What is the management of behavioral manifestations in Acute Disseminated Encephalomyelitis (ADEM)?

From the Guidelines

Management of behavioral manifestations in Acute Disseminated Encephalomyelitis (ADEM) requires a multifaceted approach focusing on both immunomodulatory treatment for the underlying condition and symptomatic management of behavioral symptoms. First-line treatment involves high-dose intravenous methylprednisolone (1 g daily for at least 3–5 days) as recommended by the Infectious Diseases Society of America 1. For severe behavioral manifestations, short-term use of antipsychotics like risperidone or haloperidol may be necessary, with benzodiazepines such as lorazepam helping to manage acute agitation, as suggested by guidelines for managing agitation in emergency settings 1. Additionally, environmental modifications including maintaining a calm, structured environment with consistent caregivers, minimizing stimulation, and providing reorientation are essential supportive measures, similar to those recommended for managing Alzheimer’s disease patients 1. Key considerations include:

• Reducing inflammation in the central nervous system with immunomodulatory treatments
• Modulating neurotransmitter systems affected by the inflammatory process
• Providing a supportive environment for recovery
• Considering intravenous immunoglobulin (IVIG) or plasmapheresis for patients not responding to steroids, as noted in the management of ADEM 1. These interventions prioritize reducing morbidity, mortality, and improving quality of life for patients with ADEM.

From the Research

Management of Behavioral Manifestation in ADEM

The management of behavioral manifestation in Acute Disseminated Encephalomyelitis (ADEM) is crucial for the overall treatment of the disease.

• Behavioral manifestations can include psychosis, depression, or abnormal behavior, and may mimic a dissociative disorder 2.
• The treatment approach for ADEM is based on its presumed autoimmune etiology, and typically consists of intravenous methylprednisolone, followed by an oral corticosteroid taper 3.
• In some cases, intravenous immunoglobulin G (IVIG) or plasmapheresis may be considered as therapeutic options 3, 4.
• Psychiatric medicines, such as antipsychotics, mood stabilizers, and antidepressants, may also be used to target activated microglia and reduce inflammation 5.
• However, there is a lack of specific recommendations for the long-term management of recurrent and multiphasic ADEM, and further research is needed to optimize treatment approaches 3, 4.

Treatment Options for Behavioral Manifestation

Some treatment options for behavioral manifestation in ADEM include:

• High-dose intravenous corticosteroids to reduce inflammation and modulate the immune response 3, 4.
• Intravenous immunoglobulin G (IVIG) to reduce inflammation and modulate the immune response 3, 4.
• Plasmapheresis to remove autoantibodies and reduce inflammation 3, 4.
• Psychiatric medicines, such as antipsychotics, mood stabilizers, and antidepressants, to target activated microglia and reduce inflammation 5.
• Decompressive craniectomy as a life-saving measure for ADEM patients with intracranial hypertension 3.

Challenges in Management

There are several challenges in the management of behavioral manifestation in ADEM, including:

• The lack of specific recommendations for the long-term management of recurrent and multiphasic ADEM 3, 4.
• The need for further research to optimize treatment approaches and improve outcomes 3, 4.
• The potential for ADEM to mimic other conditions, such as dissociative disorder, and the need for careful diagnosis and evaluation 2.