Magnetic resonance imaging in acute meningoencephalitis of viral and unknown origin: frequent findings and prognostic potential

Lena S Abbuehl; Mattia Branca; Anamaria Ungureanu; Andrea Federspiel; Stephen L Leib; Claudio L A Bassetti; Arsany Hakim; Anelia Dietmann

doi:10.3389/fneur.2024.1359437

Magnetic resonance imaging in acute meningoencephalitis of viral and unknown origin: frequent findings and prognostic potential

Front Neurol. 2024 Jan 17:15:1359437. doi: 10.3389/fneur.2024.1359437. eCollection 2024.

Authors

Lena S Abbuehl¹, Mattia Branca², Anamaria Ungureanu¹, Andrea Federspiel³, Stephen L Leib⁴, Claudio L A Bassetti¹, Arsany Hakim^#⁵, Anelia Dietmann^#¹

Affiliations

¹ Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
² CTU Bern, University of Bern, Bern, Switzerland.
³ Support Center for Advanced Neuroimaging Translational Imaging Center (sitem-insel), Institute for Diagnostic and Interventional Neuroradiology, Bern University Hospital, University of Bern, Bern, Switzerland.
⁴ Institute for Infectious Diseases, University of Bern, Bern, Switzerland.
⁵ Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.

^# Contributed equally.

Abstract

Background: Magnetic resonance imaging (MRI) findings in meningoencephalitis have mainly been described in terms of their diagnostic value rather than their prognostic potential, except for herpes simplex virus (HSV) encephalitis. The aims of our study were to describe frequency and anatomic locations of MRI abnormalities specific to limbic, circadian and motor systems in a cohort of meningoencephalitis patients, as well as to investigate the prognostic value of these MRI findings.

Methods: A secondary, selective analysis of a retrospective database including all meningitis, meningoencephalitis and encephalitis cases treated between 2016 and 2018 in the University hospital of Bern, Switzerland was performed. Patients with meningitis of any cause, bacterial or autoimmune causes of encephalitis were excluded.

Results: MRI scans and clinical data from 129 meningoencephalitis cases found that the most frequent causes were tick-borne encephalitis (TBE, 42%), unknown pathogens (40%), VZV (7%), and HSV1 (5%). At discharge, median modified Rankin Score (mRS) was 3 (interquartile range, IQR, 1), 88% of patients had persisting signs and symptoms. After a median of 17 months, median Glasgow Outcome Score (GOS) was 5 (IQR 1), 39% of patients still had residual signs or symptoms. All patients with HSV, 27% with TBE and 31% of those with meningoencephalitis of unknown etiology had fluid-attenuated inversion recovery (FLAIR) and to a lesser extent diffusion-weighted imaging (DWI) lesions in their initial MRI, with highly overlapping anatomical distribution. In one fifth of TBE patients the limbic system was affected. Worse outcome was associated with presence of DWI and/or FLAIR lesions and lower normalized apparent diffusion coefficient (ADC) signal intensities.

Conclusion: Presence of FLAIR lesions, restricted diffusion as well as the extent of ADC hypointensity in initial MRI are parameters which might be of prognostic value regarding the longterm clinical outcome for patients with meningoencephalitis of viral and of unknown origin. Although not described before, affection of limbic structures by TBE is possible as shown by our results: A substantial proportion of our TBE patients had FLAIR signal abnormalities in these regions.

Keywords: MRI; encephalitis; prognosis; tick-borne encephalitis; viral meningoencephalitis.

Grants and funding

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. AD was personally funded by academic research grants from the Bangerter Rhyner Stiftung and the University of Bern.