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PubMed2001

[A case of spontaneous intracranial hypotension with simultaneous CSF leaks at the upper and lower thoracic levels].

We presented a patient of spontaneous intracranial hypotension (SIH), in which radionuclide cisternography demonstrated multiple CSF leaks. A 51-year-old previously healthy woman awoke with a severe headache and nausea that were almost completely relieved by lying flat (day 1). The headache was not relieved by analgesics. On day 10, she visited our clinic. Neurological examination showed no abnormalities. A lumbar puncture revealed an opening pressure of 50 mmH2O, protein level of 64 mg/dl, 21 erythrocytes 21/microliter, and 4 lymphocytes/microliter. Cranial MRI on day 11 with gadolinium infusion demonstrated diffuse thickening and enhancement of the meninges. No signs of venous sinus thrombosis were identified. There was no downward displacement of the cerebellar tonsils. Indium-111 radionuclide cisternography demonstrated early accumulation of the tracer in the urinary bladder and CSF leakage at the upper thoracic level on the left side, at the lower thoracic level on both sides, and at the lumbar level. It is noteworthy that the scintigram taken 4 hours after tracer injection demonstrated CSF leakage at the injection site but not in the upper thoracic area. The patient kept sitting for about 20 minutes just before the images were obtained. Spinal MRI did not show meningeal diverticulum and epidural fluid collection. Ten days of bed-rest and transfusion failed to relieve the headache. Epidural patching with 7 ml of autologous blood performed at the Th2/3 interspace partially relieved the headache. Five days later, a second epidural patching was performed at Th11/12, which was slightly effective. A third epidural patching at L3/4 was ineffective. On day 32, a fourth epidural patching was performed at Th1/2 while the patient was lying down on her left side. The postural headache disappeared. Repeated cranial MRI with gadolinium infusion performed on day 47 showed resolution of the abnormal findings. To our knowledge, this is the second case report of SIH with double CSF leaks. To localize multiple leaks, radionuclide cisternography should be performed with a patient in various positions just before images are obtained.

Cerebrospinal Fluid↗
PubMed2002

[Bilateral papilledema in young women: two case reports of benign intracranial hypertension?].

We report two cases of bilateral papilledema in young women. The first patient was 15 years old and had experienced headaches and vomiting for one month, but no visual loss. Cerebral tomodensitometry results were normal, but lumbar puncture showed increased pressure and normal biology. Benign intracranial hypertension was diagnosed. Recent treatment with minocycline for acne vulgaris was the only etiology. Papilledema was totally regressed at 6 weeks, after interruption of the antibiotic treatment. A prescription of acetazolamide was added for a short period of 10 days. The second patient, aged 29 years, presented bilateral papilledema with severe visual loss, with vision limited to light perception with mydriasis of the right eye. Lumbar puncture was not indicated because of a hypophyseal microadenoma revealed on MRI investigation. No other associated abnormalities were observed, in particular, no cerebral sinus thrombosis. Corticotherapy using prednisolone for 72 hours had no clinical effect. Fast visual recovery was obtained with intravenous acetazolamide therapy and was completely resolved at 2 months. Right visual field defects persisted. Minocycline and obesity are recognized as precipitating factors in pseudotumor cerebri syndrome. The literature advocates consideration of surgical treatment by optic nerve sheath fenestration if antiedematous treatment has no effect and the eye is nearly blind.

Acetazolamide↗
PubMed2003

Raised intracranial pressure and seizures in the neurological intensive care unit.

