Abnormal Pupillary Response Research Articles

Complications during Adolescence Predict Mortality in Young Adults with Childhood Onset Type 1 Diabetes

Objective. Microvascular complications increase the risk of cardiovascular disease and premature death in adults with type 1 diabetes. We examined the association between microvascular complications during adolescence, including cardiac autonomic nerve dysfunction and subsequent mortality. Research Design and Methods. We undertook data linkage with the Australian National Death Index in a cohort of 409 adolescents (diagnosed between 1973 and 1993), 48% male, median age at final complications assessment 17.4 years (interquartile range: 16.0–18.9), followed longitudinally for median 22.3 years (21.0–23.4) from diagnosis. Generalized estimating equations (GEE) were used to examine associations between mortality and adolescent complications. Mortality risk was calculated as standardized mortality ratio (SMR). Results. At final adolescent visit, 20% had CAN abnormality, 30% abnormal pupillary response, 20% albuminuria, 40% early elevation of albumin excretion rate (AER) and 45% retinopathy. Data linkage 8–13 years later showed 14 were deceased (3% of cohort), 57% male, median age 28.3 years (24.8–32.9). Acute or chronic diabetes complications accounted for 25% of deaths. In multivariable GEE, elevated AER (OR 4.54, 1.23–16.80, p=0.030), pupillary abnormality (OR 4.27, 1.20–15.22, p=0.023), systolic blood pressure SDS (OR 2.17, 1.26–3.74, p=0.005) and CAN (OR 4.65, 1.03–21.0, p=0.045) predicted mortality. HbA1c was not significant. SMR was 2.5 (1.4–4.2) and was higher in females (SMR 3.5, 1.3–7.8) but not in males (SMR 2.1, 0.9–4.0). Conclusion. Mortality in young adults with type 1 diabetes is predicted by subclinical markers of autonomic neuropathy and elevated AER during adolescence, but not glycemia. Mortality was over twice that of the background population in females but not in males.

Understanding Visual Disorders through Correlation of Clinical and Radiologic Findings.

Patients presenting with visual disturbances often require a neuroimaging approach. The spectrum of visual disturbances includes three main categories: vision impairment, ocular motility dysfunction, and abnormal pupillary response. Decreased vision is usually due to an eye abnormality. However, it can also be related to other disorders affecting the visual pathway, from the retina to the occipital lobe. Ocular motility dysfunction may follow disorders of the cranial nerves responsible for eye movements (ie, oculomotor, trochlear, and abducens nerves); may be due to any abnormality that directly affects the extraocular muscles, such as tumor or inflammation; or may result from any orbital disease that can alter the anatomy or function of these muscles, leading to diplopia and strabismus. Given that pupillary response depends on the normal function of the sympathetic and parasympathetic pathways, an abnormality affecting these neuronal systems manifests, respectively, as pupillary miosis or mydriasis, with other related symptoms. In some cases, neuroimaging studies must complement the clinical ophthalmologic examination to better assess the anatomic and pathologic conditions that could explain the symptoms. US has a major role in the assessment of diseases of the eye and anterior orbit. CT is usually the first-line imaging modality because of its attainability, especially in trauma settings. MRI offers further information for inflammatory and tumoral cases. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Leber Congenital Amaurosis: Leading Cause of Inherited Blindness in Children

Leber congenital amaurosis is a group of severe congenital retinal conditions and the leading cause of inherited blindness in children. Symptoms, typically present in the first 6 months of life, include nystagmus, strabismus, photophobia, abnormal or absent pupillary responses, and cataracts. Eye examinations and visual assessments are an essential part of well-child visits. The primary care practitioner may be the first to identify symptoms or hear parents’ concerning findings during routine eye examinations at well-child or episodic visits. Early recognition of deviations from normal that lead to prompt ophthalmology referrals can result in timely diagnosis and optimized treatment to improve outcomes and quality of life.

