Abnormal Pupillary Response Research Articles

Our Experience with Surgically Treated Epidural Hematomas in Children

ObjectiveTraumatic epidural hematomas (EDHs) in children are a relatively unusual occurrence. The cause and outcome vary depending on period and region of study. The aims of this analysis were to review the cause and outcome of pediatric EDHs nowadays and to discuss outcome-related variables in a large consecutive series of surgically treated EDH in children.MethodsThis is a retrospective review of 29 patients with surgically treated EDHs between Jan 2000 and February 2010. Patients' medical records, computed tomographic (CT) scans, and, if performed, magnetic resonance imaging (MRI) were reviewed to define variables associated with outcome. Variables included in the analysis were age, associated severe extracranial injury, abnormal pupillary response, hematoma thickness, severity of head injury (Glasgow Coma Scale score), parenchymal brain injury, and diffuse axonal injury.ResultsThe mean (SD) age of the patients was 109 months (0-185 months). Most of the injuries with EDHs occurred in traffic accident (14 cases, 48.2%) and followed by slip down in 6 cases and falls in 6 cases. There were one birth injury and one unknown cause. EDHs in traffic accidents occurred in pedestrians hit by a motor vehicle, 9 cases; motorbike and car accidents, 5 cases and bicycle accidents, 1 case. The locations of hematoma were almost same in both sides (left side in 15 cases). Temporal lobe is the most common site of hematomas (13 cases, 44%). The mean size of the EDHs was 18 mm (range, 5-40 mm). Heterogeneous hematomas in CT scans were 20 cases (67%). Two patients were referred with unilateral or bilateral dilated pupil(s). There was enlargement of EDH in 5 patients (17%). All of them were heterogeneous hematomas in CT scans. Except for 4 patients, all EDHs were associated with skull fracture(s) (87%). There was no case of patient with major organ injury. CT or MRI revealed brain contusion in 5 patients, and diffuse axonal injury in one patient. The mortality was zero, and the outcomes were excellent in 26 and good in 2 patients. None of the tested variables were found to have a prognostic relevance.ConclusionRegardless of the EDH size, the clinical status of the patients, the abnormal pupillary findings, or the cause of injury, the outcome and prognosis of the patients with EDH were excellent.

Chapter 16. Glucose and nutrition

Chapter 16. Glucose and nutrition

Traumatic Epidural Hematomas in Children and Adolescents

Despite early diagnosis of traumatic epidural hematomas (EDHs) in children, mortality remained quite high in recent series. The aims of this analysis were to review the cause and outcome of pediatric EDH nowadays and to discuss outcome-related variables in a large consecutive series of surgically treated EDH in children. This is a retrospective case series of 39 patients (27 males, 69%) with surgically treated EDH between June 1997 and February 2007. Patients' medical records, computed tomographic scans, and, if performed, magnetic resonance imagings were reviewed to define variables associated with outcome. Variables included in the analysis were age, associated severe extracranial injury, abnormal pupillary response, hematoma thickness, severity of head injury (Glasgow Coma Scale score < or = 8), parenchymal brain injury, and diffuse axonal injury. Long-term follow-up (mean [SD], 51.3 [27] months) was available in 38 patients, and outcomes were classified as excellent (modified Rankin Scale score [mRS], 0; Glasgow Outcome Scale score, 5) and good (mRS scores, 1 and 2; Glasgow Outcome Scale score, 4). The mean (SD) age of the patients was 83.1 (59.9) months (range, 1-191 months). The mortality was zero, and the outcomes were excellent in 34 and good in 4 patients (one was lost to follow-up). Most of the injuries with EDH occurred in familial settings (23 cases), with falls being the most common mechanism of injury in 20 patients. Trauma was caused by traffic accidents in 14 cases (pedestrians hit by a motor vehicle, 7 cases; bicycle accidents, 5 cases; and motorbike and car accidents, 1 case each). One EDH occurred during delivery. The mean size of the EDH was 18.5 (12) mm (range, 5-40 mm). Three patients were referred with unilateral or bilateral dilated pupil(s). Except in 4 patients, all EDHs were associated with skull fracture(s) (90%). Computed tomography or magnetic resonance imaging revealed brain contusion in 13 patients, and 1 had diffuse axonal injury. None of the tested variables were found to have a prognostic relevance as tested by multivariate analysis (backward exclusion, Wald method). Regardless of the EDH size, the clinical status of the patients, the abnormal pupillary findings, or the cause of injury, the outcome and prognosis of the patients with EDH are excellent.

