Acute Disturbance Of Consciousness Research Articles

The unconscious child

Acute disturbance of consciousness in a child is a potentially life-threatening condition. There are a variety of possible causes - traumatic, infectious, toxic, metabolic/endocrine, cardio-circulatory - to name a few. The history often provides important clues to narrow down the differential diagnoses. The recognition of reversible causes and a structured diagnostic process are life-saving in an emergency.

Neurološke komplikacije teškog oblika Influenze A kod dece

Introduction: Neurological complications of Influenza infection in pediatric population vary in incidence and severity. The central nervous system is most often affected by encephalitis and encephalopathy. Acute necrotizing encephalopathy (ANE) is the most serious complication. The aim of this case study was to present a variety of severe cases of neuro-influenza in pediatric patients. Methods: The study presents five children who were hospitalized in the pediatric intensive-care unit due to neurological complications of Influenza A infection during the winter season of 2022/2023. The identification of the causative agent was carried out by the reversetranscription-polymerase chain reaction or by the detection of viral antigens in the samples of nasopharyngeal swabs. Results: Four out of five presented patients were male. The average age at admission was 6 years (min. 7 months, max. 11 years). All patients had an acute disturbance of consciousness at admission and four of them had seizures. Neurological complications of Influenza A infection presented as acute encephalitis, posterior reversible encephalopathy syndrome, acute disseminated encephalomyelitis, encephalopathy, and ANE. Neurological signs appeared approximately four days after the first symptoms. There were no lethal outcomes. Younger patients had more severe brain damage and took longer to recover. None of the children had been vaccinated against the flu. Conclusions: Children presenting with acute neurological deterioration during influenza season should be evaluated for influenza-associated central nervous system complications even if the respiratory involvement is mild or there are no respiratory signs at all. Magnetic resonance imaging is the most important tool for early diagnosis.

Acute Disseminated Encephalomyelitis in ICU Patients with Acute Disturbance of Consciousness

Acute Disseminated Encephalomyelitis in ICU Patients with Acute Disturbance of Consciousness

Clinical evaluation of acute necrotizing encephalopathy in children

ObjectiveAcute necrotizing encephalopathy (ANE) is a rare but severe encephalopathy and is associated with a high morbidity and mortality. We aimed to analyze and compare the clinical features and predictive indicators of pediatric ANE.Materials and methodsThis retrospective study included children with ANE diagnosed at Guangzhou Women and Children’s Medical Center between November 2018 and January 2020. Pediatric patients’ information, including clinical characteristics, laboratory tests, neuroelectrophysiology and brain magnetic resonance imaging (MRI) findings, MRI score, brainstem auditory evoked potential (BAEP) grades, ANE severity scores (ANE-SS), and modified Rankin scale (mRS), were collected.ResultsTwelve ANE patients were included. Among them, one patient (8.3%) died from brainstem dysfunction, one (8.3%) recovered and 10 (83.3%) experienced neurological sequelae. All patients had an initial viral infection and neurological symptoms such as acute disturbance of consciousness (ADOC) or seizure, and the interval from onset of the disease to neurological manifestations was 3 (1.25–3) days. MRI score-I ranged from 1 to 3 (1.8 ± 0.7), MRI score-II ranged from 1 to 4 (2.5 ± 1.1). ANE-SS varied from 1 to 6 (3.9 ± 1.3). The scores of mRS were from 0 to 6 (2.9 ± 1.7). Higher MRI score were associated with worse outcomes, while the BAEP grade and ANE-SS score were not significantly associated with mRS.ConclusionANE is a severe encephalopathy syndrome with rapid progression, resulting in serious neurological sequelae. Compared with BAEP grade and ANE-SS, brain MRI shows more comprehensive advantages in predicting the prognosis of ANE patients. More in-depth research and better indicators are still needed to support the evaluation and treatment of ANE.

Persistent intrathecal interleukin-8 production in a patient with SARS-CoV-2-related encephalopathy presenting aphasia: a case report.