Fixed and dilated pupils by pupillometer in lateralized periodic discharges: a case report in the neurocritical care unit

Background: Fixed and dilated pupils (FDPs) have become synonymous with devastating neurological damage and brainstem injury commonly associated with mass effect and herniation. Infrequently, changes in pupillary light response have been described with seizures; however, the loss of pupillary response with documented Neurological Pupil index has not been well established in patients with seizures.Case Report: We present a case report describing a middle-aged female patient with focal status epilepticus with intermittent FDPs. An abnormal pupillary response occurred with right hemispheric lateralized periodic discharges and resolution with anti-seizure medication escalation. To our knowledge, this is the first description of objective documentation of reversible FDP as a possible clinical correlate of lateralized periodic discharges. Conclusion: The use of handheld automated pupillometry in conjunction with electroencephalogram (EEG) has provided the therapeutic direction. Further research is warranted to fully describe the mechanistic underpinnings of these observations.

Traumatic acute subdural hematoma and coma: retrospective cohort of surgically treated patients.

Background: A subdural hematoma is defined as clot formation in the subdural space after vessel rupture or brain parenchyma damage. Several demographic and tomographic factors were associated to poor prognosis, although some debate according to their specific roles still remains.Methods: Retrospective cohort study of comatose patients admitted to a single-institution, tertiary hospital center, between the years 2013 and 2019 with traumatic acute subdural hematoma requiring surgical evacuation were studied. Demographic and tomographic data were obtained from medical records. Univariate and multivariate statistical analysis were performed, using a value of P < 0.05 for significance.Results: Seventy-seven patients were selected using the criteria and a total of 37 (48%) head CT exams were evaluated. The overall mortality was 57.1% and achieved 100% at ≥75-years-old subgroup. Univariate analysis only found young age as a good prognosis factor (P = 0.002). Gender (P = 0.784), abnormal pupillary response (P = 0.643), midline shift (P = 0.874), clot thickness (P = 0.206), compressed basal cisterns (P = 0.643), hematoma side (P = 0.879), and subarachnoid hemorrhage (P = 0.510) showed no association. Multivariate analysis showed no statistically significant association between covariates.Conclusion: Traumatic acute subdural hematoma is a life-threatening condition. Younger age was the only positive prognostic factor identified. More research is necessary to establish age as a rule-out criterion to surgical indication.

A Global Neurosurgery Approach to Reducing the Burden of Traumatic Acute Subdural Hematoma: A Narrative Review

This narrative review highlights the importance of timely neurosurgical interventional after a person suffers from a motor vehicle accident. Acute subdural hematomas account for 30-70% of traumatic brain injuries. The paper discusses the global burden of TBI as the forerunner of the public health problem, about 50% of the world population will acquire TBI once in their lifetime. There is a severe deficit in the global workforce to meet the neurotrauma, which becomes worse in low-income and middle-income countries especially in sub-Saharan and Southeast Asia. Indication for neurosurgical intervention depends upon several parameters such as clot thickness exceeding 10mm, midline shift greater than 5mm; which possibly increases intracranial pressure (ICP) more than 20 mmHg as a result of mass effect, and abnormal pupillary response such as asymmetrically unilateral or bilaterally dilated. Surgical procedures vary with different circumstances, which include mainly craniotomy, decompressive hemicraniectomy, and burr hole irrigation. Comparison of the outcomes of decompressive craniectomy and craniotomy are discussed under the DECRA and RESCUEicp trials. Robotic telepresence, task-shifting, and task-sharing are alternative interventional strategies and practices to carry various neurosurgical procedures by non-neurosurgeons in LMICs. Reintroduction of the survivors of MVA acquiring TBI into the society is a prime concern, therefore, various neurorehabilitation strategies are discussed. The barriers to becoming neurosurgeons by the young doctors as the core principle of infrastructure, governance by bodies such as World Health Organization and its universal health coverage initiative, and World Federation of Neurosurgical Societies efforts to balance the disparity in LMICs are discussed.

