Metabolic encephalopathies 2

internal medicine staff round

1. Metabolic Encephalopathies Presented By : Riham Hamdy Mostafa Neurology Resident At Cairo Hospital University

2. Agenda : Definition of encephalopathy Pathophysiology of metabolic encephalopathies Etiology of metabolic encephalopathies Common types : hepatic encephalopathy Uremic encephalopathy Diagnosis and evaluation Differential diagnosis of metabolic encepahlopathies Prognosis

3. Definition Of Encephalopathy: This term “ Encephalopathy “ is defined as altered mental status as a result of a diffuse disturbance of brain function . Or Any clinical condition that causes impairment in consciousness usually accompanied by diffuse EEG abnormalities

4. Pathophysiology Of Metabolic Encephalopathies : Mainly it depends on the cause However regardless the etiology the main mechanism is due to disruption of arousal and attention centers in the brain ( ARAS). Another mechanism including compression or injury for areas critical for memory , attention and executive functions . Abnormalities in neurotransmitters such as ( ( Ach , serotonin , GABA , dopamine , tryptophan , cytokines ) also affect these connections

5. Etiology Of Metabolic Encephalopathies :

6. Etiology Of Metabolic Encephalopathies :

7. Most Common Types Of Metabolic Encephalopathies :

8. Hepatic Encephalopathy : Pathogenesis of hepatic encephalopathy related to the acuity of developing liver failure ( high risk with acute liver failure ) Ammonia induced neurotoxicity

9. Hepatic Encephalopathy : Factors lead to hepatic encephalopathy : Hyper ammonia : astrocytes swelling and dysfunction induced vasodilation and increase cerebral edema Increase sensitivity to glutamine and GABA which are inhibitory neurotransmitters and low the threshold for seziures activity Inflammatory markers ( tumor necrosis factor ) lead to cytotoxic edema for brain cells

10. Hepatic Encephalopathy :

11. Hepatic Encephalopathy :

12. Hepatic Encephalopathy : Management : 1- cerebral edema : Monitoring of ICP is indicated in patient with grade 3&4 HE especially who are candidate to OLT. The most accurate is intraparenchymal ICP monitoring. This requires reversal of patient’s coagulopathy during placement only .

13. Management : 1- Cerebral Edema : elevate the head of bed 30 degree Maintain head in midline position Control agitation and pain Keep Co2 between 35 mm hg to 40 mm hg Maintain the patient normothermic Maintain the patient euvolmic Treat shivering Osmotic therapy : hypertonic saline 23% mannitol 20% target Na level 150 to 155meq/dl Hepatic Encephalopathy :

14. Hepatic Encephalopathy : 2- Seziures : All patient with hepatic encephalopathy should be considered for EEG monitoring More common with patient of fulminant hepatitis and Reyes syndrome Any electrolytes imbalance or hypoglyemia should be corrected Common posttransplant due to acute GABA- ergic withdrawal High risk if associated with brain hge , inc ICP Best AEDs for these patient is leverticitam

15. Hepatic Encephalopathy: 3-Hyperammonia : Lactulose is the corner stone on management of HE with nonabsorbable antibiotics such as neomycin , rifaximin especially in chronic liver failure. NAC is strongly recommended in all cases of early stage acute liver cell failure either acetaminophen overdose or not .

16. Hepatic Encephalopathy: 3-Hyperammonia : NAC affecting glutathione stores in body Oral and iv forms Loading dose 150 mg/kg in 500 ml dextrose 5% for 30 min 50 mg/kg over 4hr 1000 ml of dextrose 5% over 19 hrs Infusion continued till INR less than 1.5

17. Most Common Types Of Metabolic Encephalopathies :

18. Uremic Encephalopathy: Development of uremic encephalopathy occurred when GFR is less than normal by 10% More severe with acute patients than chronic patients Patients with hepatorenal syndrome are at higher risks

19. Uremic Encephalopathy: Pathology : Dec clearance of osmotically active toxins Proinflammatory state lead to BBB breakage Electrolytes abnormailites Seziures and myoclonus Dysequilibrium syndrome Dialysis dementia Cerebral atrophy

20. Uremic Encephalopathy: 1-Seziures and myoclonus: Occurs in about 14% to 33% either generalized or focal More common in acute renal failure and exacerbated with electrolytes abnormalities especially hyponatremia , and hypocalcemia myclonus

21. Uremic Encephalopathy: Any of abnormal movement presented in renal patient should be evaluated by EEG confirm diagnosis of myoclonus Phenytoin used as AEDs in uremic patient to control sezuires but it worse myoclonus Best choice for myoclonus is tiratam & valporic acid

22. 2-Dysequilibrium syndrome: is the occurrence of neurologic signs and symptoms, attributed to cerebral edema, during or following shortly (8hr) after intermittent hemodialysis . Due to sudden clearing of nitrogenous compounds from blood and increase urea content in brain lead to ICP Symptoms : Confusion Headache Nausea and vomiting Tremors Myclonic sezuires Usually resolve spontanously within days Uremic Encephalopathy:

23. Uremic Encephalopathy: 3-Dialysis dementia: a neurological syndrome that occurs in some long term( 2.5 yr ) dialysis  patients, is associated with aluminum intoxication (as from aluminum-containing compounds in the dialysis  fluid. Symptoms : Permenant memory loss Dysarthria Fascial grimacing Myoclonus Mood and personality changes Usually lead to death within 6 m from diagnosis

24. Diagnosis And Evaluation Of Metabolic Encephalopathies

25. Diagnosis And Evaluation Of Metabolic Encephalopathies

26. Differential Diagnosis Of Metabolic Encepahlopathies

27. Prognosis: Metabolic encephalopathy is common in the ICU setting the brain dysfunction that occurs with metabolic encephalopathy was thought to be completely reversible critically ill patients with metabolic encephalopathy are often left with long-term neurocognitive deficits . Persistent neurologic and psychiatric deficits occur in up to 32% of medical ICU survivors