1/13. Cerebral arterial gas embolism following diagnostic bronchoscopy: delayed treatment with hyperbaric oxygen.PURPOSE: To describe a clinical scenario consistent with the diagnosis of cerebral arterial gas embolism (CAGE) acquired during an outpatient bronchoscopy. Our discussion explores the mechanisms and diagnosis of CAGE and the role of hyperbaric oxygen therapy. CLINICAL FEATURES: A diagnostic bronchoscopy was performed on a 70-yr-old man who had had a lobectomy for bronchogenic carcinoma three months earlier. During the direct insufflation of oxygen into the right middle lobe bronchus, the patient became unresponsive and developed subcutaneous emphysema. Immediately, an endotracheal tube and bilateral chest tubes were placed with resultant improvement in his oxygen saturation. However, he remained unresponsive with extensor and flexor responses to pain. Later, in the intensive care unit, he exhibited seizure activity requiring anticonvulsant therapy. Sedation was utilized only briefly to facilitate controlled ventilation. Investigations revealed a negative computerized tomography (CT) scan of the head, a normal cerebral spinal fluid examination, a CT chest that showed evidence of barotrauma, and an abnormal electroencephalogram. Fifty-two hours after the event, he was treated for presumed CAGE with hyperbaric oxygen using a modified united states Navy Table 6. Twelve hours later he had regained consciousness and was extubated. He underwent two more hyperbaric treatments and was discharged from hospital one week after the event, fully recovered. CONCLUSION: A patient with presumed CAGE made a complete recovery following treatment with hyperbaric oxygen therapy even though it was initiated after a significant time delay.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
2/13. Posterior reversible encephalopathy syndrome (PRES) in critically ill obstetric patients.OBJECTIVE: To describe clinical, neuroradiological and evolutionary findings in obstetric patients with posterior reversible encephalopathy syndrome (PRES). DESIGN: Retrospective case series. SETTING: University intensive care unit (ICU). patients: Four critically ill patients. Two patients experienced PRES in late postpartum without the classical pre-eclamptic signs. All patients showed impairment of consciousness and epileptic seizures; two of them presented cortical blindness and headache, too. True status epilepticus (SE) occurred in two cases. In all patients MRI showed the typical feature of gray-white matter edema, mainly localized to the temporo-parieto-occipital areas. INTERVENTIONS: Normalization of high blood pressure (BP) and treatment of seizures. Two patients with SE and severe impairment of consciousness were treated with an intravenous valproate (ivVPA) bolus followed by continuous infusion. MEASUREMENTS AND RESULTS: In three cases, neurological and MRI abnormalities completely resolved in about a week. Another patient died due to subarachnoid hemorrhage. CONCLUSION: Posterior reversible encephalopathy syndrome is a well described clinical and neuroradiological syndrome characterized by headache, altered mental status, cortical blindness and seizures, and a diagnostic MRI picture; usually reversible, PRES can sometimes result in death or in irreversible neurological deficits, thus requiring early diagnosis and prompt treatment. PRES can have various etiologies, but pregnancy and postpartum more frequently lead to this condition. Treatment of seizures deserves special attention since the anti-epileptic drugs currently used in SE management may worsen vigilance as well as autonomic functions. Extensive research is needed to assess the role of ivVPA in this condition.- - - - - - - - - - ranking = 2keywords = consciousness (Clic here for more details about this article) |
3/13. Postmalaria neurologic syndrome: a case report.Neurologic signs and symptoms are common in acute malarial infection. However, after the parasites have been cleared from the blood and patients recover full consciousness, neurologic or psychiatric symptoms may occur or recur within 2 months after the acute illness. This phenomenon is called "postmalaria neurologic syndrome" (PMNS). We present a 50-year-old man who returned from the Republic of malawi and soon developed plasmodium falciparum malaria. Cerebral malaria, renal failure, hepatic failure, diffuse intravascular coagulation with thrombocytopenia, and upper gastrointestinal bleeding were noted during the acute stage. He was admitted to the infectious diseases ward and treated for 3 weeks. He was free from clinical general symptoms and parasites in blood smear when discharged. However, 2 weeks after discharge, he began to experience severe headache, dizziness, diplopia, mild hand tremor, unsteady gait, and easy falling. When readmitted to the neurologic ward, he presented with irritability, delirium, visual hallucination, and strange behavior. neurologic examination was normal except for mild general weakness and evident truncal ataxia when walking. brain magnetic resonance imaging revealed no structural lesions, and electroencephalography showed diffuse cortical dysfunction. Cerebral spinal fluid profile exhibited cytoalbuminologic dissociation. brain single photon emission computed tomography showed diffuse cerebral parenchymal disorder. Nerve conduction studies revealed early sensory predominant polyneuropathy. The unsteadiness persisted for the initial 2 weeks of hospitalization until corticosteroid was administered. Intravenous methylprednisolone (80 mg/day) was continued for 3 days, followed by oral prednisolone (45 mg/day). His unsteadiness improved gradually after medication, and he absconded from the hospital on the 9th day of corticosteroid treatment with clear consciousness and free ambulation. The manifestation of PMNS is diverse and may present as an acute confusional state or psychosis, generalized seizure, fine tremors, cerebellar syndromes, postural hypotension, or malarial polyneuritis. Although the neurologic syndrome is primarily self-limited in most cases, corticosteroid may be beneficial in reversing PMNS.- - - - - - - - - - ranking = 2keywords = consciousness (Clic here for more details about this article) |
