Inflamatory condition of the brain. encephalopathy and meningitis. prepared for 4th year physiotherapy students.

1. Inflammatory
disorders of brain
Ashik Dhakal

2. Learning objectives
Different Inflammatory brain conditions
Clinical picture
Diagnosis
Assessment
Goals
Management

3. Introduction
Each patient with these condition presents a combination of problems that is
unique to that pt and requires the creative design of an intervention program.
The management of the clinical problems is built on an understanding of the
underlying pathological condition.

4. The infecting agents may be bacteria, viruses, prions, fungi, protozoa, or
parasites.
The most common agents producing meningitis are bacterial, the most
common agents producing encephalitis are viral.
The site of the infection will determine the signs and symptoms of the CNS
infections, whereas the infecting organism including the time course and
severity determines the prognosis.

5. Categorization of Inflammatory Disorders
Inflammatory disorders of the brain can be categorized based on the anatomical location of the inflammatory
process and the cause of the infection, as follows:
A. Brain abscess
B. Meningitis (leptomeningitis)
Bacterial meningitis
Aseptic meningitis (viral)
C. Encephalitis
1. Acute viral
2. Parainfectious encephalomyelitis
3. Acute toxic encephalopathy
4. Progressive viral encephalitis
5. Slow virus encephalitis

6. Brain abscess
Brain abscesses occur when microorganisms reach brain tissue from a
penetrating wound to the brain (soon after the trauma or several years later),
by extension of local infection such as sinusitis or otitis or by hematogenous
spread from a distant site of infection.
Multiple abscesses may originate from the spread of microorganisms
through the blood.
Compromised immune system (chronic corticosteroid or other
immunosuppressive drug administration, administration of cytotoxic
chemotherapeutic agents, or HIV infection) predispose to develop
opportunistic infections.

7. The site and size of the abscess influence the initial symptoms.
Classic presenting triad : (occurs in <50%of pt)
increased intracranial pressure,
a focal neurological deficit,
and fever
Medical management : antibiotic therapy (depending on the infecting agent
and size and site of the abscess) and also surgical aspiration or excision.

8. Meningitis

9. Definition :
Meningitis is the infection and inflammation of the meninges and the
cerebrospinal fluid.

10. Signs and symptoms

11. Causative agents
Neonatal and older adult:- gram-negative enterobacilli, especially
Escherichia coli, and group B streptococci occur most frequently.
Children:- H.influenzae, Neisseria meningitidis, S. pneumoniae, S.
pneumoniae, N. meningitidis, and H. influenzae are the most common
causes of community-acquired meningitis.
Young children most often, adolescents and young adults:- Meningococci.
Individuals with a condition such as sickle cell anemia, alcoholism, or
diabetes mellitus and immunosuppressed are at increased risk.

12. Period of communicability
A person can pass the infection to others for as long as the bacteria are
present in discharges from the nose and mouth.
A person is no longer infectious within 24 to 48 hours after starting antibiotic
treatment.

13. Mode of transmission
Both viral meningitis and bacterial meningitis can be transmitted through
direct contact with nose and throat secretions of infected person (Droplet).
Healthy persons, who have no signs of illness, can carry these bacteria in
their nose or throat.
Viral meningitis can also be transmitted through fecal-oral route.

14. Other routes of bacterial infection
local spread as the result of an infection of the middle ear or mastoid air
cells.
As a complication of a skull fracture, which exposes CNS tissue to the
external environment or to the nasal cavity.
Fractures of the cribriform plate of the ethmoid bone producing CSF
rhinorrhea provide another route for infection.
Traumatic head injury.

15. Pathogenic signs
Nuchal rigidity:
Inability to flex the head forward due to rigidity of the neck muscles.

16. Kernigs’s sign :
It is positive when the leg is bent at the hip and knee at 90 degree angles and
subsequent extend the knee.
Resistance or pain and the inability to extend the patient's knee beyond 135 degrees,
because of pain, bilaterally indicates a positive Kernig's sign

17. Brudzinski's signs
It is the appearance of involuntary lifting of the legs in meningeal irritation
when lifting a patient's head off the examining couch, with the patient lying
supine.

18. Neurological sequelae occur in 20% to 50% of the cases, such as
Inflammatory or vascular involvement of the cranial nerves
Thrombosis of the meningeal veins.
Weeks to months after treatment, subacute or chronic pathological changes
may develop, such as communicating hydrocephalus.
The risk of an acute ischemic stroke is greatest during the first 5 days.
Approximately 5% of the survivors will have weakness and spasticity.
Other clinical symptoms: hemiparesis, ataxia, seizures, cranial nerve palsies, and gaze
preference, cognitive slowness.

19. Diagnostic procedure
Lumbar Puncture (Increase Protein and WBC, Low Sugar level)
CSF : To check for organisms known to cause illness.
BloodCulture
To check for bacteria in the bloodstream
To determine the specific bacteria causing an infection and selecting the
appropriate antibiotic to treat it.

