08/08/2025
The Importance of CERTAINTY IN NEURODIAGNOSTICS: From a Perspective of a Clinician.
Ayan tuloy. Dahil naghahanap ako ng challenge or an interesting case...
A 15 year old boy was referred due to a sudden generalized seizure episode. He presented with a history of fever, headaches, vomiting, elevated BPs and had later developed sensorial changes. By the time he was referred to our hospital, he couldn't communicate verbally and was exhibiting agitated behavior (nagwawala po talaga)--he would attempt to sit/stand while being prepped for a scan and, at one point, even had to be pacified by four members of the nursing staff.
As I had been trained, I laid down several differential diagnoses.
(Sa mga hindi po familiar, ang "differential diagnoses" ay ang proseso naming mga doktor ng paglalatag ng maraming posibleng teorya tungkol sa sakit ng isang pasyente. Magiisip po kami ng mga posibleng mga sakit ng pasyente, para wala pong ma-miss out, at isa-isa namin itong ieeliminate base sa mga resulta ng tests at presentasyon o development/evolution ng sakit habang lumilipas ang mga araw.)
Meron kaya syang nakain? Nainom? May exposure ba sa hayop, sa toxins, sa baha, sa chemicals?
Brain infection kaya? What kind? Meningitic, encephalitic or meningoencephalitic (probably the latter two because of the behavioral change)? Nagkaroon sya ng pamamaga ng kulani sa leeg isang linggo nakaraan, na ginamot ng oral antibiotic, konektado kaya ito? May abscess (nana) kaya sa utak?
Posterior reversible encephalopathy syndrome/ PRES? Isa itong kondisyon na kadalasan, ang likod na parte ng utak ay namamaga--isang sanhi nito ay biglaang pagtaas ng BP.
Autoimmune o limbic encephalitis kaya ito? Na kung saan ang isang parte ng utak, specifically ang limbic area, ay namamaga dahil sa autoimmunity--inaatake ng immune system nya ang sarili nyang cells.
Ginawa ang diagnostic lumbar tap. Malinis ang cerebrospinal fluid, kaya mukhang hindi infection. Wala syang exposure sa kung saan man. Sa initial CT scan, mukhang maga ang utak, wala akong makitang nana o bukol.
Forty-eight hours have passed without some improvement so I decided to schedule him for a cranial MRI because we also couldn't get clarity from informants regarding the history of his illness.
I also talked to the family and said that if they are amenable, we may possibly need to request that his brain-spine fluid and blood samples be sent to Manila for anti-neuronal antibody testing. The initial set of tests would cost in the range of 5 figures.
They said they were willing to spend for this.
A plain cranial MRI with Time of Flight Angiography and Arterial spin Labelling (ASL) CBF (available at Cagayan United Doctors Medical Center of Tuguegarao City, Inc - CUDMC MRI Center) was then done.
(What is ideal about ASL is that there is no need for contrast studies that may further stress the patient's kidneys.)
Dr. Irma Kintanar, head of the CUDMC MRI Center, and a renowned neuroradiologist, immediately communicated with me.
The patient's MRI answered our questions!
Aside from symmetric vasogenic edema (isang klase ng pamamaga) in almost all parts of the cortices (harap, side, at likod ng utak), the patient's ASL sequence showed almost all areas to be in blue color--this blue color means that these areas have very poor blood flow.
Walang involvement or pamamaga sa limbic lobe.
The patient has Atypical PRES.
As I said, PRES usually involves the posterior (bandang likod) parts of the brain, but in some cases, may also occur in other areas of the brain.
My discussion with Doc Irma helped me resolve a neurological dilemma.
I cancelled the request for the expensive antibody tests (buti naman at ang mahal ng mga 'to!).
We started the patient on some neurorestorative meds. Pediatric specialists had been adjusting anti-hypertensive meds, hydration, and decompression since admission.
Within less than 24 hours, the patient asked for water and food. He was communicating and can follow commands.
By the 6th day, patient has been transferred to a regular room and is on his way to recovery.
Interesting case, indeed.
