1. IMAGE OF THE WEEK
THELENGANA A
PG 1STYR
FROM IMCU WARD

2. • 15 Yrs old female presented with h/o
Fever 2 days
Asymptomatic 10 days
Headache,vomiting
Altered sensorium for 1 week
No h/o seizures/visual disturbance
No h/o vaccination /exanthematous illness

3. O/E
vitals were stable
CNS examn :Pt was drowsy , arousable with
painful stimulus
PERL , DEM preserved
exaggerated DTR
B/L plantar extensor
fundus examination – B/L disc edema
Other systemic examination was unremarkable

7. OPEN RING SIGN

8. MULTIPLE SCLEROSIS

9. DAWSONS FINGERS

10. CNS TUBERCULOSIS

11. CNS TOXOPLASMOSIS

12. PML

13. ACUTE DISSEMINATED
ENCEPHALOMYELITIS
 Inflammatory, nonvasculitic, demyeli
nating, immune
mediated, monophasic and
polysymptomatic disease of the
central nervous system
Post infectious encephalomyelitis,
Post vaccination encephalomyelitis

14. PATHOGENESIS
• Molecular mimickery: brain vaccines
– Th2 lymphocytes have increased reactivity to
myelin basic protein
• Inflammatory cascade concept:
– CNS infections triggering immune response,
damage to BBB, brain specific antigens spills into
systemic circulation and initiates immunologic
process

15. ADEM MULTIPLE SCLEROSIS
PRODROMAL PHASE NO PRODROMAL PHASE
ALTERED SENSORIUM PRESERVED AWARENESS
MENINGISMUS NO MENINGISMUS
NEUROSYCHIATRIC DISORDER NO NEUROPSYCHIATRIC
B/L OPTIC NEURITIS UNILATERAL OPTIC NEURITIS
COMPLETE TRANSVERSE MYELITIS INCOMPLETE
SEIZURES DIPLOPIA
ATAXIA RELAPSING
MONOPHASIC POLYPHASIC
POLYSYMPTOMATIC MONOSYMPTOMATIC

16. INVESTIGATIONS
CSF ANALYSIS
CT BRAIN
MRI – T2 , FLAIR, CONTRAST
– MTR
EEG,VEP

17. NEUROIMAGING
• MRI: extensive, multifocal, subcortical
white matter abnormalities
• MRI: subcortical white matter, may be grey
matter also,
• CT may be normal in 50% cases
• Convalescent MRI helpful in diffrentating with
MS, new lesions in MS

18. MRI Features
ADEM
• Patchy, poorly marginated areas of increased signal
intensity; large, asymmetric, multiple
• Four patterns:
– ADEM with less than 5 mm lesions
– Large, confluent lesions with edema and mass
effect
– ADEM with additional symmetric bithalamic
involvement
– Acute hemorrhagic encephalomyelitis (worst
prognosis)

19. RECURRENCE
OF ADEM
RDEM MDEM

20. TREATMENT
• Broad spectrum antibiotics and acyclovir until
an Infectious etiology is excluded.
• Methylprednisolone in a dose of 30 mg/kg per
day intravenously up to a maximum dose of
1000 mg per day X 5 days
• Plasmapharesis
• Intravenous immunoglobulin
• Cyclosporin , cyclophosphamide
• Methylpred + IVIG

21. PROGNOSIS
• Mortality: 10% in older studies, Now <2%
• Morbidity: visual, motor, autonomic, and intellectual
deficits and epilepsy.
– Problems persist after the first few weeks of
illness in only about 35% of cases, and in most of
these patients, the deficits resolve within 1 year of
onset.

22. FOLLOW UP
• The long-term (10-y follow-up) risk of patients
with ADEM for development of MS is 25%.
• Risk for MS is highest in children whose ADEM
onset was
– (1) afebrile,
– (2) without mental status change,
– (3) without prodromal viral illness or
immunization,
– (4) without generalized EEG slowing,
– (5) associated with an abnormal CSF immune
profile