Pediatric Head Injury

Pediatric Head Injury

Outcome following decompressive craniectomy for malignant swelling due to severe head injury

The aim of this study was to assess outcome following decompressive craniectomy for malignant brain swelling due to closed traumatic brain injury (TBI). During a 48-month period (March 2000-March 2004), 50 of 967 consecutive patients with closed TBI experienced diffuse brain swelling and underwent decompressive craniectomy, without removal of clots or contusion, to control intracranial pressure (ICP) or to reverse dangerous brain shifts. Diffuse injury was demonstrated in 44 patients, an evacuated mass lesion in four in whom decompressive craniectomy had been performed as a separate procedure, and a nonevacuated mass lesion in two. Decompressive craniectomy was performed urgently in 10 patients before ICP monitoring; in 40 patients the procedure was performed after ICP had become unresponsive to conventional medical management as outlined in the American Association of Neurological Surgeons guidelines. Survivors were followed up for at least 3 months posttreatment to determine their Glasgow Outcome Scale (GOS) score. Decompressive craniectomy lowered ICP to less than 20 mm Hg in 85% of patients. In the 40 patients who had undergone ICP monitoring before decompression, ICP decreased from a mean of 23.9 to 14.4 mm Hg (p < 0.001). Fourteen of 50 patients died, and 16 either remained in a vegetative state (seven patients) or were severely disabled (nine patients). Twenty patients had a good outcome (GOS Score 4-5). Among 30-day survivors, good outcome occurred in 17, 67, and 67% of patients with postresuscitation Glasgow Coma Scale scores of 3 to 5, 6 to 8, and 9 to 15, respectively (p < 0.05). Outcome was unaffected by abnormal pupillary response to light, timing of decompressive craniectomy, brain shift as demonstrated on computerized tomography scanning, and patient age, possibly because of the small number of patients in each of the subsets. Complications included hydrocephalus (five patients), hemorrhagic swelling ipsilateral to the craniectomy site (eight patients), and subdural hygroma (25 patients). Decompressive craniectomy was associated with a better-than-expected functional outcome in patients with medically uncontrollable ICP and/or brain herniation, compared with outcomes in other control cohorts reported on in the literature.

Autonomic Disorders and the Eye

Autonomic Disorders and the Eye

Prevalence and clinical implications of hypocalcemia in acutely ill patients in a medical intensive care setting: Dasai TK Carlson RW, Geheb MA. Am J Med 1988; 84:209–214

Prevalence and clinical implications of hypocalcemia in acutely ill patients in a medical intensive care setting: Dasai TK Carlson RW, Geheb MA. Am J Med 1988; 84:209–214

Classification of Computerized Tomography and Prognosis of Traumatic Primary Brain Stem Injury

Clinical signs, computerized tomography (CT), continuous monitoring of intracranial pressure (ICP), serial recording of auditory brain stem response (ABR), and autopsy were examined in 40 cases of primary brain stem injury (PBSI) which showed clinical symptoms of prolonged coma, abnormal motor responses (decorticate, decerebrate or flaccid), impaired oculocephalic and/or pupillary responses, and no evidence of focal mass lesions on initial CT scanned within 2 hours after the injury. The consciousness levels of the 40 cases of PBSI on admission were 5 or less by the Glasgow Coma Scale; 5 in 12 cases; 4 in 15 cases; 3 in 13 cases. CT findings of the brain stem region (mesencephalon, pons, and medulla oblongata) of PBSI were classified into 7 types: brain stem hemorrhage (Type I); IVth ventricle hemorrhage (Type II); subarachnoid hemorrhage in the basal cisterns (Type III); compressed basal cisterns (Type IV); pneumocephalus in the basal cisterns (Type V); combined abnormal findings in the brain stem regions (Type VI); no abnormal findings in the brain stem regions (Type VII). Those cases of PBSI with initial CT findings of Type I, Type II, Type III, Type V, and Type VI all died. On the other hand, 7 cases of PBSI (17.5%) demonstrating good recovery or moderate disability by the Glasgow Outcome Scale (6 months after injury) were of Type IV (mortality 66.7%) and Type VII (mortality 50%); 5 of these cases (71.5%) were children. It has become obvious that there are many types of CT findings in PBSI besides brain stem hemorrhage that continuous ICP monitoring is very important to protect against secondary brain damage caused by increased ICP and that serial ABR recording predicts the outcome of PBSI very well as it provides reliable information about the function of the brain stem.

