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PubMed1997

[Infection: impaired consciousness as the initial symptom. Clinical and pathophysiologic aspects of septic encephalopathy].

Septic encephalopathy (SE) is present in up to 70% of all patients with sepsis. In some cases, SE may proceed other parameters of sepsis. Loss of consciousness to a various extent is the leading symptom. CSF findings and CCT are usually unremarkable. EEG is a sensitive parameter to monitor SE. EEG-changes deteriorate in correspondence to the degree of SE. If sepsis can be treated successfully, clinical and electrophysiological signs are completely reversible. SE has a complex etiology. Bacterial endotoxins and other microbial products trigger the release of a multitude of mediators of sepsis. Due to liver dysfunction in sepsis, the brain neurotransmitter profile may be deranged. Other etiological factors include bacteriemia, liver or renal dysfunction, fluid and electrolyte imbalance, hypoglycemia and drug effects. Due to the prognostic significance of early adequate treatment, recognition of SE as a possible initial sign may be crucial for patients with sepsis.

Aged↗
PubMed2003

Comparison of the Glasgow Coma Scale and the Reaction Level Scale for assessment of cerebral responsiveness in the critically ill.

OBJECTIVE: The Glasgow Coma Scale (GCS) is a well-known source of error in outcome prediction models. We compared assessment of cerebral responsiveness with the GCS and the Reaction Level Scale (RLS) in two otherwise similar outcome prediction models. DESIGN AND SETTING: Prospective, observational study in a general intensive care unit. PATIENTS AND PARTICIPANTS: All admissions of patients with or at risk of developing impaired brain function between 1997 and 1998 ( n=534). MEASUREMENTS AND RESULTS: Admissions were scored by RLS and APACHE II (includes scoring with the GCS). The RLS scores were transformed to APACHE II central nervous system scores according to a predetermined protocol. APACHE II estimated probability of death was calculated conventionally with the GCS and the RLS. Vital status 90 days after admission was secured from a national database. Bias and precision was 0.5% and 16.6%, respectively. The area under receiver operating characteristic curves was slightly but significantly greater with the RLS-based APACHE II model than with the GCS-based model (0.92 vs. 0.90). Discrimination was improved primarily in admissions with low and intermediate probability of death. CONCLUSIONS: Scoring of cerebral responsiveness with the RLS instead of the GCS was associated with minimal bias of the APACHE II probability of death estimate. Assessment of consciousness in critically ill with the RLS deserves further evaluation

APACHE↗
PubMed2004

A randomised controlled study of the efficacy of hypromellose and Lacri-Lube combination versus polyethylene/Cling wrap to prevent corneal epithelial breakdown in the semiconscious intensive care patient.

OBJECTIVE: To compare the efficacy of two forms of eye care (hypromellose and Lacri-Lube combination vs polyethylene/Cling wrap covers) for intensive care patients. DESIGN: Randomised-controlled trial. SETTING: University affiliated, tertiary referral hospital. PATIENTS AND PARTICIPANTS: One hundred ten patients with a reduced or absent blink reflex were followed through until they regained consciousness, were discharged from the facility during study enrolment, died or developed a positive corneal ulcer or eye infection. INTERVENTIONS: All patients received standard eye cleansing every 2 h. In addition to this, group one ( n=60) received a treatment combining hypromellose drops and Lacri-Lube (HL) to each eye every 2 h. Group two ( n=50) had polyethylene covers only placed over the eye to create a moisture chamber. MEASUREMENTS AND RESULTS: Corneal ulceration was determined using corneal fluorescein stains and mobile slit lamp evaluation, performed daily. No patients had corneal ulceration in the polyethylene cover group, but 4 patients had corneal ulceration in the HL group. CONCLUSIONS: Polyethylene covers are as effective as HL in reducing the incidence of corneal damage in intensive care patients.

Australia↗
PubMed2001

Decision-making capacity and surrogate designation in French ICU patients.

