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European Stroke Journal Jun 2024Malignant middle cerebral artery infarction (MCI) needs rapid intervention. This study aimed to enhance the prediction of MCI using computed tomography perfusion (CTP)...
INTRODUCTION
Malignant middle cerebral artery infarction (MCI) needs rapid intervention. This study aimed to enhance the prediction of MCI using computed tomography perfusion (CTP) with varied quantitative benchmarks.
MATERIALS AND METHODS
We retrospectively analyzed 253 patients from a single-center registry presenting with acute, severe, proximal large vessel occlusion studied with whole-brain CTP imaging at hospital arrival within the first 24 h of symptoms-onset. MCI was defined by clinical and imaging criteria, including decreased level of consciousness, anisocoria, death due to cerebral edema, or need for decompressive craniectomy, together with midline shift ⩾6 mm, or infarction of more than 50% of the MCA territory. The predictive accuracy of baseline ASPECTS and CTP quantifications for MCI was assessed by receiver operating characteristic (ROC) area under the curve (AUC) while -score was calculated as an indicator of precision and sensitivity.
RESULTS
Sixty-three out of 253 patients (25%) fulfilled MCI criteria and had worse clinical and imaging results than the non-MCI group. The capacity to predict MCI was lower for baseline ASPECTS (AUC 0.83, -score 0.52, Youden's index 6), than with perfusion-based measures: relative cerebral blood volume threshold <40% (AUC 0.87, -score 0.71, Youden's index 34 mL) or relative cerebral blood flow threshold <35% (AUC 0.87, -score 0.62, Youden's index 67 mL). CTP based on rCBV measurements identified twice as many MCI as baseline CT ASPECTS.
DISCUSSION AND CONCLUSION
CTP-based quantifications may offer enhanced predictive capabilities for MCI compared to non-contrast baseline CT ASPECTS, potentially improving the monitoring of severe ischemic stroke patients at risk of life-threatening edema and its treatment.
PubMed: 38872264
DOI: 10.1177/23969873241260965 -
Cureus Mar 2024Epstein-Barr virus (EBV) can cause follicular conjunctivitis, keratitis, oculoglandular syndrome, meningitis, and encephalitis. We report a 54-year-old Hispanic male who...
Epstein-Barr virus (EBV) can cause follicular conjunctivitis, keratitis, oculoglandular syndrome, meningitis, and encephalitis. We report a 54-year-old Hispanic male who presented with right pupil-involved complete ophthalmoplegia, orbital and masticatory muscle inflammation, trigeminal enhancement, and new corneal infiltrate highly suggestive of EBV. Labwork was negative except for positive EBV polymerase chain reaction (PCR) in serum. Magnetic resonance imaging (MRI) of his brain and orbits with contrast showed enhancement of the right ganglion of the trigeminal nerve, oculomotor nerve, all extraocular muscles in the right orbit, and right masticatory and temporalis muscles and a right subacute lacunar infarct. The patient was diagnosed with encephalitis and orbital-face inflammation secondary to EBV infection. The patient improved with systemic steroids.
PubMed: 38659504
DOI: 10.7759/cureus.56888 -
Cureus Mar 2024Unilateral pharmacologic mydriasis is one of the differential diagnoses of anisocoria. This is a clinical case of a 37-year-old male patient admitted to the...
Unilateral pharmacologic mydriasis is one of the differential diagnoses of anisocoria. This is a clinical case of a 37-year-old male patient admitted to the ophthalmology emergency department with unilateral mydriasis, an infrequent side effect of the antihistaminic drug azelastine. A comprehensive medical history including ocular medication was essential to avoid the need for additional tests and to exclude life-threatening conditions responsible for a similar presentation.
PubMed: 38646409
DOI: 10.7759/cureus.56649 -
Journal of Family Medicine and Primary... Feb 2024The differential diagnosis for anisocoria is broad and ranges from benign to life-threatening causes. Often, patients with new onset anisocoria present to their primary...
The differential diagnosis for anisocoria is broad and ranges from benign to life-threatening causes. Often, patients with new onset anisocoria present to their primary care physician, an urgent care center, or an emergency room. As such, it is important for non-ophthalmologist physicians to be familiar with its common causes. We present two cases of pharmacologic anisocoria from (glycopyronnium), a wipe used in the treatment of hyperhidrosis. Identifying this medication as a cause of anisocoria in patients with hyperhidrosis can reduce costs and unnecessary testing. Furthermore, physician education about safer usage can be provided.
PubMed: 38605781
DOI: 10.4103/jfmpc.jfmpc_698_23 -
Journal of Ayub Medical College,... 2023Epidural hematoma is one of the most common surgical emergencies encountered in neurosurgery. This study was conducted to determine the mortality and prognostic factors...