1582 AUTONOMIC DYSFUNCTION ASSOCIATED WITH SECRETORY DIARHEA: A NEW SYNDROME

A 1 year old male had features of autonomic dysfunction including lack of axon flare in response to intradermal histamine, abnormal pupillary response to conjunctival instillation of methacholine, absent fungiform papillae of the tongue, lack of overflow tears, decreased response to deep pain, and a history of recurrent aspiration pneumonias and failure to thrive. The patient differed from individuals with familial dysautonomia (FD) in that 1) he was not of Jewish heritage, 2) sweating was absent, 3) corneal reflexes were present, 4) temperature and vasomotor instability were absent. The patient differed from individuals with congenital sensory neuropathy with anhidrosis (CSN) in that 1) overflow tearing and fungiform papillae of the tongue were absent, 2) deep tendon reflexes were present, and 3) methacholine caused prompt pupillary miosis. True secretory diarrhea is a feature of neither FD or CSN, but was present in our patient. During a 9-day fast stool volume averaged 20 gm/kg/day. Stool electrolytes were Na 111 mEq/L, K 26 mEq/L, Cl 55 mEq/L. There was no evidence of malabsorption. Enteropathic bacteria and parasites were absent from the stool. No histologic abnormalities were evident in biopsies of the small bowel or rectum. The diarrhea improved during treatment with tincture of opium. Studies in animals and man have demonstrated that the autonomic nervous system contributes to the control of secretion from the small bowel and colon. This is the first report of a syndrome of a congenital autonomic dysfunction associated with secretory diarrhea.

Evaluation of brain function in severe human head trauma with multimodality evoked potentials. Part 2: Localization of brain dysfunction and correlation with posttraumatic neurological conditions.

✓ Electrophysiological investigations were undertaken in 51 comatose patients with severe head trauma to locate areas of brain dysfunction and to relate the loci of dysfunction to the patient's posttraumatic neurological condition. On the basis of evoked potential data, the presence of decortication or decerebration depended on cerebral hemispheric dysfunction. Brain-stem dysfunction, defined by evoked potentials, did not correlate with posturing. On the other hand, impaired oculocephalic responses and bilateral abnormal pupillary light responses were associated with brainstem dysfunction, while hemispheric dysfunction did not correlate with either: Duration of coma was dependent on hemispheric dysfunction. Brain-stem dysfunction was not significantly associated with prolonged coma. Furthermore, 80% of the head trauma patients who had Grade I or II multimodality evoked brain-injury potentials recorded in the acute period following head trauma (mean Day 3) became responsive within 30 days of their injury. Graded somatosensory brain injury potentials appeared to be a powerful prognostic tool as they significantly correlated with the patient's final outcome even when recorded early after injury. Abnormal multimodality evoked potentials recorded acutely consistently defined dysfunction of the visual, auditory, and motor systems in comatose patients, and were considerably more effective than the clinical neurological examination in diagnosing persisting focal deficits of these systems.

Abnormal pupillary responses in myasthenia gravis. A pupillographic study.

Using an open-loop stimulus (Maxwellian view), the direct pupillary response to light and its derivative curves (velocity and accleration of pupillary reactions) were recorded by infrared video pupillography in seven patients with myasthenia gravis and in three normal subjects. Responses before and after intravenous injection of 5 mg edrophonium hydrochloride were determined. Five of the patients had never taken anticholinesterase drugs except for diagnostic injections of edrophonium while the other two patients had been treated with oral preparations of corticosteroids. Analyses of the pupillary responses showed reduced amplitude, amximal velocity, and maximal acceleration of pupillary constriction in the myasthenic patients. On the other hand, changes in parameters of pupillary dilatation were minimal. Abnormal values returned towards normal within five minutes after edrophonium injection in all patients except in one individual who was being treated with corticosteroids at the time of examination. These results suggest that involvement of the iris sphincter may be common in patients with myasthenia gravis and this can be demonstrated by analysing the pupillary reaction and its derivative curves in response to an open-loop stimulus.