Fulminant Sepsis-Associated Encephalopathy in Two Children: Serial Neuroimaging Findings and Clinical Course

Abstract

We report on two children with sepsis-associated encephalopathy. They presented with fulminant neurological damage on clinical, neuroimaging, and neurophysiological findings. At onset, both went into deep coma after status epilepticus, resulting in near brain death. Both patients showed diffuse brain edema on CT and severe brain dysfunction on electroencephalography within a day of onset. Brain magnetic resonance (MR) imaging of one patient on day 2 showed restricted diffusion in the basal ganglia and the subcortical white matter of the frontal and occipital lobes. Brain edema aggravated and lasted for a few months despite a variety of treatments. MR imaging in the chronic phase revealed cracking lesions extending to the cerebral white matter, the cerebellum, and the brainstem. MR angiography showed diminished intracranial major arteries. These serial neuroradiological findings suggested severe brain damage resulting from fulminant elevation of intracranial pressure, which mimicked “brain death” or “respirator brain”.

Key words

sepsis-associated encephalopathy - neuroimaging - respirator brain

References

• 1 Consales G, de Gaudio AR. Sepsis associated encephalopathy.  Minerva Anestesiol. 2005;  71 39-52
• 2 Davies DC. Blood-brain barrier breakdown in septic encephalopathy and brain tumours.  J Anat. 2002;  200 639-646
• 3 Fenelli PF, Uphoff DF. Magnetic resonance imaging abnormalities with septic encephalopathy.  J Neurol Neurosurg Psychiatry. 2004;  75 1189-1191
• 4 Green R, Scott LK, Minagar A. et al . Sepsis associated encephalopathy(SAE): a review.  Front Biosci. 2004;  1 1637-1641
• 5 Karantanas AH, Hadjigeorgiou, Paterakis K. et al . Contribution of MRI and MR angiography in early diagnosis of brain death.  Eur Radiol. 2002;  12 2710-2716
• 6 Papadopoulos MC, Davies CD, Moss RF. et al . Pathophysiology of septic encephalopathy: a review.  Crit Care Med. 2000;  28 3019-3024
• 7 Potts MB, Koh SE, Whetstone WD. et al . Traumatic injury to immature brain: inflammation, oxidative injury, and iron-nediated damage as potential therapeutic targets.  NeuroRx. 2006;  3 143-153
• 8 Saez-Liorens X, McCracken Jr GH. Sepsis syndrome and septic shock in pediatrics: Current concepts of terminology, pathophysiology, and management.  J Pediatr. 1993;  123 497-508
• 9 Walker AE, Diamond EL. The neuropathological findings in irreversible coma. A critique of the “respiratory brain‚.  J Neuropathol Exp Neurol. 1975;  34 295-323
• 10 Waren HS, Gonzalez RG, Tian D. Case 38-2003: A 12-year-old girl with fever and coma.  N Engl J Med. 2003;  249 2341-2349

Correspondence