From the Guidelines
The management of acute encephalopathy should prioritize a comprehensive diagnostic workup and treatment approach as outlined in the best practice recommendations for autoimmune encephalitis, which includes evaluating the likelihood of autoimmune encephalitis, performing brain MRI and/or EEG, lumbar puncture, and sending blood tests to rule out other potential causes 1. The initial steps in managing acute encephalopathy include stabilizing vital signs, securing the airway if consciousness is impaired, and ensuring adequate oxygenation and circulation.
- Immediate diagnostic workup should include:
- Neuroimaging (CT or MRI) to look for focal or multifocal brain abnormality
- Lumbar puncture to support inflammatory aetiology and rule out infective/neoplastic causes, testing oligoclonal bands, IgG index, IgG synthesis rate, and neuronal autoantibodies in the cerebrospinal fluid (CSF) 1
- EEG to rule out non-convulsive status epilepticus
- Comprehensive laboratory tests including complete blood count, metabolic panel, liver function tests, toxicology screen, and blood cultures
- Empiric antimicrobial therapy should be initiated if infection is suspected, and seizures should be controlled with benzodiazepines followed by antiepileptic medications if needed.
- Acute immunotherapy with high-dose corticosteroids (or IVIG or PLEX if steroids are not preferred or contraindicated) should be started once infection is ruled out, and consideration should be given to starting with a combination therapy of steroids/IVIG or steroids/PLEX from the beginning in patients with severe initial presentation 1. The prognosis depends on the underlying cause, rapidity of diagnosis, and treatment initiation, and neuroprotective measures include maintaining normothermia, normoglycemia, and appropriate blood pressure control 1.
From the Research
Management Approach for Acute Encephalopathy
The management of acute encephalopathy involves a comprehensive approach, including early diagnosis, identification of the underlying cause, and timely treatment. Key aspects of management include:
- Early recognition of symptoms, such as changes in baseline cognitive status, ranging from delirium to coma 2
- Identification of the underlying cause, which can be viral, autoimmune, or other pathogens 3, 4
- Use of validated tools, such as the CAM-ICU(-7) and the ICDSC, for clinical delirium assessment 2
- Continuous EEG monitoring and neuroimaging for early detection of secondary brain injury and treatment of reversible causes 2
- Evidence-based pharmacologic treatments, such as dexmedetomidine for mechanically ventilated patients with delirium 2
- Consideration of prognostic factors, including age, congenital anomalies, epilepsy, and level of consciousness, to identify patients who may benefit from early aggressive therapeutic interventions 4
Specific Considerations
- Viral infections, such as herpes simplex virus and influenza virus, can have favorable outcomes with prompt treatment 3, 4
- Autoimmune encephalitis, including paraneoplastic limbic encephalitis, requires awareness of its potential for treatability with immunosuppressive agents 3
- Certain medications, such as ceftriaxone, can induce acute encephalopathy, particularly in patients with renal failure or preexisting neurological disease 5
- Guidelines for the diagnosis and treatment of acute encephalopathy in childhood emphasize the importance of early recognition and treatment of individual syndromes, such as acute necrotizing encephalopathy and acute encephalopathy with biphasic seizures and late reduced diffusion 6