BACKGROUND: The relationship between changes in intracranial pressure and incidence of subclinical seizures in patients requiring neurological intensive care is not fully understood. The aim of this study was to investigate if acute increases in intracranial pressure were accompanied by subclinical seizures. METHODS: We prospectively studied 17 intensive care patients (11 male, aged 3-66 yr) who were selected from 85 patients requiring intracranial pressure measurement. Patients were selected to have a 30 min, 16-channel electroencephalogram (EEG) recorded when intracranial pressure remained increased despite preliminary treatments. RESULTS: Diagnoses included head injury, intracranial haemorrhage, subarachnoid haemorrhage and sagittal sinus thrombosis. All patients had at least one acute episode of intracranial pressure increase. Pressures ranged from 90 to 440 mm H(2)O. Encephalopathic features (delta/theta rhythms and burst suppression) were noted on all EEGs. No seizure activity was recorded. CONCLUSIONS: We conclude from this pilot study that seizures are an uncommon cause of acute raised intracranial pressure. To determine whether raised intracranial pressure causes seizures, long-term monitoring in a large cohort of intensive care patients would be necessary, studying patients with similar diagnoses and ages.

Adolescent↗
PubMed2003

Idiopathic hypertrophic cranial pachymeningitis: case report with 7 years of imaging follow-up.

Idiopathic hypertrophic cranial pachymeningitis is a rare inflammatory disease with diffused involvement of the dura. Often, the definite diagnosis is made immediately with biopsy and the involved dura is removed surgically. Consequently, extensive preoperative imaging studies usually are not available. We reviewed a case of idiopathic hypertrophic cranial pachymeningitis and collectively summarized the interesting features from the 7 years preceding surgical treatment. These chronologic imaging findings with progressive intracranial involvement included dural thickening, dural mass, sinus thrombosis, and venous congestion constituted comprehensive pictures of idiopathic hypertrophic cranial pachymeningitis. The thickened dura may also at times mimic dural masses, such as en plaque meningioma.

Adult↗
PubMedDate not supplied

The safety and practicality of selective head cooling in asphyxiated human newborn infants, a retrospective study.

UNLABELLED: To evaluate the practicality and safety of selective head cooling in asphyxiated human newborn infants. DESIGN: Retrospective chart analysis of asphyxiated neonates. SETTING, PATIENTS AND INTERVENTION: During a period of 13 months (1st June 1998 to 30 June 1999) fourteen newborns (10 mild and 4 moderate PHIE) were managed by selective head-cooling (mean GA 38.8 +/- 2.3) and 12 newborns (9 mild and 3 moderate PHIE) were managed conservatively without head cooling and served as controls (mean GA 39.1 +/- 1.6). Selective head cooling was accomplished by applying cool-packs to the parieto-temporal regions. RESULTS: There were no significant differences in the perinatal characteristics of the two groups. The mean scalp temperature of 33.8 +/- 0.4 degrees C (28.7-36.5 degrees C) was lower than the mean body temperature of 35.8 +/- 0.2 degrees C (32.2-37.0 degrees C) in the study group during the cooling period, compared to a mean body temperature of 36.7 +/- 0.2 degrees C (36.1-37.3 degrees C) in the control group during the study period. There were no significant differences in the incidence of possible adverse effects between the two groups of infants. No infants developed cardiac arrhythmia, bradycardia, pulmonary edema or hemorrhage, metabolic acidosis, hypoglycemia, hypokalemia, NEC, systemic infection, thrombocytopenia, polycythemia, or cavernous sinus thrombosis during cooling. CONCLUSIONS: Our data demonstrates that selective head cooling is practical and effective in keeping a gradient between the scalp and body temperature with no observed systemic side effects.

Asphyxia Neonatorum↗
PubMed2003

[Vascular complications after acoustic neurinoma surgery].

