There are over different terms that modify or precede "encephalopathy" in the medical literature; the purpose of this article is to introduce the reader to the main categories of conditions that fall under the broad term of encephalopathy. What causes encephalopathy?
These examples do not cover all of the potential causes of encephalopathy but are listed to demonstrate the wide range of causes. Although numerous causes of encephalopathy are known, the majority of cases arise from several major categories some examples in parentheses :. Some drugs may cause encephalopathy; for example, posterior reversible encephalopathy syndrome PRES may occur due to the use of drugs like tacrolimus and cyclosporine. This syndrome manifests with symptoms of headache , confusion , and seizures.
Getting your bell rung was once a badge of honor in sports. The ability to shake it off and not miss a play was accepted and routine. The realization was slow in coming that the same injury to the brain could occur in football players, and that the most popular sport in the country could be a potential cause of psychiatric disturbances and early dementia.
A new term was born: Chronic traumatic encephalopathy CTE describes a gradual degeneration in brain function due to repeated head injuries that causes both concussions with symptoms and concussions that are asymptomatic do not cause symptoms. Once the initial symptoms of concussion have faded, months and years later, new symptoms occur.
CTE symptoms start slowly and creep up on the patient. Initially, there may be concentration and memory problems with episodes of disorientation and confusion, dizziness, and headache. It is as if the concussion symptoms were starting to return even without a new head injury. What are the symptoms of encephalopathy? Despite the numerous and varied causes of encephalopathy, at least one symptom present in all cases is an altered mental state.
The altered mental state may be subtle and develop slowly over years for example, in hepatitis the decreased ability to draw simple designs, termed apraxia or be profoundly obvious and develop rapidly for example, brain anoxia leading to coma or death in a few minutes. Often, symptoms of altered mental status can present as inattentiveness, poor judgment, or poor coordination of movements.
Often the severity and type of symptoms are related to the severity and cause of the brain disease or damage. For example, alcohol-induced liver damage alcoholic cirrhosis can result in involuntary hand tremors asterixis , while severe anoxia lack of oxygen may result in coma with no movement. Other symptoms may not be as severe and may be more localized such as cranial nerve palsies damage to one of the 12 cranial nerves that exit the brain. Some symptoms may be very subtle and result from repeated injury to the brain tissue. For example, chronic traumatic encephalopathy CTE , due to injury like concussions repeatedly sustained by football players and others who play contact sports, may cause slow changes over time that are not easily diagnosed.
Such injury may lead to chronic depression or other personality changes that can result in life-changing consequences. Even infants and children can suffer encephalopathy. Similar symptoms can occur in the perinatal period if the neonate had any compromise to brain blood flow during its development.
Rasmussen's encephalitis is a rare disease that is seen in children that progresses to intractable seizures if untreated. It may be due to autoantibody development. Another rare form of encephalopathy that usually develops in younger people about ages 4 to 20 years is the MELAS syndrome "Mitochondrial Encephalopathy, Lactic Acidosis, Stroke-like episodes " due to faulty DNA in the patient's mitochondria a tiny part within the cell that is responsible for energy conversion.
How is encephalopathy diagnosed? The diagnosis of encephalopathy is usually made with clinical tests done during the physical examination mental status tests, memory tests, and coordination tests that document an altered mental state. In most cases, findings on clinical tests either diagnose or presumptively diagnose encephalopathy.
Usually, the diagnosis occurs when the altered mental state accompanies another primary diagnosis such as chronic liver disease , kidney failure, anoxia, or many other diagnoses.
Consequently, physicians may utilize several different tests at the same time to diagnose both the primary condition the cause of encephalopathy and the encephalopathy itself. This approach to diagnosis is done by most physicians, because encephalopathy is a complication that occurs because of a primary underlying health problem. The most frequently utilized tests are listed below with some of the major primary causes the tests may help diagnose:. This list is not exhaustive, and not all of the above tests need to be done on every patient.
Specific testing is usually ordered by the treating physician according to the symptoms and history of the patient.
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What is the treatment for encephalopathy? Treatment of encephalopathy varies with the primary cause of the symptoms. Consequently, not all cases of encephalopathy are treated the same. The key to treatment of any encephalopathy is to understand the basic cause and thus design a treatment plan to reduce or eliminate the cause s.
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There is one type of encephalopathy that is difficult or impossible to treat; it is static encephalopathy an altered mental state or brain damage that is permanent. The best that can be done with static encephalopathy is, if possible, to prevent further damage and implement rehabilitation to allow the individual to perform at his or her highest possible functional level.
What are the complications of encephalopathy?
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Complications of encephalopathy vary from none to profound mental impairments that lead to death. The complications can be similar in some cases. Also, many investigators consider encephalopathy itself to be a complication that arises from a primary health problem or primary diagnosis. Complications depend on the primary cause of encephalopathy and can be illustrated by citing a few examples from the wide variety of causes:. The best way to understand potential complications is to discuss these with the diagnosing doctor who can discuss the possible problems associated with the specific cause s of the type of encephalopathy.
What is the prognosis outlook for encephalopathy? The prognosis for a patient with encephalopathy depends on the initial causes and, in general, the length of time it takes to reverse, stop, or inhibit those causes. Consequently, the prognosis varies from patient to patient and ranges from complete recovery to a poor prognosis that often leads to permanent brain damage or death. This highly variable prognosis is exemplified by patients that get encephalopathy from hypoglycemia.
If patients with hypoglycemia are given glucose at the first signs of encephalopathy for example, irritability, mild confusion , most patients recover completely. Delays in correcting hypoglycemia hours to days may lead to seizures or coma, which may be halted by treatment with complete or partial recovery minimal permanent brain damage.
A long delay or multiple delays in treatment can lead to a poor prognosis with extensive brain damage, coma, or death. Although the symptoms and time frame vary widely from patient to patient and according to the initial causes of encephalopathy see above sections for examples of causes , the prognosis of each case usually follows the pattern described in the hypoglycemic example above and depends upon the extent and rapidity with which the underlying cause is treated.
The doctor or team of doctors treating the underlying cause of encephalopathy can offer the best information on the individual's prognosis.
Q&A: Encephalopathy due to UTI versus metabolic encephalopathy due to UTI
Can encephalopathy be prevented? Many cases of encephalopathy can be prevented. The key to prevention is to stop or limit the chance of developing any of the multitudes of causes of encephalopathy. If encephalopathy develops, the quicker the underlying cause is treated, the more likely that severe encephalopathy can be prevented. Methods for prevention of encephalopathy are about as numerous as the underlying causes; however, some cases of encephalopathy may not be preventable for example, congenital and accidental traumatic encephalopathy.
For more information on types of encephalopathy. The precipitant of DKA in this case is unclear given his absent period prior to admission, and may have been multifactorial. We postulate that it may be due to a combination of omission of insulin with or without alcohol misuse, as this was his previous precipitant. Starvation and alcohol excess may have also contributed to ketoacidosis. There are multiple differentials of encephalopathy in this case. As the patient was not seen for two days prior to presentation he may have had an unwitnessed traumatic brain injury however this was not apparent on imaging.
Toxic brain injury was also considered however the radiological findings were inconsistent with this and toxicology screen was negative. Infectious aetiology should always be considered in patients presenting with encephalopathy.