Herein, the authors present a summary of brain disorders in which mr spectroscopy has an impact on patient. We present a child with rasmussen encephalitis and highlight the pitfalls of diagnosis when magnetic resonance imaging mri is negative for atrophy. It is considered the most common clinical manifestation of john cunningham virus jc virus infection in the brain 7, and is. Mri and proton spectroscopy in a child with rasmussens. Follows by motor function deterioration with hemi paresis or hemiplegia, progressive cognitive decline etiology unknown. The paper presents imaging studies in eight patients with polymerase chain reaction proven herpes simplex encephalitis hse. Proton mr spectroscopy in herpes simplex encephalitis. However most of the time imaging is meant to rule out other possible causes in an acutely ill febrile patient showing focal neurological deficits and. However, existing criteria for autoimmune encephalitis are too reliant on. The first step is to obtain mri of the brain and csf examination. Herpes simplex encephalitis, limbic encephalitis, computed tomography, magnetic resonance imaging, mr spectroscopy introduction herpes simplex encephalitis hse is one of the most serious viral diseases of the central nervous system cns. Mr spectroscopy demonstrated an increased choline peak at the level of the medial left temporal lobe, suggestive of neoplastic disease see figure 3. Rasmussens encephalitis is a chronic inflammation of the brain that leads to progressive neurologic deficits. Small cell lung carcinoma sclc have been found in at least 70% of cases with ple.
Herpes simplex encephalitis radiology reference article. Rethinking the magnetic resonance imaging findings in. Jul 31, 2001 central nervous system cns infections continue to pose a serious problem in health care even with improved knowledge and treatment. Magnetic resonance imaging of brain is the investigation of choice and the diagnosis may be confirmed by the polymerase chain reaction test for the virus in the cerebrospinal fluid. Grossman and yousem said if you need this to help you, go back to page 1. Herpes simplex encephalitis hse associated with hiv infection is a rare complication and may present with atypical clinical and neuropathologic features 1 3. Clinical presentation and differential diagnoses may suggest certain diagnostic tests, but mri and csf analysis including pcr for hsv and other viruses are usually done, typically with other tests eg, serologic tests to identify the causative virus. On mr imaging, the white matter lesions, which could be seen in the subacute stage, but not in the acute or chronic stage, might represent edema due to postinfectious neuroallergic phenomena. Followup mr and mrs studies in herpes simplex encephalitis. Herpes simplex virus 2 hsv2 infections of the central nervous system usually manifest as subacute encephalitis, recurrent meningitis, myelitis, and forms. Seizures typically are focal motor type, begin abruptly in previously normal children. Mr spectroscopy of pediatric brain disorders springerlink.
Advanced mr imaging techniques in the evaluation of nonenhancing gliomas. Early diagnosis is important for appropriate management. Autoimmune encephalitis, also known as autoimmune limbic encephalitis, is an antibodymediated brain inflammatory process, typically involving the limbic system, although all parts of the brain can be involved. Diffusion mri studies of 3 cases of rasmussens encephalitis were performed using the echoplanar trace sequence tr5700 ms, te9. Mri abnormalities in the medial temporal lobes are helpful in confirming a diagnosis of limbic encephalitis, but normal imaging does not exclude the diagnosis. Clinical proton mr spectroscopy in central nervous system. Diffusion mri and spectroscopy in rasmussens encephalitis. Normal mri findings in herpes simplex virus encephalitis. Mri findings in the diagnosis and monitoring of rasmussens encephalitis andreia v. Longitudinal mr imaging and proton mr spectroscopy in.
This test can also be used to detect tissue changes in stroke and epilepsy. However, the sensitivity of ct in diagnosing pediatric encephalitis in comparison to mri is generally poor. Encephalitis lethargica is an atypical form of encephalitis. A clinical approach to diagnosis of autoimmune encephalitis. Fundamentals of mr spectroscopy center for functional. Balabhai nanavati hospital and research centre, vile parle, mumbai 400 056, india. Autoimmune meningitis and encephalitis in adultonset. An extensive workup was negative for both infectious and neoplastic diseases and he was afterward diagnosed with antinmethyldaspartate. Mr perfusion demonstrated patchy areas of hyperperfusion within the left perisylvian region and left. It is not intended to be and should not be interpreted as medical advice or a diagnosis of any health or fitness problem, condition or disease. This is perhaps a little harsh, however, it is fair to say that mrs.