Ophthalmic and Neuro-ophthalmic Manifestations of Coronavirus Disease 2019 (COVID-19)

ABSTRACT Purpose To describe a case of inflammatory chorioretinopathy and Adie’s syndrome possibly associated with COVID-19. Methods Observational case report. Results A 51-year-old woman developed fever, cough, and headache followed by retro-ocular pain and reading impairment. She tested positive for SARS-COV-2 infection by qualitative real-time reverse-transcriptase-polymerase-chain-reaction. The slit-lamp and funduscopic exam revealed abnormal pupillary response and yellowish creamy deep chorioretinal lesions, which were not present in previous examinations. Instillation of pilocarpine demonstrated denervation supersensitivity, and it was suggestive of bilateral Adie tonic pupil. A comprehensive work-up ruled out other systemic, autoimmune, or infectious diseases. Conclusions This case illustrates the possible association between multifocal chorioretinitis and Adie’s syndrome, and the SARS-COV-2 infection in humans. Further investigation of virus infectivity specifically within ocular tissues has to be conducted.

Outcomes of paediatric cardiac patients after 30 minutes of cardiopulmonary resuscitation prior to extracorporeal support.

To characterise the mortality and neurological outcomes of paediatric cardiac patients requiring cardiopulmonary resuscitation for more than 30 minutes prior to extracorporeal membrane oxygenation cannulation and to identify risk factors associated with adverse outcomes in this population. Observational retrospective cohort study in paediatric cardiac patients undergoing cardiopulmonary resuscitation for greater than 30 minutes prior to cannulation in a tertiary children's hospital, from July 2000 to July 2013. Seventy-three paediatric cardiac patients requiring cardiopulmonary resuscitation for more than 30 minutes prior to cannulation were included in the study. Survival to hospital discharge was 43.8%, with 75% of survivors having either normal neurologic function or only mild disability. Multivariable logistic regression analysis demonstrated that increased use of calcium during resuscitation (odds ratio 14.5, p 0.01), cardiopulmonary resuscitation duration >50 minutes (odds ratio 4.12, p 0.03), >6 interruptions of chest compressions during cannulation (odds ratio 6.40, p 0.03), the need for continuous renal replacement therapy (odds ratio 11.1, p 0.001), and abnormal pupillary response during extracorporeal membrane oxygenation (odds ratio 33.9, p 0.006) were independent predictors for hospital mortality. Survival after cardiopulmonary resuscitation for more than 30 minutes prior to extracorporeal membrane oxygenation cannulation in our paediatric cardiac cohort was 43.8%. Factors associated with mortality included calcium use during resuscitation, longer cardiopulmonary resuscitation, increased chest compression pauses during cannulation, the use of continuous renal replacement therapy, and abnormal pupils during extracorporeal membrane oxygenation support. A prospective assessment of these factors in paediatric cardiac patients may be beneficial in improving outcomes.

Correlation of Clinical Findings With Computed Tomography in Orbital Traumas.

Although the eye is a well-protected organ, it is frequently affected by trauma. The timely detection of ocular injuries is extremely important. In this study, the authors evaluated the consistency between findings in computed tomography (CT) examination for orbital fractures and globe integrity and clinical findings in patients presenting to the emergency department due to orbital trauma. The authors retrospectively reviewed the files of patients presenting with orbital trauma between January 2015 and January 2018 from emergency department records. Ophthalmology consultation and follow-up notes, radiology reports, and the emergency physician's notes were reviewed. During the study period, 286 patients presented to the emergency department with orbital trauma. A total of 119 eyes of 83 patients who underwent orbital CT were included in the study. Orbital bone fracture was detected in 54.6% (n = 65) of the eyes. Of these, 73.8% (n = 48) involved multiple fractures. Among all eyes, the distribution of fractures in the orbital walls was lateral wall in 41.2% (n = 49), floor in 32.8% (n = 39), medial wall in 31.1% (n = 37), and roof in 10.9% (n = 13). Multiple wall fractures were detected in 36.9% (n = 44) of the eyes. At least 1 clinical finding such as diplopia, laceration, abnormal pupillary response, hypoesthesia, and exophthalmos was observed in 47.1% (n = 56) of the eyes. This rate was 56.8% among eyes with orbital fractures and 35.2% in those without fracture. There was a statistically significant relationship between floor fractures and diplopia (P = 0.002). No significant correlations were found between the other radiological and clinical findings. Our study revealed a relationship between the presence of orbital fracture and eye damage. In particular, the authors found that the frequency of diplopia was significantly higher in eyes with maxillary bone fracture in the orbital floor. However, orbital CT findings other than bone fracture were not consistent with clinical findings.