OBJECTIVE: To evaluate the capacity and willingness of French-speaking patients to designate a surrogate within 24 h of their ICU admission. French laws fail to indicate what should be done when an otherwise legally competent patient transiently loses his decision-making capacity. DESIGN: Surrogate designation was prospectively evaluated during two study periods. Only conscious patients were assessed using the Glasgow Come Score in the first study period, and all admitted patients were assessed in the second period. Decision-making capacity was evaluated using the Mini Mental Status Examination (MMSE) in the second study period. SETTING: Twenty six-bed intensive care unit (ICU) in a French teaching hospital. PATIENTS AND PARTICIPANTS: Over a 8-month period 495 patients were included in the study, 415 in the first study period and 80 in the second. MEASUREMENTS AND RESULTS: Of the 495 patients 185 (37.3%) were interviewed, and 62.7% designated a surrogate. The surrogate was the spouse in 50% of cases and a child in 28.4%. Only 25.8% were considered to have decision-making capacity; 78.1% of competent patients and 28% of the patients without decision-making capacity agreed to designate a surrogate. CONCLUSIONS: Surrogate designation by a patient should be evaluated in the light of the decision-making capacity of the patient. The traditional French paternalism still practiced by many French physicians appears out of tune with the wishes of their patients. We suggest that there is a need for developing a simple and effective tool for assessing decision-making capacity in ICU patients.

Aged↗
PubMed2002

[Traction retinal detachment, optic atrophy, apallic syndrome after shaking trauma in an infant].

INTRODUCTION: Ophthalmological examinations are important in children with suspected shaken baby and/or battered child syndrome. Retinal and epiretinal haemorrhages can indicate non-accidental injuries. We observed a case of extensive retinal hemorrhages, edema of the optic disc followed by development of optic atrophy, neovascularisation and tractional retinal detachment over the course of months. CASE REPORT: A 6-week-old infant with no history of systemic disease or trauma was admitted to the children's hospital because of a disorder of consciousness, respiratory insufficiency, taut fontanel and dilated pupils with sluggish reaction to light. A subdural haematoma was diagnosed. Ophthalmological examination showed no signs of trauma in the anterior segment. Ophthalmoscopy revealed extensive retinal haemorrhages and swollen optic nerve heads. During the next months optic atrophy, subretinal fibrosis at the posterior pole, neovascularisation at the optic disc and non-rhegmatogenous retinal detachment developed. The child is in a persistent vegetative state. DISCUSSION: Non-accidental injuries can cause direct trauma and indirect traumatic sequelae. Retinal haemorrhages, especially in conjunction with unexplained trauma or changes of consciousness should arouse suspicion of shaken baby syndrome. The ophthalmologist should emphasize this and strongly recommend further investigation if not previously undertaken.

Battered Child Syndrome↗
PubMed2006

Aseptic meningo-radiculo-encephalitis presenting initially with urinary retention: a variant of acute disseminated encephalomyelitis.

We report three male patients with aseptic meningoencephalo- radiculitis presenting with acute urinary retention. Viral antibody titers for herpes types I and II and the PCR studies were negative. The cerebrospinal fluid revealed elevated myelin basic protein. The serum antibodies against a panel of gangliosides, some of which are known to be associated with acquired demyelinating neuropathies, were all negative. The magnetic resonance imaging (MRI) studies revealed spotty T2 high intensities in the basal ganglia, thalamus and brainstem in two patients. In one patient,meningeal gadolinium enhancement of the conus and cauda equina of the spinal cord was recognized. On urodynamic studies, all patients showed features of atonic bladder with or without detrusor hyperactivity. They were treated conservatively without using steroids or immunoglobulins, and made a remarkable functional recovery with the disappearance of abnormal MRI findings.However, all three were left with erectile dysfunction, and two continued to use self-intermittent catheterization at more than 3-year follow-up. There was no recurrence of symptoms. The underlying causes remain unclear, though they may represent a variant of acute disseminated encephalomyelitis.

Adult↗
PubMed2002

Neuroleptic malignant syndrome in a 4-year-old girl associated with alimemazine.

UNLABELLED: Neuroleptic malignant syndrome (NMS) is a rare but serious disorder caused by antipsychotic medication including phenothiazines. For sedative purposes, increasing doses of alimemazine were administered to a 4-year-old multiple handicapped girl, with cerebral damage of the basal ganglia. She developed extra-pyramidal motor disturbances, an autonomic disorder, lowered consciousness and hyperthermia, characterising NMS. Alimemazine was stopped and dantrolene and supportive measures, including ventilation under sedation and paralysis with midazolam and vecuronium, were started. As clinical symptoms remained unabated, increasing doses of bromocriptine were administered. Two days after maximal bromocriptine dosage, her clinical condition improved and paralysis and ventilation were stopped. Midazolam and bromocriptine could be gradually decreased and suspended during the following months. A few days after bromocriptine cessation NMS recurred and was complicated by a fatal cardiorespiratory arrest. CONCLUSION: caution must be exercised when prescribing alimemazine, especially to children with basal ganglia damage and in the case of inexplicable fever and restlessness, neuroleptic malignant syndrome should be considered. Long-term therapy with bromocriptine combined with dantrolene and midazolam may be a successful medical treatment.