20. The type and severity — directly relate to the
Area affected
Extent of CNS infection
Age and general health of the individual
The level of consciousness at the initiation of pharmacological therapy
The pathological agent involved

21. Imaging
X-rays and CT scans of the head, chest or sinuses may reveal swelling or
inflammation.
Also help to look for infection in other areas of the body that may be
associated with meningitis.

22. Drugs of choice
Antibiotics:
Ampicillin
Other drugs include, Digoxin (to control arrythmias), Mannitol (to decrease
cerebral edema) or a Sedative (to reduce restlessness) and Aspirin or
Acetaminophen (to relieve headache and fever).

23. Rifampicin and Ciprobay
Anti-fungal, Antibiotic, Mannitol
Corticosteroid (Dexamethasone/Solucortef)
Anti-convulsant (Phenytoin) (to reduce restlessness)

24. Medical management :
Vancomycin Hydrochloride in combination with one of the Cephalosporins
is administered IV.
Dexamethasone
Dehydration and shock are treated with fluid volume expanders.
Phenytoin - treatment for seizures if occurs.

25. Pathophysiology
Nasopharyngeal Colonization
Local Invasion
Bacteremia
Endothelial Cell Injury
Meningeal Invasion
Sub arachnoid Space Inflammation
Increased CSF outflow resistance
Interstitial Edema
Increased Intracranial Pressure
Decreased Cerebral Blood Flow

26. Aseptic Meningitis.
Aseptic meningitis refers to a non-purulent inflammatory process confined to
the meninges and choroid plexus.
It is usually caused by contamination of the CSF with a viral agent, although
other agents can trigger the reactions.
The symptoms are similar to those of acute bacterial meningitis but typically
are less severe.
The individual may be irritable and lethargic and complain of a headache, but
cerebral function remains normal unless unusual complications occur.
Aseptic meningitis of a viral origin usually causes a benign and relatively short
course of illness.

27. The enteroviruses (echoviruses and the Coxsackie viruses), herpesviruses,
and HIV are the most common causes.
The primary non-viral causes of aseptic meningitis are Lyme Borrelia and
Leptospira.
The glucose level of the CSF in bacterial meningitis is usually depressed, but
in viral meningitis it is normal.
Treatment of aseptic meningitis consists of management of symptoms.
The condition does not typically produce residual neurological sequelae, and
full recovery is anticipated within a few days to a few weeks.

28. Encephalitis :
Encephalitis is irritation and swelling (inflammation) of the brain
parenchyma, most often due to infections.
Encephalitis with meningitis is known as meningoencephalitis.

29. Causative agents
Rural areas : Arboviruses or Arthropod-borne Viruses (viruses carried by
arthropods, such as mosquitoes and tick)
Urban areas : Most frequently caused by Enteroviruses (Coxsackievirus,
Poliovirus and Echovirus)

30. Signs and symptoms
Severe headache
Fever
Vomiting
General malaise
Altered consciousness
Confusion or agitation
Personality changes
Seizures
Nuchal rigidity,

31. Loss of sensation or paralysis in certain areas of the body
Muscle weakness
Hallucinations
Double vision
Perception of foul smells
Problems with speech or hearing
Hypersensitivity or exaggerated emotional responses

32. Acute viral encephalitis : exclusively CNS infection. eg, herpes simplex
encephalitis.
Parainfectious encephalomyelitis is associated with viral infections such as
measles, mumps, or varicella.
Reye syndrome :global neurological signs, such as hemiplegia and aphasia,
are usually present.

33. Drug of choice
Antiviral medications, such as Acyclovir (Zovirax) and Foscarnet (Foscavir)
— to treat herpes encephalitis or other severe viral infections (however, no
specific antiviral drugs are available to fight encephalitis)
Antibiotics — if the infection is caused by certain bacteria
Anti-seizure medications (Phenytoin) — to prevent seizures
Steroids (Dexamethasone) — to reduce brain swelling (in rare cases)
Sedatives — to treat irritability or restlessness
Acetaminophen — for fever and headache

34. Diagnostic procedure
Lumbar puncture
To check the spinal fluid for an increase in white blood cells and protein.
Electroencephalography(EEG)
To identify abnormal brain waves.
To diagnose certain seizure disorders, brain damage from head injuries, specific
viral infections such as herpes virus, and inflammation of the brain.
Blood tests.
To test type of virus.
Specific diagnosis may be established only by biopsy or autopsy.