Machine Learning to Predict In-Hospital Morbidity and Mortality after Traumatic Brain Injury

Recently, successful predictions using machine learning (ML) algorithms have been reported in various fields. However, in traumatic brain injury (TBI) cohorts, few studies have examined modern ML algorithms. To develop a simple ML model for TBI outcome prediction, we conducted a performance comparison of nine algorithms: ridge regression, least absolute shrinkage and selection operator (LASSO) regression, random forest, gradient boosting, extra trees, decision tree, Gaussian naïve Bayes, multi-nomial naïve Bayes, and support vector machine. Fourteen feasible parameters were introduced in the ML models, including age, Glasgow Coma Scale (GCS), systolic blood pressure (SBP), abnormal pupillary response, major extracranial injury, computed tomography (CT) findings, and routinely collected laboratory values (glucose, C-reactive protein [CRP], and fibrin/fibrinogen degradation products [FDP]). Data from 232 patients with TBI were randomly divided into a training sample (80%) for hyperparameter tuning and validation sample (20%). The bootstrap method was used for validation. Random forest demonstrated the best performance for in-hospital poor outcome prediction and ridge regression for in-hospital mortality prediction: the mean statistical measures were 100% sensitivity, 72.3% specificity, 91.7% accuracy, and 0.895 area under the receiver operating characteristic curve (AUC); and 88.4% sensitivity, 88.2% specificity, 88.6% accuracy, and 0.875 AUC, respectively. Based on the feature selection method using the tree-based ensemble algorithm, age, Glasgow Coma Scale, fibrin/fibrinogen degradation products, and glucose were identified as the most important prognostic factors for poor outcome and mortality. Our results indicate the relatively good predictive performance of modern ML for TBI outcome. Further external validation is required for more heterogeneous samples to confirm our results.

Early progression of Krabbe disease in patients with symptom onset between 0 and 5\u2009months

BackgroundKrabbe disease is a rare neurological disorder caused by a deficiency in the lysosomal enzyme, β-galactocerebrosidase, resulting in demyelination of the central and peripheral nervous systems. If left without treatment, Krabbe disease results in progressive neurodegeneration with reduced quality of life and early death. The purpose of this prospective study was to describe the natural progression of early onset Krabbe disease in a large cohort of patients.MethodsPatients with early onset Krabbe disease were prospectively evaluated between 1999 and 2018. Data sources included diagnostic testing, parent questionnaires, standardized multidisciplinary neurodevelopmental assessments, and neuroradiological and neurophysiological tests.ResultsWe evaluated 88 children with onset between 0 and 5 months. Median age of symptom onset was 4 months; median time to diagnosis after onset was 3 months. The most common initial symptoms were irritability, feeding difficulties, appendicular spasticity, and developmental delay. Other prevalent symptoms included axial hypotonia, abnormal deep tendon reflexes, constipation, abnormal pupillary response, scoliosis, loss of head control, and dysautonomia. Results of nerve conduction studies showed that 100% of patients developed peripheral neuropathy by 6 months of age. Median galactocerebrosidase enzyme activity was 0.05 nmol/h/mg protein. The median survival was 2 years.ConclusionsThis is the largest prospective natural history study of Krabbe disease. It provides a comprehensive description of the disease during the first 2 years of life. With recent inclusion of state mandated newborn screening programs and promising therapeutic interventions, enhancing our understanding of disease progression in early onset Krabbe disease will be critical for developing treatments, designing clinical trials, and evaluating outcomes.

