Acute necrotising encephalitis of childhood (ANEC) is a rare type of encephalopathy characterized by multiple bilateral brain lesions, mainly involving the thalami, but also the putamina, internal and external capsules, cerebellar white matter, and the brainstem tegmentum.
ANEC is a rare condition with less than 150 cases reported in literature. From the first case described in 1995, many cases have been reported both in Asia as well as western countries. Most cases are sporadic; however, few cases of recurrent and/or familial episodes have been reported suggesting an inherited pattern.
ANEC is seen in children around the age of 4 years. Clinically, it is characterized by acute encephalopathy, with dramatical neurological deficits/symptoms. A viral etiology has been proposed in some cases; viral prodrome hence may precede the neurological deficits.
The aetiology and the pathogenesis of ANEC remain partially clear. Usually, it develops secondary to viral infections, including influenza A and influenza B, parainfluenza, varicella and enterovirus.
Pathologically, the lesions show oedema, haemorrhage, and necrosis. ANEC is characterised by the lack of inflammatory cells in affected brain parenchyma in comparison to the more common entities of acute disseminated encephalomyelitis and acute hemorrhagic encephalitis 1.
On a CT-scan, the corresponding thalamic, putamina, cerebral, cerebellar and brainstem density abnormalities are hypodense.
Intracranial hemorrhage and cavitation may also be seen, both of which are associated with a worse prognosis.
In most cases of ANEC, there is bilateral symmetrical thalamic involvement. Abnormal signals on MRI are hypointense on T1 and hyperintense on T2. These findings can be quite extensive. Haemorrhage, cavitation, and post contrast enhancement are also seen.
Treatment and prognosis
ANEC carries a very poor prognosis; the mortality rate is near 70%. Treatment is mainly supportive, as the precise etiology remains unknown.
If characteristic symmetric imaging findings are present, the differential diagnosis is limited. Lactic acidosis is not a classic finding of ANEC. Otherwise, the differential diagnoses include:
- 1. Wong AM, Simon EM, Zimmerman RA et-al. Acute necrotizing encephalopathy of childhood: correlation of MR findings and clinical outcome. AJNR Am J Neuroradiol. 2006;27 (9): 1919-23. AJNR Am J Neuroradiol (full text) - Pubmed citation
- 2. Skelton BW, Hollingshead MC, Sledd AT et-al. Acute necrotizing encephalopathy of childhood: typical findings in an atypical disease. Pediatr Radiol. 2008;38 (7): 810-3. doi:10.1007/s00247-008-0823-z - Pubmed citation
- 3. Gallucci M, Smith JD, Limbucci N et-al. Pediatric Inflammatory Diseases. Part II: Acute Post-Infectious Immune Disorders. Neuroradiol J.25 (6): 702-14. Pubmed citation
- 4. Khan MR, Maheshwari PK, Ali SA et-al. Acute necrotizing encephalopathy of childhood: a fatal complication of swine flu. J Coll Physicians Surg Pak. 2011;21 (2): 119-20. Pubmed citation
- 5. Wu X, Wu W, Pan W et-al. Acute necrotizing encephalopathy: an underrecognized clinicoradiologic disorder. Mediators Inflamm. 22;2015: 792578. doi:10.1155/2015/792578 - Free text at pubmed - Pubmed citation