BACKGROUND
Epidural hematoma is one of the most common surgical emergencies encountered in neurosurgery. This study was conducted to determine the mortality and prognostic factors in patients operated for traumatic intracranial epidural hematoma in a resource-constrained setting from a developing country.
METHODS
This retrospective study was conducted in the Department of Neurosurgery at Ayub Teaching Hospital Abbottabad from 1st January 2019 to 31st Dec 2021. Inclusion and exclusion criteria were created. The medical record of 116 patients admitted and operated on for traumatic extradural hematoma was retrospectively reviewed. Information was recorded using a standardized structured questionnaire. The outcome was measured in terms of the Glasgow coma outcome score.
RESULTS
Out of 116 patients, 93 were male and 23 were female.19 (16.4%) patients were in the age range 0-5 years, 42 (36.2%) were in the age range 6-15, 35(31.0%) were in the age range 16-30, 11 (9.5%) were in the age range 31-45 years, 7 (6.0%) were in the age range 46-60 years while only one patient included in this study was above 60 years. Overall mortality was 4.3%. Mortality was higher in females and in those aged less than 5 years (3.4%). 4 out of 16 patients died with GCS less than 8, while none of the patients died when GCS was above 12. Mortality was significantly higher in the presence of associated lesions (4.4% vs. 0%) and anisocoria (2.6% vs.1.7%). Patients who operated within 6 hours of trauma resulted in better outcomes with a mortality rate of 0.0% and functional recovery of 57.8 % while for those who operated after 6 hours, mortality was significantly higher (4.3%) and functional recovery was significantly low (15.5%).
CONCLUSION
Good surgical outcomes can be achieved with early operative intervention if indicated. Female gender, low preoperative GCS score, presence of pupillary dilatation, presence of associated lesions, delayed surgical intervention and age less than 5 years are significant predictors for poor outcomes.
Topics: Humans; Male; Female; Infant, Newborn; Infant; Child, Preschool; Hematoma, Epidural, Cranial; Retrospective Studies; Prognosis; Glasgow Coma Scale; Neurosurgical Procedures
PubMed: 38406908
DOI: 10.55519/JAMC-S4-12780 -
Oxford Medical Case Reports Feb 2024Glanzmann thrombasthenia (GT) is a rare platelet disorder characterized by qualitative/quantitative deficiencies of the platelets' fibrinogen receptor, glycoprotein (GP)...
Glanzmann thrombasthenia (GT) is a rare platelet disorder characterized by qualitative/quantitative deficiencies of the platelets' fibrinogen receptor, glycoprotein (GP) IIb/IIIa complex, resulting in impaired platelet aggregation and increased bleeding time. Most cases are hereditary with an autosomal recessive pattern of inheritance, but acquired GT also occurs. We report the surgical management of symptomatic chronic subdural hematoma (CSDH), a rare condition in young individuals, in a 37-year-old man who had GT and a history of mild head trauma approximately one month before admission. Despite hematologic consultation, normal bleeding time and clotting time, and platelet transfusion before surgery, massive hemorrhage during surgery, epidural hematoma, and anisocoria in the ICU occurred that led to craniectomy. This report highlights that CSDH management in patients with GT requires close monitoring of these patients as well as collaboration between neurosurgeons, intensive care physicians, hematologists, and anesthesiologists.
PubMed: 38370496
DOI: 10.1093/omcr/omae004 -
Indian Journal of Ophthalmology Feb 2024
Topics: Humans; Vitrectomy; Anisocoria; Undifferentiated Connective Tissue Diseases; Scleral Buckling; Retinal Detachment; Retrospective Studies; Treatment Outcome
PubMed: 38271411
DOI: 10.4103/IJO.IJO_2547_23 -
Case Reports in Ophthalmology 2024The most frequently encountered symptoms in internal carotid artery dissection (ICAD) are head or neck pain and cerebral ischemia. Ocular symptoms or signs have been...
INTRODUCTION
The most frequently encountered symptoms in internal carotid artery dissection (ICAD) are head or neck pain and cerebral ischemia. Ocular symptoms or signs have been reported as the presenting feature in up to 50% of patients, with (painful) Horner syndrome being the most frequently associated. Horner syndrome is part of the classic triad that depicts the characteristic presentation of ICAD and that consists of pain in the ipsilateral neck, head and orbital regions, (partial) Horner syndrome, and cerebral or retinal ischemia. All patients presenting with painful Horner syndrome should therefore require prompt investigations to rule out carotid artery dissection. In patients with confirmed diagnosis, treatment should be started early to prevent permanent ocular or cerebral complications.