35. CT SCAN and MRI
This can reveal signs of brain inflammation, hemorrhage, or other brain
abnormalities

36. Mode of transmission
Breathing in respiratory droplets from an infected person
Skin contact
Mosquito, tick, and other insect bites
Tick of Horses
Migratory Birds
Contaminated food or drink

37. Pathophysiology
Arthropod - Borne Virus
Mosquito bite
Inadequate Host Immune Response
Viremia
Cerebral Capillaries
Central Nervous System
Cortical Gray Matter, Brain Stem and Thalamus
Meningual Exudates
Irritating The Meninges
Increasing Intracranial Pressure

38. • Fungal encephalitis
Fungal Spores (enter body through inhalation)
Infect the Lungs
Vague Respiratory Symptoms or Pneumonitis
Bloodstream
Fungemia
Central Nervous System
Encephalitis

39. Therapeutic Management of encephalitis
Observation of Current Functional Status
Evaluation of Physiological Responses to Therapeutic Activities
Examination of Functional Abilities
Evaluation of Sensory Channel Integrity and Processing
Examination of Movement Abilities

40. Practice patterns for physical therapists that apply to this population include
the following:
5C: Impaired Motor Function and Sensory Integrity Associated with Non-
progressive Disorders of the Central Nervous System—Congenital Origin or
Acquired in Infancy or Childhood
5D: Impaired Motor Function and Sensory Integrity Associated with Non-
progressive Disorders of the Central Nervous System—Acquired in
Adolescence or Adulthood
5I: Impaired Arousal, Range of Motion, and Motor Control Associated with
Coma, Near Coma, or Vegetative State
5A: Primary Prevention/Risk Reduction for Loss of balance and falling.

41. Management of inflammatory brain conditions
Maintain fluid and nourishment
Sedatives
Corticosteroids
Antibiotics and antiviral
Anti convulsions
PT management :
Assessment
Outcome
Treatment

42. PT Assessment
Presenting complains : headache, nausea, vomiting, fever, convulsions, confusion,
abnormal movements
History: preceding infection, general weakness, frequent headache
Vitals :BP,PR,RR, temp abnormalities may be noted
Observation :
Posture : abnormal posturing
Gait : may be ataxic
Limb attitude : abnormal attitudes (synergies)
Abnormal respiratory patterns

43. Higher function :
Level of consciousness : altered sensorium
Orientation : confusion
Memory : affected
Speech : dysarthria, aphasia, mutism
Cranial nerve assessment : features of lower cranial nerve palsy will be seen
Sensory system : impaired
Tonal abnormalities will be present
Reflexes : exaggerated DTR, positive plantar response, presence of primitive reflexes.

44. ROM : decreased range and flexibility
Strength : decreased
Chest examination and respiratory assessment: accumulation of secretions,
decreased chest expansion or abnormal respiratory pattern may be seen
Gustatory examination: swallowing and speech difficulty.

45. Bladder and bowel involvement
Functional disability
Special test : kernig, brudjinski shows positive response

46. Investigations : blood and CSF examination, CT or MRI, gram stain, biopsy
Problem listing

47. Outcome measures
Barthel index
FIM
BBS
OGA

48. PT aims
Psychological support
Prevent chest complication
Prevent DVT, PS
Correct deformity
Promote vital functions
Normalize tone
Normalize postural reflexes
Promote integration of sensory input
Promote voluntary movement pattern
Improve overall function

49. Management
1. Psychological support
Maintain a non threatening positive attitude
Gain confidence of the patient
Concealing of family members and patient
Give information as necessary only

50. 2. Prevent chest complications
Breathing exercise, postural drainage and suctioning as required
Cervical and thoracic mobility exercise
Strengthening of respiratory muscles

51. 3. Prevent DVT
Active and passive ATM
Active limb exercise
Limb elevation
Early mobilization as soon as possible
Propped up position in bed and bed mobility exercise

52. 4. Prevent PS
Positioning
Use of water bed
Regular inspection of the skin
Use cotton clothing to absorb sweat
Avoid dragging during transfer
Regular position change

53. 5. Correct deformity
Proper positioning
if synergy is present, facilitation and inhibition techniques
Splinting and serial casting

54. 6. Promote vital functions
Improve respiratory capacity with positioning and tech s/a glossopharyngeal
breathing exercise in respiratory paralysis
Keeping the neck in slight flexion improves respiratory capacity
Specific position - air entry in targeted lobes
Maintaining cardio respiratory endurance with active exercise of possible
muscle work

55. 7. Normalize tone
Use facilitation and inhibitory technique.
8. Promote integration of sensory Stimulation by combined proprioceptive,
visual & auditory input
• Cues & commands
• Demonstration of activity
• Sensory re education if necessary
• Training in different environment

56. 9. Promote voluntary movement pattern
• Open kinematic chain exercise to improve mobility
• Close kinematic chain exercise to improve stability
• Transfer techniques
• Including functional challenges
• Problem solving task

57. 10. Improve overall function
• Maintenance of physical activity
• Maintenance of CV endurance
• Early Return to activity or work

58. Thank you