Primary Assessment of the Patient With Orbital Fractures Should Include Pupillary Response and Visual Acuity Changes to Detect Occult Major Ocular Injuries

Sight-threatening injuries associated with orbital fractures are of major concern to maxillofacial surgeons whom are often the first asked to assess these patients. Eliciting signs and symptoms that are predictive of these injuries would allow expedited ophthalmic consultation and appropriate management. We hypothesized that abnormal pupillary response is predictive of major ocular injuries. A retrospective cohort study of patients with facial fractures was instituted with review of all associated ophthalmic injuries. The primary predictor variables were the presence or absence of post-traumatic ocular symptoms and signs (visual acuity change, diplopia, flashes and floaters, pain on globe movement, abnormal pupillary response, restriction of eye movement, and visual field defects). Secondary predictors were pattern of fracture and mechanism of fracture. The primary outcome variable was the presence or absence of major ocular injury assessed during formal ophthalmology consultation. Descriptive statistics were calculated as categorical values. Correlation between the presence or absence of predictors and outcome (major ocular injury) was calculated using χ2 analysis, with the significance value set at P≤.01. The study included 75 patients (25% of whom were female patients) with a mean age of 41±22years. We recorded 165 minor ocular injuries and 43 major ocular injuries. The mechanisms of injury included assault (48%, n=36), motor vehicle accident (21%, n=16), fall (17%, n=13), sport (11%, n=8), and occupational (3%, n=2). The fracture pattern included zygomaticomaxillary (36%, n=27), isolated orbital floor (25%, n=19), complex (20%, n=15), and isolated orbital nonfloor (19%, n=14). Of the primary outcome predictors, only abnormal pupillary response (odds ratio, 36; P<.001) and subjective visual acuity changes (odds ratio, 10; P<.001) were predictive of major ocular injury. The mechanism of injury and pattern of fracture were not predictive of major ocular injury. During primary assessment of the patient with orbital fractures, abnormal pupillary response and subjective visual acuity changes are key predictors of occult major ocular injury.

Pupillary Responses to Full-Field Chromatic Stimuli Are Reduced in Patients with Early-Stage Primary Open-Angle Glaucoma

To evaluate the ability of chromatic pupillometry to reveal abnormal pupillary responses to light in patients with early-stage primary open-angle glaucoma (POAG) and to test whether the degree of pupillometric impairment correlates with structural hallmarks of optic nerve damage in the disease. Cross-sectional study. Forty-six patients with early-stage POAG (63.4±8.3 years, 63% male, 87% ethnic-Chinese) and 90 age-matched healthy controls (61.4±8.6 years, 34% male, 89% ethnic-Chinese). Patients with POAG had a visual field mean deviation (VFMD) of-6 decibels or better on automated perimetry. Each participant underwent a monocular 2-minute exposure to blue light (462 nm) followed by another 2-minute exposure to red light (638 nm) using a modified Ganzfeld dome equipped with a light-emitting diode lighting system. The light stimuli intensity was increased logarithmically to evaluate the combined extrinsic and intrinsic response of intrinsically photosensitive retinal ganglion cells (ipRGCs). Light-induced changes in horizontal pupil diameter were assessed monocularly using infrared pupillography. Baseline-adjusted, light-induced pupillary constriction amplitudes were calculated, and individual irradiance-response curves were constructed for each stimulus. Pupillary constriction amplitudes were compared between groups and across light intensities using a linear mixed model analysis. The linear relationship between pupillometric parameters and different structural and functional features of glaucoma was assessed using Pearson's correlation analysis. Light-induced pupillary constriction was reduced in patients with early-stage POAG compared with controls at moderate to high irradiances (≥11 Log photons/cm2/s) of blue (P= 0.003) and red (P < 0.001) light. Maximal pupillary constriction amplitude was correlated with retinal nerve fiber layer thickness (RNFL) thickness (blue: r= 0.51, P < 0.001; red: r= 0.45, P= 0.002) in patients with POAG but not in controls. Conversely, pupillometric parameters were not correlated with visual field scores in patients with early-stage POAG. Patients with early-stage POAG exhibit reduced pupillary responses to moderate and high irradiances of blue and red lights. This wavelength-independent functional alteration correlates with structural thinning of the RNFL and could be the consequence of dysfunction or loss of melanopsin expressing ipRGCs in the early stages of the disease.

Outcome after operative intervention for traumatic brain injuries in the elderly.