Mri findings in the diagnosis and monitoring of rasmussens. A decreased naa peak has been reported 714 weeks after onset, and in some cases, an elevated choline peak is seen. Rasmussen encephalitis radiology reference article. Wide differential diagnosis was performed including laboratory findings, contrast enhanced mri, mr spectroscopy, flow cytometry and finally brain biopsy to exclude neoplastic or infectious origin. Cmv is also one of the most frequent prenatal infections, which is discussed. Could it be simply me or do a few of the responses come across like they are written by brain dead peoplep and, if you are posting on additional social sites, i would like. A differential diagnosis included herpes encephalitis and infiltrative glioma. Mr revealed sparing of hippocampi and limbic cortices, necrosis of both cingulate gyri, and cerebellar involvement.
Mri spectroscopy please see next section for ordering mri spectroscopy 76390 primary brain tumor metastasis abscess indeter minate intracranial lesion encephalitis neurocysticercosis multiple sclerosis metabolic abnormality mri brain w and wo contrast and mri spectroscopy please order both exams if is the first time that the patient. Mri brain protocols, planning, positioning and indications. Magnetic resonance imaging with diffusion and spectroscopy article pdf available in neurology india 532. Mri of a 71yearold female patient with herpes simplex encephalitis who presented with fever and impaired consciousness.
Rasmussen encephalitis, also known as chronic focal encephalitis, is a chronic inflammatory disease of unknown origin, usually affecting one brain hemisphere. Head ct commonly shows areas of edema or petechial hemorrhage in the same areas. Mri may improve the sensitivity for detection of patients of encephalitis using. The greater sensitivity of magnetic resonance spectroscopy mrs compared with mri to brain abnormalities in rasmussens encephalitis was demonstrated in a 3yearold boy.
The frequency of hse in hiv patients with neurologic symptoms was 2% in an autopsy. To assess the role of imaging in the early management of encephalitis and the agreement on findings in a welldefined cohort of suspected encephalitis cases enrolled in the prospective aetiological study of encephalitis conducted by the health protection agency now incorporated into public health england. Magnetic resonance spectroscopy in neurological diagnosis. Ketonen moved from trated on brain imaging,but have an extensive chap massachusetts general hospital in boston to the u ter on the spine and a smaller chapter on the head versity of rochester it. A large body of published work shows that proton hydrogen 1 1 h magnetic resonance mr spectroscopy has evolved from a research tool into a clinical neuroimaging modality. It is not to be confused with a rasmussen aneurysm. There was a suspiciously detectable hyperintensity in temporal lobes on initial mri and increased myoinositol mi. Serial proton mr spectroscopy and diffusion imaging. Cytomegalovirus encephalitis radiology reference article. While magnetic resonance imaging mri identifies the anatomical location of a tumor, mr spectroscopy compares the chemical composition of normal brain tissue with abnormal tumor tissue. Mri ordering guide texas tech university health sciences. Tajima y, isonishi k, kashiwaba t, tashiro k 1998 serial mri, spect and 1hmrs findings in a case of herpes simplex encephalitis. Background herpes simplex encephalitis is one of the most common and serious sporadic encephalitides of immunocompetent adults.