Basal Ganglia↗
PubMed2005

Early surgery for brainstem cavernomas.

BACKGROUND: The purpose was to review our experience with the surgical management of brainstem cavernomas (BSCs) and especially the impact of the surgical timing on the clinical outcome. METHOD: We retrospectively reviewed 22 patients harboring a BSC, who underwent 23 procedures. FINDINGS: Surgery was carried out during the early stage after the last haemorrhage, with a mean delay of 21.6 days (range 4-90 days). Sixteen procedures were performed after a first bleeding event while seven after multiple bleedings. Complete resection was achieved in 19 patients (86.4%). Early after surgery, 12 patients (52.2%) improved neurologically, 5 (21.7%) were stable and 6 (26.1%) worsened. New postoperative deficits were noted after 9 procedures (39.1%). Statistically significant factors for postoperative aggravation were: late surgery (P = 0.046) and multiple bleedings (P = 0.043). No patient operated on within the first 19 days after bleeding did worsen (n = 11), as opposed to 6 out of 12 who did when operated on later. After a mean follow-up of 44.9 months, 20 patients (90.9%) were improved, 1 patient (4.6%) was worse and 1 patient was lost to follow-up (4.6%), after reoperation for rebleeding of a previously completely resected cavernoma. Late morbidity was reduced to 8.6%. The mean Glasgow Outcome Scale (GOS) at the end of the follow-up period was 4.24, compared to a mean preoperative GOS of 3.22 (P<0.001). Complete neurological recovery of motor deficits, sensory disturbances, cranial nerves (CNs), internuclear ophtalmoplegia and cerebellar dysfunction were respectively 41.7%, 38.5%, 52.6%, 60.0% and 58.3%. Among the most affected CNs: CN 3, CN 5 and CN 7 were more prone to completely recover, respectively in 60.0%, 70.0% and 69.2%. CONCLUSIONS: Surgical removal of BSCs is feasible in experienced hands with acceptable morbidity and good outcome. Early surgery and single bleeding were associated with better surgical results.

Adolescent↗
PubMed2005

Rerupture following endovascular treatment for dissecting aneurysm of distal anterior inferior cerebellar artery with parent artery preservation: retreatment by parent artery occlusion with Guglielmi detachable coils.

Distal anterior inferior cerebellar artery (AICA) aneurysms are rare and most cases have been treated surgically by clipping, wrapping or trapping. We recently treated this 20-year-old male patient by an endovascular technique. At first, he was treated by intra-aneurysmal embolisation with parent artery preservation. But he presented with rerupture 1 month after embolisation. Follow-up angiography revealed the regrowth of the aneurysm, which was considered as a dissecting aneurysm. We performed occlusion of the AICA just proximal to the aneurysm to prevent fatal rebleeding. He gradually improved and his level of consciousness fully recovered. At 2 year follow up, he had no neurological deficits. We suggest that embolisation of distal AICA aneurysm with parent artery occlusion may be safe and a simple method in the treatment of distal AICA aneurysms.

Adult↗
PubMed2006

Dural arteriovenous fistulas of the cavernous sinus with onset of intracerebral haemorrhage mimicking hypertensive putaminal hemorrhage.

We describe a patient with dural arteriovenous fistulas of the cavernous sinus (CS-dAVFs) who developed an intracerebral haemorrhage (ICH) mimicking hypertensive putaminal haemorrhage. Drainage into the superior ophthalmic vein (SOV) and inferior petrosal sinus (IPS) was not demonstrated on cerebral angiography, and only cortical venous reflux into the Sylvian vein was observed. In cases of venous drainage concentrated on the Sylvian vein, CS-dAVFs could indicate ICH with radiological appearance resembling putaminal haemorrhage.

Aged↗