OBJECTIVE: To report six cases of vascular complications occurring after acoustic neuroma surgery and to discuss the postoperative signs and symptoms that should alert the surgeon, in order to undertake the appropriate treatment as soon as possible. METHODS: Four hundred thirty-two cases of acoustic tumors operated by the same surgeons between January 1991 and December 2000 were reviewed. RESULTS: Six cases of vascular complications were identified: one case of cerebral vasospasm secondary to persistence of subarachnoid blood after injury to Dandy's vein; three cases of arterial infarction giving rise to a partial anterior inferior cerebellar artery (AICA) syndrome with an unusual nystagmus in two cases (ipsilateral in one patient and strong controlateral in one patient presenting preoperative vestibular areflexia); one case of hematoma of the cerebello-pontine angle (CPA) causing strong ipsilateral nystagmus; and one case of venous infarction of the cerebellar vermis secondary to accidental sinus thrombosis. CONCLUSIONS: Vascular complications after acoustic neuroma surgery are potentially devastating and should be identified as early as possible. Rapid extubation is recommended for systematic neurologic assessment. Among abnormal signs and symptoms that should alert the surgeon, marked nystagmus ipsilateral to the operated side or contralateral in patient presenting preoperative vestibular areflexia appears to be of great value.

Adult↗
PubMed1992

Otitis media and CNS complications.

Intracranial complications from otitis media can be quite devastating to the patient if an early diagnosis is not made. Patients may develop meningitis, venous sinus thrombosis or cranial nerve palsies, as well as intracranial abscess. The presenting features in such cases may be subtle and include headache, nausea, vomiting, personality changes and signs of increased intracranial pressure as well as focal neurological deficits. A case of intracranial brain abscess is presented in a patient with a history of chronic otitis media with cholesteatoma. Delay in the diagnosis of intracranial complications of otitis media can lead to improper treatment with increased morbidity and mortality. The etiology and treatment of complications affecting the CNS is discussed.

Brain Abscess↗
PubMed1992

Four-year experience with bronchial asthma in a pediatric intensive care unit.

Charts of all children with severe acute asthma admitted to the Pediatric Intensive Care unit (PICU) of this hospital between January 1987 and December 1990 were reviewed retrospectively. There were 47 admissions for life threatening asthma to the PICU over this period, representing about 2% of all acute asthma admissions to our hospital. The mean duration of symptoms in these patients before admission was 54 hours. Only 55% of the PICU admissions had received bronchodilators before coming to our hospital emergency room from where they were admitted. From arterial blood gas analysis, 57% of the patients had hypercapnia (PaCO2 > 45 mmHg). All the patients received nebulized salbutamol frequently as well as intravenous aminophylline and hydrocortisone. Mechanical ventilation was used in only 8.5% of the patients. Only two patients developed pneumothorax, neither of whom had been mechanically ventilated, but they did not require surgical intervention for drainage. There was only one death in a patient who was known to have sickle cell anemia and developed sagittal sinus thrombosis. We conclude from our series that the mortality for children with life threatening asthma admitted to PICU is very low if bronchodilators and steroids are used optimally in their management, along with judicious selection of those requiring mechanical ventilation.

Asthma↗
PubMed2003

[Vascular endothelial growth factor expression in the rat dural arteriovenous fistula model].

UNLABELLED: Although various mechanisms of the development of dural arteriovenous fistula (DAVF) have been proposed, the pathogenesis of these lesions are still unclear. Recent experimental evidence suggested a role of angiogenic growth factors in the genesis of vascular malformations of the central nervous system. To further investigate the pathogenesis of DAVF, we examined the expression of the angiogenic growth factor, vascular endothelial growth factor (VEGF), in rat DAVF model. MATERIAL AND METHODS: Male Wistar rats (weighting 280 to 300 g, n = 40) were used. Each rat was mounted on a stereotaxic frame under general anesthesia. DAVF model (Spetzler et al.) was made by common carotid artery-external jugular vein anastomosis, bipolar coagulation of the vein draining the transverse sinus, and superior sagittal sinus thrombosis (SSS). SSS was thrombosed by a hemostatic agent through 16-gauge needle. Venous hypertension was induced in 30 rats, which were divided into two experimental groups; (1) immunohistological study group (n = 15) and (2) angiography group (n = 15). Immunohistological analysis was performed by VEGF antibody 1 week after, and angiography was done 90 days after the surgery. Developing of angiographical DAVF was observed with the magnifying X-ray camera. Each 5 rats served as sham-operated controls, which received a similar surgery without induction of venous hypertension. RESULTS: VEGF expression and DAVF were not observed in sham group. In immunohistological study group, VEGF expression in the endothelium and the connective tissues of the dura mater in the five rats (33%) and in the neurons in the eleven rats (73%) of the cerebral cortex and the basal ganglia were identified. In angiography group, DAVF formed in 6 among 15 rats (40%). CONCLUSION: The findings of this study provide the first experimental evidence that angiogenic growth factors VEGF may participate in the genesis of DAVF. These results suggest a novel strategy for the management and prevention of DAVF and related disorders.