CASE PRESENTATION
Case 1: A 61-year-old woman presented with right temporal headache, an episode of transient visual loss and drooping of the right upper eyelid. Examination revealed anisocoria, which was more important in darkness. Reversal of anisocoria was observed after instilling drops of apraclonidine 0.5%. Neuroimaging demonstrated intrapetrous ICAD. Headaches, eyelid ptosis, and anisocoria all had resolved the next day. Apraclonidine pharmacologic testing a few weeks later was no longer dilating the previously smaller pupil. Case 2: A 48-year-old man presented with drooping of the right upper eyelid and right occipital headache and facial pain that all started one day after an intense yoga workout. Anisocoria was noticed upon examination, with topical cocaine 10% pharmacologic testing confirming a right Horner syndrome. Neuroimaging revealed ICAD. The patient reported resolution of his eyelid ptosis a few days later. Eyelid ptosis and anisocoria had indeed resolved at a follow-up examination a few weeks later. However, cocaine drop testing still produced anisocoria, compatible with subclinical Horner syndrome.
CONCLUSION
Transient or subclinical Horner syndrome can be the presenting feature in ICAD; in such cases, the characteristic eyelid ptosis and anisocoria may be short-lived and resolve in only a few days. If suspected by clinical history, pharmacologic testing may be helpful in identifying subclinical cases.
PubMed: 38196925
DOI: 10.1159/000535475 -
Legal Medicine (Tokyo, Japan) Feb 2024We present the case of a 69 years old man who was hit by a car while crossing the road. A CT scan of the skull and brain showed fracture of the left occipital bone,...
We present the case of a 69 years old man who was hit by a car while crossing the road. A CT scan of the skull and brain showed fracture of the left occipital bone, bilateral hemispheric subarachnoid hemorrhage, right frontal-temporal-parietal subdural hematoma with a shift of midline structures of 18 mm and complete obliteration of the third ventricle. He showed signs of anisocoria, absence of mobility of all 4 limbs and was immediately intubated and admitted to intensive care. The neurosurgeon was immediately consulted. He underwent drainage of subdural hematoma and two decompressive craniotomies, but died 15 days after the initial trauma. At autopsy, the stomach was full of a greenish poltaceous material. This gave us vital information in reconducting the actual brain death of the man to the immediacy of the investment, helping in the process of ruling out any possible profiles of professional liability.
Topics: Male; Humans; Aged; Hematoma, Subdural; Brain; Subarachnoid Hemorrhage; Fractures, Bone; Tomography, X-Ray Computed
PubMed: 38154350
DOI: 10.1016/j.legalmed.2023.102377 -
Cureus Nov 2023Despite the clear benefits of Impella in patients with cardiogenic shock, bleeding is a possible complication. Herein, we report three cases of intracerebral hemorrhage...
Despite the clear benefits of Impella in patients with cardiogenic shock, bleeding is a possible complication. Herein, we report three cases of intracerebral hemorrhage in patients with Impella implantation for cardiogenic shock, which were treated with hematoma evacuation. We present the clinical features, diagnosis, and management (hematoma evacuation) of patients with the Impella device (Abiomed, Danvers, Massachusetts) who developed intracerebral hemorrhage. Case one was a 56-year-old man who presented with chest pain and loss of consciousness, was diagnosed with acute myocardial infarction, and underwent urgent percutaneous coronary intervention and Impella placement. After eight days, the patient developed anisocoria. Computed tomography revealed a left intracerebral hemorrhage. An emergency hematoma evacuation was successfully performed (intraoperative blood loss: 2600 mL). Case two was a 54-year-old male who presented with persistent chest pain and loss of consciousness, was diagnosed with acute myocardial infarction, and underwent an emergency percutaneous coronary intervention with Impella implantation and venoarterial extracorporeal membrane oxygenation. The patient developed intracerebral hemorrhage after 26 days. Hematoma evacuation was successfully performed (intraoperative blood loss: 380 mL). Case three was a 52-year-old male who presented with dyspnea and hypotension, was diagnosed with dilated cardiomyopathy, and underwent Impella implantation and venoarterial extracorporeal membrane oxygenation, followed by which the patient developed subcortical hematoma. An emergency hematoma evacuation was performed (intraoperative blood loss: 3205 mL). The patient died 14 days after admission. Intracerebral hemorrhage is a potential cause of morbidity associated with Impella placement. Although hematoma evacuation is optimal, the bleeding tends to increase.
PubMed: 38106739
DOI: 10.7759/cureus.48863