These include differentiating tumor from other focal lesions giant demyelinating plaques, encephalitis, obtaining a definitive diagnosis of atypical ringenhancing. Typical imaging features of the most common intracranial masses in adults primary neoplasms highgrade and lowgrade, secondary metastatic neoplasms, lymphoma, tumefactive demyelinating lesions, abscesses, and encephalitis on perfusion mri, diffusion mri, and proton mr spectroscopy and examples of individual cases were summarized in a. Mri spectroscopy in neurological disorders book chapter. Unlike magnetic resonance imaging mri, which gives us a picture of anatomical and physiological conditions, mrs generates a frequency domain spectrum that provides information about biochemical and metabolic processes occurring within tissues. Rasmussens encephalitis is a devastating syndrome of multifocal brain dysfunction and focal seizures. Brain 18ffluorodeoxyglucose 18ffdg positron emission tomography pet of a patient with autoimmune encephalitis shows areas of hypermetabolism in. The purpose of this study was to evaluate the diffusion mri and proton mr spectroscopy findings in a rare disorder, rasmussens encephalitis. A scan of the brain can help show whether you have encephalitis or another problem such as a stroke, brain tumour or brain aneurysm a swelling in an artery. Proton magnetic resonance spectroscopy 1hmrs is one such technique which. Autoimmune encephalitis can be divided broadly into two groups, based on whether or not antibodies are the result of an underlying tumor. Magnetic resonance mr findings, associated with clinical data and electroencephalogram eeg, may indicate the diagnosis and could be an indicative of prognosis. The symptoms of encephalitis can have a number of possible causes, so several tests may be needed to diagnose it. Rethinking the magnetic resonance imaging findings in early. This section of the website will explain planning for various types of mri scans, mri protocols, positioning for mri, and common indications for mri scans.
Atypical brainstem encephalitis caused by herpes simplex virus 2. Samann pg, schlegel j, muller g, prantl f, emminger c, et al. Abnormalities have been revealed in brain mri, which was performed due to persistent headaches, visual disturbances, fever, fatigue and cognitive decline. Proton mr spectroscopy findings in herpes simplex encephalitis. P i actually do have 2 questions for you if you usually do not mind. Mr spectroscopy counts as a molecular imaging technique because it can measure the concentration of certain molecules within the imaged region. Mri of a patient with autoimmune encephalitis shows inflammatory changes in the temporal lobes bilaterally. Technical discussion focuses on the few remaining issues, localization, spectral display, and interpretation because interesting questions surrounding this widely diverse methodology have been resolved, and a single coherent diagnostic mrs protocol can be applied worldwide on clinical mri scanners. Magnetic resonance spectroscopy and hypoxicischemic conditions. Evolution of mri changes in rasmussens encephalitis. Sep 09, 2011 rasmussen encephalitis, a chronic progressive encephalitis results in severe, intractable epilepsy.
The most common nuclei that are used are 1 h proton, 23 na sodium, 31 p phosphorus. Autoimmune encephalitis radiology reference article. Clinical proton mr spectroscopy in central nervous system disorders. Magnetic resonance spectroscopy mrs provides useful information regarding. Eee and tickborne encephalitis may show similar increased mri signal intensity in the basal ganglia and thalamus. Patterns of imaging abnormalities are described in cohorts of more common encephalitis aetiologies, such as hsv encephalitis. Magnetic resonance spectroscopy mrs is a userfriendly, widely available imaging modality that can be. Herpes simplex hsv encephalitis is the most common cause of fatal sporadic fulminant necrotizing viral encephalitis and has characteristic imaging findings. Patkar, sanjay desai department of mri, mammography and bmd, dr. Serial cranial mr imaging and single voxel proton mr. Feb 07, 2015 mr spectroscopy is conducted on the same machine as conventional mri. Rasmussen encephalitis is a chronic, progressive inflammation of the brain of unknown origin.
Mr perfusion demonstrated patchy areas of hyperperfusion within the left perisylvian region and left anterior temporal lobe, also supporting a diagnosis of neoplastic disease. Progressive multifocal leukoencephalopathy radiology. Acute encephalitis constitutes a medical emergency. The patient, with symptoms, signs and morphological findings consistent with rasmussens encephalitis, was followed with mri and mrs over 30 months. However, detection in adults is increasing with routine mri. The content on this site is presented in a summary fashion, and is intended to be used for educational and entertainment purposes only. Recent research suggests a possible viral origin or a viralinduced autoimmune.