4/13. Neurological complications after a single severe exposure to toluene di-isocyanate.A total of 23 men complained of neurological symptoms after a single severe exposure to toluene di-isocyanate. Effects of exposure were immediate in five men and consisted of euphoria, ataxia, and loss of consciousness. These men and nine others complained of headache, difficulty in concentration, poor memory, and confusion during the next three weeks. Four years later it was found that nine further men had experienced symptoms that they had not been aware of at three weeks. In all, 13 men still complained of poor memory, personality change, irritability, or depression after four years. Psychometric testing showed a selective defect for relatively long-term recall in those with persistent symptoms at four years.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
5/13. Toxic shock syndrome (TSS) in children.Toxic shock syndrome is uncommon in the prepubertal age group. Two children presented with pyrexia, macular erythroderma, vomiting, hypotension and rapid deterioration of consciousness. One child had severe neurological involvement. The diagnosis of toxic shock syndrome was established in both cases by the exclusion of other causes and by culturing staphylococcus aureus. We postulate that the neurological manifestations were caused by a direct neurotoxic action of the staphylococcal-produced toxin. Both children made a complete recovery.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
6/13. Neurotoxic complications of contrast computed tomography in children.Four children with brain tumors had marked alterations in levels of consciousness and vital signs after contrast-enhanced cranial computed tomography (CT). Each had clinical evidence of increased intracranial pressure but was alert and coherent before CT. During the procedure, 2 to 2.5 mL/kg 60% diatrizoate meglumine was administered intravenously, and within hours the patients became progressively lethargic and disoriented and bradycardia and hypertension developed; two had generalized seizures. Two children died immediately after the CT procedure. Contrast-enhanced CT may produce grave neurologic complications in children with brain tumors, and this study should be reserved for those patients in whom the probability of obtaining additional information is high. Use of low-osmolality agents or nonionic contrast agents may decrease the morbidity and mortality associated with the procedure.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
7/13. Hyperekplexia: a syndrome of pathological startle responses.We describe a family and three sporadic cases of startle disease, or hyperekplexia. Sudden unexpected noises caused the patients to fall rigidly, often injuring themselves but retaining consciousness. This unusual entity differs from startle epilepsy and cataplexy. clonazepam proved ineffective in three patients. valproic acid, 5-hydroxytryptophan, or piracetam markedly reduced the abnormal startle in three patients.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
8/13. Acute neurological dysfunction associated with destructive lesions of the basal ganglia in children.Three children ranging in age from 1 to 4 1/2 years suffered an acute illness with disturbance of consciousness followed by motor rigidity, loss of spontaneous movements and language, axial hypotonia, and a stereotyped response to any kind of stimulus. In two cases, images on computerized tomography were consistent with necrosis of the lenticular and caudate nuclei. The acute onset was followed by later improvement and stabilization. One child died, probably not as a direct consequence of the neurological disorder, autopsy showed bilateral necrosis of the putamina. We suggest that these three patients, together with two previously reported cases, constitute a clinically and radiologically recognizable subgroup among the heterogeneous disorder that produce bilateral striatal necrosis in children. The cause of the syndrome is unknown.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
9/13. language and motor disorders after penetrating head injury in Viet Nam.aphasia occurred in 244 of 1030 patients with head wounds, correlating with gunshot cause (p < 0.03) and initial loss of consciousness (p < 10(-6)). aphasia disappeared within 10 years in 84 cases (34%). Sensorimotor aphasia usually changed to motor aphasia; motor aphasia disappeared; and sensory aphasia persisted. These improvements continued years after the accompanying hemiparesis stabilized, and were not related to wound site, depth, or whether the wound was caused by gunshot or fragment. Parietal wounds caused hemiparesis more often (p < 10(-6))than did wounds elsewhere. Regardless of the features of the hemiparesis initially, the severity of the final syndrome was greatest in the hand and arm and least in the face.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
10/13. Transient neurological disturbances induced by the chemotherapy of high-dose methotrexate for osteogenic sarcoma.Temporary neurologic abnormalities were observed in one out of 23 patients undergoing chemotherapy with high-dose methotrexate (HD-MTX) for osteogenic sarcoma. This patient developed sequential symptoms including alternative hemiparesis, dysarthria and altered consciousness 5 days after the second course of HD-MTX (8 gm/m2 by 6 h continuous infusion) with leucovorin rescue. Laboratory evaluations disclosed normal electrolytes, hemograms and non-toxic serum MTX levels at the onset of the symptoms. Computed tomography of the brain was normal but electroencephalography showed focal theta and delta slow waves over the right temporal-parietal-occipital area. The neurological symptoms resolved completely within 72 h.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
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