Article Text

What to see when you are looking at confusion: a review of the neuroimaging of acute encephalopathy
  1. Raoul Sutter1,2,3,4,
  2. Peter W Kaplan1,2
  1. 1Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  2. 2Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
  3. 3Clinic of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
  4. 4Department of Neurology, University Hospital Basel, Basel, Switzerland
  1. Correspondence to Dr Raoul Sutter, Department of Neurology and Intensive Care Units, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland; Raoul.Sutter{at}


Acute encephalopathy is a clinical conundrum in neurocritical care facing physicians with diagnostic and therapeutic challenges. Encephalopathy arises from several concurrent causes, and delayed diagnosis adds to its grim prognosis. Diagnosis is reached by melding clinical, neurophysiological and biochemical features with various neuroimaging studies. We aimed to compile the pathophysiology of acute encephalopathies in adults, and the contribution of cerebral CT, MRI, MR spectroscopy (MRS), positron emission tomography (PET) and single-photon emission CT (SPECT) to early diagnosis, treatment and prognostication. Reports from 1990 to 2013 were identified. Therefore, reference lists were searched to identify additional publications. Encephalopathy syndromes best studied by neuroimaging emerge from hypoxic-ischaemic injury, sepsis, metabolic derangements, autoimmune diseases, infections and rapidly evolving dementias. Typical and pathognomonic neuroimaging patterns are presented. Cerebral imaging constitutes an important component of diagnosis, management and prognosis of acute encephalopathy. Its respective contribution is dominated by rapid exclusion of acute cerebral lesions and further varies greatly depending on the underlying aetiology and the range of possible differential diagnoses. CT has been well studied, but is largely insensitive, while MRI appears to be the most helpful in the evaluation of encephalopathies. MRS may provide supplementary biochemical information and determines spectral changes in the affected brain tissue. The less frequently used PET and SPECT may delineate areas of high or low metabolic activity or cerebral blood flow. However, publications of MRS, PET and SPECT are limited only providing anecdotal evidence of their usefulness and sensitivity.

  • Behavioural Disorder
  • Neuroradiology
  • MRI
  • MRS
  • PET

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