Advanced mr imaging techniques in the diagnosis of. Spectroscopy is a series of tests that are added to the mri scan of brain or spine to measure the chemical metabolism of a suspected lesion. Markedly reduced myoinositol, and to a lesser degree choline. A minimal virus consists of a genome plus a proteinaceous coat, known as a capsid. Despite the introduction of newer antimicrobial agents and diagnostic techniques, the morbidity and mortality associated with cns infections remain high. Different nuclei can be targeted such as carbon and phosphorous31.
We studied the mri findings in 16 patients with rasmussens encephalitis re, further analysed serial mri changes in 11 of them and correlated it with clinical features. We report the case of pathologically proved atypical herpes simplex encephalitis hse in a 40yearold male patient with aids who was followed up by mr imaging, which included diffusionweighted imaging and proton mr spectroscopy 1hmrs. Localized1h mr spectroscopy also proved promising in. Oct 10, 2019 advanced mr techniques are being increasingly used to study herpes encephalitis. Sometimes a procedure called magnetic resonance spectroscopy mrs is done during the mri scan. Magnetic resonance imaging mri characteristics of tick. Magnetic resonance imaging with diffusion and spectroscopy sona a.
It was proposed that the right temporal lesion could represent postictal change. Hypoxic ischemic encephalopathy hie results from a deficient supply of oxygen to the brain. Perfusionweighted imaging compared with proton magnetic resonance spectroscopy and tumor grade 1 october 20 the neuroradiology journal, vol. Abstract rasmussens encephalitis is a devastating syndrome of multifocal brain dysfunction and focal seizures. Mr spectra of bilateral temporal lobes were acquired by the single voxel method using 1. The condition has previously been studied by various imaging modalities including mr imaging and mr spectroscopy. An update on diagnostic imaging studies for viral encephalitis. Most cases 85% cases occur in children under the age of 10 years 1. Herpes simplex hsv encephalitis is the most common cause of fatal sporadic fulminant necrotizing viral encephalitis and has characteristic imaging findings two subtypes are recognized which differ in demographics, virus, and pattern of involvement. Magnetic resonance spectroscopy 1 h mrs is an imaging method that provides additional information about the metabolic characteristics of brain tissues. Paraneoplastic limbic encephalitis ple is a rare complication of cancer.
The morbidity associated with cns infections may be even more important than the death rate especially. Atypical brainstem encephalitis caused by herpes simplex. Two subtypes are recognized which differ in demographics, virus, and pattern of involvement. Advanced mr techniques are being increasingly used to study herpes encephalitis. Mr spectroscopy using proton spectroscopic mri has demonstrated a reduction of the nacetylaspartate naatocholine ratio. This is an atlas on contemporary mr imaging of the reer in neuroradiology she has continuously gathered pediatric central nervous system. Mr spectroscopy provides a measure of brain chemistry. Clinical applications of mr spectroscopy presents a short, practical treatment of mrs today. Encephalitis with meningitis is known as meningoencephalitis, while encephalitis with involvement of the spinal cord is known as encephalomyelitis. Longitudinal mr imaging and proton mr spectroscopy were performed in an 11 yearold female case of herpes simplex encephalitis with a complete recovery. There are several different metabolites, or products of metabolism, that can be measured to differentiate between tumor types. Domingues rbfink mcdtsanaclis amc et al diagnosis of herpes simplex encephalitis by magnetic resonance imaging and polymerase chain reaction assay of cerebrospinal fluid. Proton magnetic resonance spectroscopy of the central nervous.
Clinical applications of magnetic resonance spectroscopy. Encephalitis is suspected in patients with unexplained alterations in mental status. Autoimmune encephalitis is an important cause of newonset altered mental status, the scope of which has only recently begun to be recognized in the medical literature. Aug 07, 2018 in hse, mri may show several foci of increased t2 signal intensity in medial temporal lobes and inferior frontal gray matter. The latest mri techniques, namely diffusion, perfusion, and spectroscopy, offer more than the anatomical information that conventional imaging provides. Methodology the diagnosis of re was based on the european consensus statement brain, 128, 2005, 454. Haemorrhagic changes are much better seen on mri than on ct. Clinical application of mr spectroscopy in identifying biochemical.