Introduction:The management of traumatic brain injuries in the elderly (age ≥ 65 years) is a constant dilemma. The aim of this study is to investigate for factors that may predict outcome of operative treatment in this group of patients.Materials and Methods:A retrospective analysis was conducted on 68 elderly patients who had been operated in a designated center from 2006 to 2010. Patients’ age, Glasgow Coma score (GCS), pupillary responses, imaging findings, medical conditions, and the use of anticoagulant/antiplatelet agents on patient outcomes were studied.Results:The overall mortality rate was 55.9%. Older age, abnormal pupillary response, low GCS, the presence of midline shift and cistern obliteration on computerized tomography were associated with poor survival. Patient aged 75-84 with normal bilateral pupillary response still had an overall survival rate of 52.6% and good outcomes (Glasgow outcome score: 4 or 5) in 36.8% of patients. Abnormal pupillary response in at least one eye and preoperative GCS ≤ 12 were associated with very poor prognosis.Conclusions:More advanced age was found to be associated with progressively worse outcome. A subgroup patients aged below 85 would survive and could achieve good clinical outcome. The prognosis of those aged over 85 with moderate or severe head injuries was extremely poor.

Evaluation of the visual function of patients with locked-in syndrome: Report of 13 cases

Although visual function is thought to be preserved in patients with locked-in syndrome (LIS), enabling them to communicate through vertical or lateral eye movements or blinking of the upper eyelid, nothing is known about the actual visual function of patients with LIS. The goal of this study is to evaluate the visual function of patients with LIS which may enable better evaluation of the state of consciousness of these patients. Patients with LIS seen in a single neurovascular unit of a tertiary center between 1997 and 2013 were retrospectively reviewed. Each patient had a specialized neuro-ophthalmological evaluation under optimal environmental conditions (light, contrast, examination distance, head position, best ergonomic adaptation, and establishment of a means of communication with help from the patient's friends/family). Visual acuity, extraocular eye movements, confrontational visual field, slit lamp and fundus examination were performed. Thirteen patients (6M/7F) were included in this study. Mean visual acuity was 20/60. Oculomotor examination was abnormal in 77%. Forty-six percent of patients presented binocular diplopia mainly related to a VIth nerve palsy. One patient presented complete ophthalmoplegia. Forty-six percent of patients had nystagmus responsible for oscillopsia (oculopalatal tremor). An abnormal visual field was observed in 17% of patients, and abnormal pupillary light response leading to photophobia was present in 22% of patients. Keratitis or dry eye syndrome was present in most patients and was a major cause of pain and visual impairment. Our results suggest that the visual function is impaired in all patients with LIS. This impairment is multifactorial including mostly binocular diplopia or oscillopsia but also refractive errors, dry eye syndrome, keratitis or visual field defect. This altered visual function may alter the ability of the patient to interact with his environment and lead to underestimation of their state of consciousness. An ophthalmologic evaluation would allow for improvement of these patients' comfort, their ability to communicate, and the assessment of their state of consciousness.

Severe cranial neuropathies caused by falls from heights in children.

Falls from heights are the most common traumatic event associated with emergency department visits in children. This study investigated the incidence and clinical course of cranial neuropathies caused by falls from heights in children. The computerized records of a tertiary pediatric medical center were searched for all patients admitted to the emergency department in 2004-2014 with a head injury caused by falling from a height. Those with cranial neuropathies involving optic and eye-motility disturbances were identified, and their clinical, imaging, and outcome data were evaluated. Of the estimated 61,968 patients who presented to the emergency department during the study period because of a fall, 18,758 (30.3%) had head trauma. Only 12 (seven boys, five girls, average age 6.7years) had a visual disturbance. Eight were diagnosed with traumatic optic neuropathy, one after a 6-month delay, including two with accompanying cranial nerve (CN) III injuries. Five patients had anisocoria or an abnormal pupillary response to light at presentation, one patient had CN VI paralysis and temporary vision loss, and one patient had an isolated CN III injury diagnosed on follow-up. Visual improvement varied among the patients. Cranial neuropathies due to falls from heights are rare in children and are associated with high visual morbidity. Vision or ocular motility impairment, especially monocular vision loss, may be missed during acute intake to the emergency department, and a high index of suspicion is needed. Assessment of the pupillary response to light is essential.

