Brain Lesions in Septic Shock

1. BRAIN LESIONS IN SEPTIC SHOCK
Ade Wijaya, MD – June 2018

2. OUTLINE
• Sepsis and Septic Shock
• Introduction
• Post-mortem examination
• Pathophysiology
• Brain lesions on MRI
• Summary

4. INTRODUCTION
• Septic shock mortality : 40 – 60 %
• Delirium in 70-80 % sepsis patients related to poor outcome
• Pathological processes seen on MRI
Annane D, Bellissant E, Cavaillon J-M (2005) Septic shock. Lancet 365:63–77
Nguyen DN, Spapen H, Su F, Schiettecatte J, Shi L, Hachimi-Idrissi S, Huyghens L (2006) Elevated serum levels of S-100β protein and neuronspecific enolase are associated with brain injury in patients with severe sepsis and septic shock. Crit
Care Medicine 34:1967–1974
Eidelman LA, Putterman D, Putterman C, Sprung CL (1996) The spectrum of septic encephalopathy. Definitions, etiologies, and mortalities. JAMA 275:470–473

5. POST-MORTEM EXAMINATION
• Ischaemia
• Haemorrhage
• Disseminated intravascular coagulopathy
• Micro-abscesses
• Multifocal necrotising leucoencephalopathy
Sharshar T, Annane D, de la Grandmaison G, Brouland JP, Hopkinson NS, Gray F (2004) The neuropathology of septic shock. Brain Pathol 14:21–33
Sharshar T, Gray F, Poron F, Raphael JC, Gajdos P, Annane D (2002) Multifocal necrotizing leukoencephalopathy in septic shock. Crit Care Med 30:2371–2375

6. PATHOPHYSIOLOGY
• BBB breakdown
• Neuronal damage resulting from metabolic or inflammatory mediators
• Brain inflammation and nitric oxide induced neuronal apoptosis
Papadopoulos MC, Lamb FJ, Moss RF, Davies DC, Tighe D, Bennett ED (1999) Faecal peritonitis causes oedema and neuronal injury in pig cerebral cortex. Clin Sci (Lond) 96:461–466
Sharshar T, Hopkinson NS, Orlikowski D, Annane D (2005) The brain in sepsis – culprit and victim. Crit Care 9:37–44
Sprung CL, Cerra FB, Freund HR, Schein RM, Konstantinides FN, Marcial EH, Pena M (1991) Amino acid alterations and encephalopathy in the sepsis syndrome. Crit Care Med 19:753–757
Sharshar T, Gray F, Lorin de la Grandmaison G, Hopkinson NS, Ross E, Dorandeu A, Orlikowski D, Raphael J-C, Gajdos P, Annane D (2003) Apoptosis of neurons in cardiovascular autonomic centres triggered by inducible nitric oxide
synthase after death from septic shock. Lancet 362:1799–1805

7. BRAIN LESIONS ON MRI
• Leukoencephalopathy
• Ischaemic stroke in watershed area
• MCA thrombosis
Sharshar T, Carlier R, Bernard F, Guidoux C, Brouland JP, Nardi O, de la Grandmaison GL, Aboab J, Gray F, Menon D, Annane D. Brain lesions in septic shock: a magnetic resonance imaging study. Intensive care medicine. 2007 May
1;33(5):798-806.

8. SUMMARY
• Septic shock causing pathological processes in the brain
• Brain lesions: leukoencephalopathy, watershed infarction, MCA
thrombosis