When an autoantibody is found it is usually to either vgkc or nmdar. Serial proton mr spectroscopy and diffusion imaging findings. Mr imaging and spectroscopy of central nervous system infection. Autoimmune encephalitis, also known as autoimmune limbic encephalitis, is an antibodymediated brain inflammatory process, typically involving the limbic system, although all parts of the brain can be involved autoimmune encephalitis can be divided broadly into two groups, based on whether or not antibodies are the result of an underlying tumor. Mr spectroscopy evaluation of white matter signal abnormalities of. Mri studies in the acute phase of infection have presented both typical and unusual changes. Realtime pcr of her cerebrospinal fluid revealed 320,000 copies.
Viruses are infectious, obligate intracellular parasites whose genomes consist of either dna or rna. We report the case of pathologically proved atypical herpes simplex encephalitis hse in a 40yearold male patient with aids who was followed up by mr imaging, which included diffusionweighted imaging and proton mr spectroscopy 1 hmrs. Clinical application of mr spectroscopy in identifying. Antibodies to the voltage gated potassium vgkc channel interfere with peripheral neuromuscular and ganglionic transmission. Central nervous system cns infections continue to pose a serious problem in health care even with improved knowledge and treatment. Mr spectroscopy is conducted on the same machine as conventional mri. Cytomegalovirus cmv encephalitis is a cns infection that almost always develops in the context of profound immunosuppression. Mri findings in the diagnosis and monitoring of rasmussen. An mrs is used to diagnose tumors based on their chemical makeup.
Proton spectroscopy is easier to perform and provides much higher signaltonoise than either sodium or phosphorus. We report the serial cranial mr imaging mri and single voxel proton magnetic resonance spectroscopy 1 hmrs findings of the brain, at 3 and 11 weeks after the onset of symptoms in a patient with paraneoplastic limbic encephalitis ple in association with antihu antibodies. Magnetic resonance imaging mri and proton magnetic resonance mr spectroscopy revealed some lesions in the right cerebellar hemisphere and ipsilateral cerebellar tonsil suggestive of encephalitis. Magnetic resonance imaging mri is the imaging modality of choice for establishing diagnosis, classification, surgical planning, and post.
The technique of magnetic resonance spectroscopy usually shortened to mr spectroscopy or mrs allows tissue to be interrogated for the presence and concentration of various metabolites. Encephalitis is a severe inflammatory disorder of the brain with many possible causes and a complex differential diagnosis. The sensitivity, specificity, ppv, and npv of proton mr spectroscopy in differentiating the grades of glioma were high in comparison to conventional mri indicating that proton mrs spectroscopy is a useful tool in differentiating grades of glioma. In vivo magnetic resonance spectroscopy mrs is a specialized technique associated with magnetic resonance imaging mri magnetic resonance spectroscopy mrs, also known as nuclear magnetic resonance nmr spectroscopy, is a noninvasive, ionizingradiationfree analytical technique that has been used to study metabolic changes in brain tumors, strokes, seizure disorders, alzheimers. Progressive multifocal leukoencephalopathy pml is a demyelinating disease which results from the reactivation of john cunningham virus jc virus infecting oligodendrocytes in patients with compromised immune systems.
Mr imaging and spectroscopy of central nervous system. When adequate motion control can be achieved, mri becomes the examination of choice in the diagnosis and followup of herpes simplex encephalitis. Advances in autoimmune encephalitis research in the past 10 years have led to the identification of new syndromes and biomarkers that have transformed the diagnostic approach to these disorders. Localized proton magnetic resonance spectroscopy 1hmrs was conducted in two patients with herpes simplex virus type i encephalitis hse. The importance of mr imaging, singlephoton emission computed tomography, and proton mr spectroscopy in the workup of this disease is discussed.
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