Animals↗
PubMed1992

[A case of benign intracranial hypertension with fluctuated symptoms and CSF pressure synchronized with menstrual cycle].

A 39-year-old woman presented with a 2-month history of repeated severe headache, nausea and diplopia. On admission she was obese with bilateral papilledma and abducens weakness. Mass lesion and sinus thrombosis were ruled out by brain CT and angiography. CSF pressure was normal initially. CSF pressure fluctuated with menstrual cycle, sometimes showing over 600 mmH2O with worsening of the symptoms. She was diagnosed as benign intracranial hypertension (BIH). Diuretics did not improve the symptoms, and visual disturbances ensued and deteriorated. A spinal subarachnoid space-peritoneal shunt was inserted to control CSF pressure, showing rapid improvement of headache and diplopia but visual disturbances remained almost unchanged. Optic nerve sheath fenestration was performed without improvement of visual deterioration. We postulated multiple factors such as obesity, menstrual abnormality, iron deficiency anemia and analgesic drugs played important roles to produce BIH in this case. Careful quantitative perimetry should be done to decide a suitable time for surgical treatment in BIH.

Adult↗
PubMedDate not supplied

[Stroke as the first manifestation of a concealed pancreatic neoplasia].

INTRODUCTION: Stroke is very seldom seen as the first manifestation of a neoplasia. The mechanisms that are most frequently involved in its pathogenesis are Trousseau's syndrome, haematological disorders such as disseminated intravascular coagulation or thrombocytosis, and the release of mucin by the tumour. Secondarily, non bacterial thrombotic endocarditis, septic or neoplastic cell embolism, venous sinus thrombosis and atherosclerosis secondary to radiotherapy have been reported. CASE REPORTS: Case 1: a 27-year-old male who presented a stroke in the right thalamus with a torpid progression and digestive complications; neuroimaging studies revealed unknown neoplasia of the head of the pancreas. Case 2: a 53-year-old male with repeated stroke (left sylvian and right occipitotemporal) and progressive neurological deterioration secondary to disseminated neoplastic disease, which had its origins in the body and tail of the pancreas. In both cases all the diagnostic explorations carried out in an attempt to determine the aetiopathogenesis of the stroke were negative. The post mortem study in the second patient revealed the existence of a non bacterial thrombotic endocarditis, which was taken as being one of the mechanisms involved. CONCLUSIONS: The pathogenic mechanisms of cerebral ischemia associated to neoplasia are discussed and the primary and secondary forms are differentiated. We highlight the idea that when dealing with a stroke with an unknown aetiology and a torpid progression, the neurologist must consider the existence of a concealed neoplasia with stroke as its first manifestation.

Adult↗
PubMed2004

Multisection CT venography of the dural sinuses and cerebral veins by using matched mask bone elimination.

Matched mask bone elimination (MMBE) is a technique for the automatic removal of bone pixels from CT angiography data sets. We describe the use of this technique in two patients with the clinical suspicion of dural sinus thrombosis. We conclude that multisection CT venography with MMBE is a useful adjunct for the visualization of the intracranial venous circulation by removing bone from the image. In contrast to techniques described previously, MMBE is fully automated and operator independent.

Adult↗