immune disorders

May be caused by : acutely elevated blood pressure (BP) an infection agent (bacteria, virus) metabolic dysfunction brain tumor increased intracranial pressure exposure to toxins : drugs, alcohol, chemicals lack of oxygen or cerebral blood flow chronic progressive trauma

Clinical Features
Hallmark of encephalopathy is an altered mental state Common neurological symptoms depend on type and severity :
progressive loss of memory and cognitive ability subtle personality changes inability to concentrate lethargy progressive loss of consciusness

May include :
Seizures, myoclonus Involuntary twitching of muscles Tremor Nystagmus Dementia Loss of ability to speak or swallow

Diagnosis
Blood tests Spinal fluid examination (lumbal puncture) Electroencephalograms Diagnosis for the various cases of encephalopathy
Acute liver failure Acute renal failure Blood pressure Imaging, etc.

Therapy
Treatment is symptomatic and varies, according to type / severity of the encephalopathy Anticonvulsants : to reduce or halt any seizures Changes to diet and nutritional supplements In severe cases, dialysis or surgery may be needed In a special case maybe need liver transplantation

Hypoxic encephalopathy
Definition Hypoxic encephalopathy is a term refers to a lack of oxygen supply and lack of cerebral blood flow to the cerebral hemispheres or the entire brain, can cause brain damage

Causes and risk factors

Numerous causes, include : Drowning Asphyxiation (smoke inhalation) Very low blood pressure Strangling Cardiac arrest Carbon monoxide poisoning High altitudes Paralyze of the respiratory muscles

 Brain cells : very sensitive to oxygen depriviation

start dying just under five minutes after O2 supply is cut

In mild case :
Inattentiveness, poor judgment Motor in-coordination

Brain hypoxia can cause :

Death Severe brain damage

Severe case :
Complete unawareness, unresponsiveness (pupillary respone to light, breathing reflex)

Damage can occur within 5 minutes, once brain damage occurs, it is irreversible This is an emergency condition need sooner oxygen supply restore

If lack of O2 is limited periode

reversible

coma may be

Seizures may occur, which may be continous

(status epilepticus)

Diagnosis and test

Clinical history Physical examination Include :
Blood test Electroencephalography EKG Imaging

Treatment
Depends on the underlying cause Importantly : basic life support :
Secure the air way Blood pressure supported with fluids, medications Controlled heart rate Seizures treated

Hypertensive encephalopathy (HTE)

HTE is an acute neurologic (cerebral) syndrome precipated by sudden severe hypertension (HT) Associate with crisis HT HTE is a medical emergency recuiring intensive / effective treatment : if untreated lead
to coma and death

HT Crisis
HT emergency
(Diast blood pressure > 140mmHg, syst

with target organ damage (TOD) : encephalopathy, aortic dissection, acute renal failure, myocardial infarction, stroke Need HT reduction with parenteral therapy and intensive monitoring HT urgency : without evidence of TOD : can be achieved by oral agents of anti HT
blood pressure > 250mmHg)

Clinical Features
The presence of acut or ongoing end organ damage

Yes Hypertensive emergency A few hours Requirement of reduction in BP

No Hypertensive urgency 2424-48 hours

HTE may present as any age (commond in 34th decades) History of chronic HT Headache
nausea, vomiting confussion, agitated

Sometimes develop in the setting of

renal failure vasculitis

Intravenous

Anti hypertensive agents

Oral, possible

Visual symptoms
bluring scotoma cortical blindness nystagmus

Seizures focal or generalized Confusion agitate coma Funduscopy : grade III-IV Keith Wagner (KW) retinal
changes, exsudate, hemorrhage

Diagnosis - Acutely elevated BP - Clinical feature of neurologic syndrom - Acute or ongoing end organ damage :
brain renal heart retinal

Head CT Scan : bilateral areas of low attenuation of the

brain (reversible with reduction of BP)

Treatment
Directed toward lowering arterial BP :
avoid excessive BP lowering prevent cerebral ischemia lowering DBP to 100-110 mmHg

Acute monitoring in ICU

Mean Arterial Pressure (MAP) monitoring required for adequate titration of pharmac. agents End organ function

Anti HT Nitroprusside : first line therapy rapid onset, short duration of action reduces peripheral resistance Nitroglycerin : rapid reduction BP decreases coronary vasospasm Labetalol : steady consistent drop in BP without compromissing CBF Nicardipine : potent, rapid onset of action ease titration, lack of toxic metabolites Electrolite, acid-base balance

Anti convulsants
Administer phenitoin. Dose : 18-20mg/kg iv Diazepam. Dose 5-10 mg iv 10-20 min, not to exceed 30 mg/kg. Lorazepam. Dose 4 mg iv slowly at 2 mg/min : if seizure continues after 10-15 min additional 4mg iv slowly at 2 mg/min.

ENCEPHALITIS
Encephalitis is as acute inflamation of the brain, commonly caused by viral infection It can be caused by a bacterial such as :
meningitis encephalitis supurative or cerebral absces or a complication of other infections disease :
Parasitic : toxoplasmosis, amoebic

Further Care
Routinely : Monitoring MAP-adequate titration of pharmac.agents : Perform neurologic reassessment due to inadequate treatment : Progression neurologic result

Symptoms : Fever, headache, photophobia, seizures, weakness Stiffness of the limbs, slowness in movement Seizure

DIAGNOSIS
Acute onset of fever, headache, confusion Seizures Irritability LP : protein

TREATMENT
Usually symptomatic Anti viral agent (acyclovir, etc) Antibiotic for bacterial encephalitis Anti convulsant Supportive treatment such as mechanical ventilation, etc

cell (wbc) glucose normal EEG : sharp waves

Detection of antibodies in CSF againts specific viral agent (herpes, varicella, etc)