Stroke Tumor Infection Inflammation Metabolic Toxic
Aetiology
Basilar artery occlusion (due to cardioembolism, trauma, hypercoagulable disorders, unknown) Vertebral artery dissection (+/- after neck traumatism) Brainstem ischemic syndrome in NF2 Unknown Diffuse high-grade glioma (+/- 75%) Focal low-grade glioma Exophytic glioma (low grade) Langherans cell histiocytosis Epidermoid/dermoid tumor
Listeria, Enterovirus, HSV
ADEM † Multiple sclerosis ANE ‡ (after influenza A, B, parainfluenza, HHV6) Bickerstaff encephalitis (ganglioside GQ1b antibodies, after Campylobacter jejuni or Mycoplasma pneumoniae)
Mitochondrial disease
Central pontine myelinolysis
Specific symptoms In addition of headaches, cranial nerve palsy, motor deficit
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Ataxia
Fever Encephalopathy Seizures Ataxia +/- after a viral infection Encephalopathy Seizures Bickerstaff : Ophtalmoplegia, ataxia, coma, areflexia +/- decompensation after a viral infection Multisystemic symptoms, ataxia, dystonia, regression severe alteration of plasma osmolality or hyponatremia Encephalopathy Confusion
Brain MRI And other tests T2 and flair hypersignal pons > medulla reduction in diffusion T2 hypersignal High grade glioma : mass effect, oedema, infiltration, absent or inhomogeneous contrast enhancement Low grade glioma focal, less oedema Exophytic glioma from the 4th ventricle, as low grade glioma Langherans cell histiocytosis With hypothalamic-pituitary lesions (Epi)dermoid tumor Focal, no oedema, reduction in diffusion T2 hypersignal multiple lesions, patchy, asymmetric, +/- abscess , +/- supra-tentorial lesions CSF § : WBC ↑, protein normal or ↑, glucose : normal or ↓ Culture and PCR T2 hypersignal with supra tentorial lesions in white matter (except Bickerstaff : only brainstem) CSF § : WBC ↑, protein ↑, normal glucose, +/-oligoclonal bands, ganglioside GQ1b antibodies + in Bickerstaff T2 hypersignal Grey matter : substantia nigra, medullary and pontine tegmentum, basal ganglia and diffuse supra -tentorial leukoencephalopathy Blood test : lactate ↑, alanine ↑, urine organic acid : abnormal CSF § : protein normal or ↑, lactate ↑ Molecular analysis T2 hypersignal Central pontine myelinolysis central pons, +/- trident shape +/- midbrain and middle cerebellar peduncles Blood test : Osmolality alteration
Treatment
Anticoagulation or Aspirin +/- thrombolysis
According histology
Antimicrobial treatment
Corticoids
Vitamins and supportive therapy
Prevention Supportive therapy
Outcome good except if size > 50% or coma at presentation According histology Poor outcome in 50% According aetiology Poor Variable