Carbamazepine induced optic neuropathy in an adolescent boy with conduct disorder: A rare case report.

Byline: Sujita. Kar, Manish. Borasi, Deepak. Kumar, Sumit. Gupta Sir, The etiology of optic neuropathy is multi-factorial and toxin-induced (toxic) optic neuropathy (toxic amblyopia) is one of the common cause of optic neuropathy.[sup][1] The clinical manifestations can be in the form visual impairment, which is usually progressive, painless and involve both eyes.[sup][1],[2] Involvement of the color vision is the earliest sign which usually out of proportion to the visual impairment in totality.[sup][1],[3] Abnormal pupillary response to light, optic disc changes and disc hemorrhage may be seen in ophthalmoscopic examination in toxic optic neuropathy.[sup][1],[3] An antiepileptic drug like carbamazepine is known to cause ocular adverse effects like nystagmus, diplopia and paralysis of extra-ocular muscles, abnormalities of saccadic eye movements.[sup][4],[5] The diagnosis of toxic optic neuropathy is based on detail medical history, ocular examination, hematological investigations, visual field examination, neuro-imaging and electrophysiological tests.[sup][1] Withholding the offending medications, intravenous steroids, multivitamin supplementation are the mainstay of treatment in toxic optic neuropathy.[sup][1] A 15-year-old boy with features of conduct disorder was brought for psychiatric consultation by a nongovernment organization for his attempts of deliberate self-harm. The patient was hospitalized for his high-risk behavior. Behavioral therapy in the form of positive reinforcement was initiated for his conduct problems. For his impulsive behavior, tablet carbamazepine (controlled-release) 200 mg/day was initiated, which was later escalated to 400 mg over next 3 days, immediately after which he had developed generalized pruritic rashes all over the body, pain in both eyes, difficulty in identifying colors and difficulty in vision. He was very much distressed about his visual difficulties. There was no history of trauma to eyes or history of any form of visual difficulty, prior to this episode. Ophthalmology and dermatology opinion was taken for his above-mentioned complaints. His visual acuity was found to be 3/60 in the right eye and 6/24 in the left eye. Ophthalmological examination revealed anisocoria and sluggish pupillary response to light in the right eye. Ophthalmoscopic examination revealed bilateral mild disc hyperemia with nasal bulging of disc margin and mild venous tortuosity. On slit lamp examination, the anterior chamber of both eyes appears to be normal. Hematological investigations, including folic acid and Vitamin B12 levels and neuro-imaging (magnetic resonance imaging) were within normal limits except raised eosinophil percent (11% in differential leukocyte count). There was no concomitant use of any other medication in this patient. A diagnosis of carbamazepine-induced optic neuropathy was considered for which he was prescribed an intravenous injection of methyl-prednisolone (1 g/day) for 3 consecutive days. Immediately, carbamazepine was stopped. There was a significant improvement in vision and retro-orbital pain with this treatment. …

Chapter 12 - Surgical management of civilian gunshot wounds to the head

Each year close to 20000 Americans are involved in gunshot wounds to the head (GSWH). Over 90% of the victims of GSWH eventually fail to survive and only a meager 5% of the patients have a chance to continue with a useful life. One of the fundamental jobs of providers is to realize who the best candidate for the best possible management is. Recent evidence indicates that a good Glasgow Coma Scale (GCS) score at the time of admission puts such patients at high priority for management. Lack of abnormal pupillary response to light, trajectory of slug away for central gray, and visibility of basal cisterns upgrade the need for utmost care for such a victim. Surgical management is careful attention to involvement of air sinuses and repair of base dura. Patients with diffuse injury should have intraventricular intracranial pressure (ICP) monitoring and if needed a timely decompressive craniectomy. Since close to 2% of patients with penetrating brain injury may harbor a vascular injury, subjects with injuries close to the Sylvian fissure and those with the fragment crossing two dural compartments should have computed tomography angiography and if needed digital subtraction angiography to rule out traumatic intracranial aneurysms. In case of a positive study, these patients should have endovascular management of their vascular injuries in order to prevent catastrophic intracerebral hematomas and permanent deficit. Although supported by class III data, subjects of GSWH need to be on broad spectrum antibiotics for a period of 3-5 days. If cerebrospinal fluid (CSF) fistulas are observed at any time during the patient's hospital course, they should be taken very seriously and appropriate management is needed to prevent deep intracranial infections.

