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Prof. Semenov V. A., prof. Subbotin A. V.

 

Kemerovo State Medical Academy

 

Magnetic resonance imaging in patient with chronic tick-borne encephalitis and early manifestation of convulsion-hyperkinetic disorder

 

 

Currently, chronic tick-borne encephalitis is a poorly understood phenomenon. There are virtually no clinical data on its early manifestations as well as data obtained from advanced neuroimaging techniques [1].

                                                Material and methods

A rare case of chronic tick-borne encephalitis in vaccinated patient is presented. The patient N was born in 1961, was immunized twice (0.5 ml, FSME-Immun, series AB) against tick-borne encephalitis on 01.10.2009 and 25.02.2010. Acute disease: the infectious syndrome developed on 25.07.2010; the patient was admitted to the hospital on 27.07.2010, the in-hospital period was 46 days; timely outpatient follow-up is currently performed. Neurological status was assessed in the acute phase of the disease: peripheral paresis of the proximal left upper extremity nerves, 1-2 scores; tremor of the upper extremities. Discharge diagnosis: tick-borne encephalitis, meningoencephalitis, subcortical and cerebellar syndrome. The patient is in satisfactory condition.

Outpatient follow-up period between 2010 and 2014. The patient has a tremor of the upper extremities; high titers of tick-borne encephalitis virus-specific IgG antibodies are present in the samples.

EEG, performed on 06.09.2013. Short-term aperiodic oscillations formed high-amplitude sharp waves with deformed theta and delta slow wave activity in the frontal, temporal and parietal regions of the right hemisphere of the brain were recorded. Chronic tick-borne encephalitis, the onset of convulsion-hyperkinetic syndrome were diagnosed [2].

Magnetic resonance imaging (MRI) of the brain was acquired on a Siemens HARMONY 1,0T (23.08.2010), a Philips Achieva Nova 1,5T (02.11.2013), GE Brivo MR355 1,5T (03.12.2013) using the standard protocol, including T1- and T2- - weighted sequences and inversion recovery (IR).

Bioelectric brain activity was measured by electroencephalography (EEG). EEG electrode setup internationally standardized 10-20 system with bipolar and uninopolar measurements. EEG recording was carried out on 17-channel electroencephalograph “Nihon Konden” (Japan) using the software “NeuroCheck”, allowing the calculation of the spectrum signals using the fast Fourier transform for 1-16 second epochs with digital band-pass filtering, including the efficient amplitude detection and measurement in 4 frequency bands (delta, theta, alpha, beta).

Immunological studies of blood and cerebrospinal fluid to verify the causative agent were performed by ELISA in the Immunology Laboratory of the Kemerovo Regional Clinical Hospital, using test systems “Vector-Best” (Novosibirsk) Vecto-TBE-IgM, series 123, and Vecto-TBE-IgG, series 131.

 

                                            Results and Discussion

The brain MRI, performed in the subacute phase of tick-borne encephalitis (23.08.10), revealed asymmetric, predominantly left-sided multifocal white matter lesions (up to 5 foci) of hyperintense signal on T2WI and TIRM, of iso- to hypointense on T1WI, localized predominantly periventricular to posterior horns of the lateral ventricles. The foci sizes ranges from 0.5 cm to 1.0 cm with a small perifocal edema. The signs of paravasal microcirculatory disorders associated with dilated Virchow-Robin spaces in the white matter of both hemispheres have been found in the basal structures (globus pallidus, inferolateral fibers of the internal capsule) to a lesser extent. Small areas of gliosis have been observed. There were no focal changes on DWI (b = 500, b = 1000), ADC mapping.

Follow-up MRI (2013) revealed indirect signs of intracranial hypertension: enlarged perioptic subarachnoid spaces without cerebral cavity expansion; there were no signs of brain atrophy. Within the white matter of the brain (posterior watershed zone), both on the right and on the left sides (Fig. 1, 2), T2 / FLAIR hyperintense small foci, located in the juxtacortical, subcortical and deep white matter areas (the border zone) have been found; another similar focus has been visualized juxtacortical in the front insular region on the left. The foci were rounded or spindle-shaped with the radial type of location perpendicular to the boundaries of the lateral ventricles. There were no signs of pathological accumulation of gadolinium - containing contrast agent after its administration. The number of foci as well as their sizes and shapes did not undergo any significant transformation. Due to cumulative signs the referred foci probably belong to the perivascular domain, suggesting infectious / inflammatory etiology for these lesions [3].

A comparison of the obtained data with the available brain MRI findings in tick-borne encephalitis, indicating the presence of foci of neuronal inflammatory degradation of the central nervous system with reactive astrocytosis and neuronophagia [4,5], is consistent with the descriptions of pathological changes typical perivascular infiltrates with multifocal neurodegeneration and gliosis in chronic tick-borne encephalitis [6].

The presented MRI findings of the changes in the brain correspond to the manifestations of chronic tick-borne encephalitis.

 

 

 

 

 

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                                              References:

1. Khafizova I.F., Yakupov E.Z., Matveeva T.V. et al. Chronic encephalitis with disseminated encephalomyelitis (case report). // Journal of Neurology and Psychiatry in 2012, ¹9, Issue 2, P.48-51

2 Subbotin A.V. Prognostic methods for chronic encephalitis with Kozhevnikov epileptic syndrome SU 1806599 A1

3. S. Medrano Martorell, M. Cuadrado Blazquez, D. Garcia Figueredo, S. Gonzalez Ortiz, J. Capellades Font // Hyperintense punctiform images in the white matter: A diagnostic approach // Radiologa. 2012; 54 (4): R.321-335

4. Alkadhi H, Kollias SS. MRI in tick-borne encephalitis. // Euroradiology. 2000 Oct; 42 (10): 753-5.

5. Marjelund S, Tikkakoski T, Tuisku S, Räisänen S. Magnetic resonance imaging findings and outcome in severe tick-borne encephalitis. Report of four cases and review of the literature. // Acta Radiol. 2004 Feb; 45 (1): 88-94.

6. Shapoval A.N. Tick-borne encephalomyelitis. M., Med. 1980. – 255 p.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fig. 1 Supratentorial axial T2 FLAIR - weighted, slice thickness 5 mm.

 

 

 

 

Fig. 2 Supratentorial axial T2 irFSE - weighted, slice thickness 4 mm.

 

 

Authors

1 Vladimir A. Semenov – MD., PhD., Professor, FSBEI HPE “Kemerovo State Medical Academy of the Ministry of Health of the Russian Federation” (Kemerovo)

2 Anatoly V. Subbotin – MD., PhD., Professor, the Head of the Neurology, Neurosurgery and Medical Genetics Department at the FSBEI HPE “Kemerovo State Medical Academy of the Ministry of Health of the Russian Federation” (Kemerovo)

 

 

Key Words

Chronic tick-born encephalitis, MRI.

 

 

Abstract

 

The MRI findings of the early onset of chronic tick borne encephalitis with convulsion-hyperkinetic syndrome in a vaccinated patient are presented.

 

 

 

 

 

Figure notes:

Fig. 1 Supratentorial axial T2 FLAIR - weighted, slice thickness 5 mm.

Fig. 2 Supratentorial axial T2 irFSE - weighted, slice thickness 4 mm.