Predictors of outcome in civilian gunshot wounds to the head

Civilian gunshot wounds to the head (GSWH) are often deadly, but some patients with open cranial wounds need medical and surgical management and are potentially good candidates for acceptable functional recovery. The authors analyzed predictors of favorable clinical outcome (Glasgow Outcome Scale scores of 4 and 5) after GSWH over a 24-month period. The authors posited 2 questions: First, what percentage of civilians with GSWH died in the state of Maryland in a given period of time? Second, what were the predictors of favorable outcome after GSWH? The authors examined demographic, clinical, imaging, and acute care data for 786 civilians who sustained GSWH. Univariate and logistic regression analyses were used to analyze the data. Of the 786 patients in this series, 712 (91%) died and 74 (9%) completed acute care in 9 trauma centers. Of the 69 patients admitted to one Maryland center, 46 (67%) eventually died. In 48 patients who were resuscitated, the Injury Severity Score was 26.2, Glasgow Coma Scale (GCS) score was 7.8, and an abnormal pupillary response (APR) to light was present in 41% of patients. Computed tomography indicated midline shift in 17%, obliteration of basal cisterns in 41.3%, intracranial hematomas in 34.8%, and intraventricular hemorrhage in 49% of cases. When analyzed for trajectory, 57.5% of bullet slugs crossed midcoronal, midsagittal, or both planes. Two subsets of admissions were studied: 27 patients (65%) who had poor outcome (25 patients who died and 2 who had severe disability) and 15 patients (35%) who had a favorable outcome when followed for a mean period of 40.6 months. Six patients were lost to follow-up. Univariate analysis indicated that admission GCS score (p < 0.001), missile trajectory (p < 0.001), surgery (p < 0.001), APR to light (p = 0.002), patency of basal cisterns (p = 0.01), age (p = 0.01), and intraventricular bleed (p = 0.03) had a significant relationship to outcome. Multivariable logistic regression analysis indicated that GCS score and patency of the basal cistern were significant determinants of outcome. Exclusion of GCS score from the regression models indicated missile trajectory and APR to light were significant in determining outcome. Admission GCS score, trajectory of the missile track, APR to light, and patency of basal cisterns were significant determinants of outcome in civilian GSWH.

Comparative study of decompressive craniectomy in traumatic brain injury with or without mass lesion

Objective. Decompressive craniectomy (DC) is one of the most ardently debated topics in traumatic brain injury (TBI) treatment. The aim of this study is to compare the differences between DC with and without mass evacuation in patients with TBI. Methods. From January 2005 to December 2009, 164 patients underwent DC at our centre. Seventy-one of the 164 patients underwent DC for diffuse injury (group B). Ninety-three patients underwent DC as part of an operation to treat a mass lesion (group A). Patient characteristics and post-operative outcomes were compared between the two groups. Results. Thirty-six patients died during this study (22.0%). Fifty-nine of these patients (36.0%) remained either vegetative (n = 30) or severely disabled (n = 29). Sixty-nine patients (42%) had a Glasgow Outcome Scale (GOS) score of 4 to 5. Three predictors were significantly related to 60-day mortality: age older than 50 years (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.01–5.52), abnormal pupillary response to light (OR, 3.79; 95% CI, 1.29–11.14), and DC with mass evacuation (OR, 0.31; 95% CI, 0.12–0.79). Mortality differed substantially between patients with (group A) and without (group B) mass evacuation (14.0% versus 32.4%). Only one predictor was significantly related to good outcome: Glasgow Coma Scale (GCS) score at admission: (OR, 2.43; and 95% CI, 1.39–4.24). Conclusions. DC for patients with or without mass lesion has different patient characteristics. DC with mass evacuation has lower mortality than DC without mass evacuation. Outcome prediction following DC should be adjusted according to mass evacuation.