BackgroundNeurological manifestations of coronavirus disease 2019 (COVID-19) are increasingly recognized and include encephalopathy, although direct infection of the brain by SARS-CoV-2 remains controversial. We herein report the clinical course and cytokine profiles of a patient with severe SARS-CoV-2-related encephalopathy presenting aphasia.Case presentationAn 81-year-old man developed acute consciousness disturbance and status epileptics several days after SARS-CoV-2 infection. Following treatment with remdesivir and dexamethasone, his consciousness and epileptic seizures improved; however, amnestic aphasia and agraphia remained. Two months after methylprednisolone pulse and intravenous immunoglobulin, his neurological deficits improved. We found increased levels of interleukin (IL)-6, IL-8, and monocyte chemoattractant protein-1 (MCP-1), but not IL-2 and IL-10 in the serum and cerebrospinal fluid (CSF), and the levels of serum IL-6 and MCP-1 were much higher than those in the CSF. The level of IL-8 in the CSF after immunotherapy was four times higher than that before immunotherapy.ConclusionThe cytokine profile of our patient was similar to that seen in severe SARS-CoV-2-related encephalopathy. We demonstrated (i) that the characteristic aphasia can occur as a focal neurological deficit associated with SARS-CoV-2-related encephalopathy, and (ii) that IL8-mediated central nervous system inflammation follows systemic inflammation in SARS-CoV-2-related encephalopathy and can persist and worsen even after immunotherapy. Monitoring IL-8 in CSF, and long-term corticosteroids may be required for treating SARS-CoV-2-related encephalopathy.

Hepatic Encephalopathy Mimicking Creutzfeldt-Jakob Disease on Laboratory, Physiological, and Imaging Evaluations

Patient: Female, 84-year-old Final Diagnosis: Hepatic encephalopathy Symptoms: Cognitive impairment Medication:— Clinical Procedure: — Specialty: Neurology Objective: Unusual clinical course Background:Creutzfeldt-Jakob disease (CJD) is an irreversible, neurodegenerative, prion disease presenting with cognitive, behavioral, and motor dysfunction. The clinical presentations or laboratory findings of treatable autoimmune and metabolic processes may mimic those of CJD. Hepatic encephalopathy (HE) is a complication of severe hepatic failure that is characterized by neuropsychiatric manifestations. A case of HE whose laboratory, physiological, and imaging results were similar to that of Creutzfeldt-Jakob disease (CJD) in the process of treatment for HE is presented.Case Report:An 84-year-old woman with hepatic encephalopathy (HE) was admitted to our hospital because of acute consciousness disturbance. She had chronic hepatitis type C, liver cirrhosis, and hepatocellular carcinoma, and had had an episode of HE once. Her severe consciousness disturbance did not improve after treatment for concurrent hyperammonemia, unlike in her previous episode. Diffusion-weighted brain magnetic resonance imaging (MRI) showed widespread hyperintensity of the whole cortex. Her electroencephalogram showed periodic sharp wave complexes (PSWCs). Both total t-tau and 14-3-3 proteins were detected in her cerebrospinal fluid. According to these clinical data, CJD was highly suspected. However, the consciousness disturbance was alleviated by the tenth day of admission, and her general condition was markedly improved, which supported the initial diagnosis of HE.Conclusions:The present results suggest that treatable disorders, such as HE, should be considered before making a final diagnosis of a fatal disease such as CJD, since the spectrum of diseases that CJD mimics is vast. We should also aggressively treat patients with severe conditions from which recovery is possible.

Characteristics and Mortality Risk Factors of Influenza-Associated Encephalopathy/Encephalitis in Children in a Tertiary Pediatric Hospital in China, 2016-2019

Objective: Seasonal influenza associated neurological complications had high mortality and morbidity rates in children. In this study, we aimed to investigate the clinical characteristics and mortality risk factors in children with influenza-associated encephalopathy. Methods: Retrospectively analyze the clinical data, laboratory tests, and imaging examinations of 68 children diagnosed with influenza-associated encephalopathy from January 2016 to December 2019 at Guangzhou Women and Children’s Medical Center, and the cases were divided into survival and non-survival groups by disease outcome and analyzed between two groups Results: Among the 68 children with influenza-associated encephalopathy, 40 were male, and 28 were female, aged from 3 months to 13 years, of which 66.18% (45/68) were under 5 years old. Pathogenetic tests showed that influenza virus type A accounted for 63.24% (43/68), and influenza virus type B accounted for 36.76% (25/68). Typical brain MRI changes in childhood influenza-associated encephalopathy were bilateral symmetrical lesions of the thalamus, basal ganglia, brainstem, and cerebellum. 68 patients had a mortality rate of 20.59% (14/68), with a significantly higher proportion of fever peak >39°C, Acute Disturbance Of Consciousness (ADOC), and cardiac arrest in the non-survival group than in the survival group (P<0.05). Laboratory tests showed significantly higher Alanine Aminotransferase (ALT), Aspartate Transaminase (AST), Creatinine Kinase (CK), and Lactate Dehydrogenase (LDH), Lactate, C-Reactive Protein (CRP), and CSF protein levels in the non-survival group compared with the survivor (P<0.05), and among them, elevated ALT, AST, LDH, and CSF protein were independent high-risk factors for death from influenzaassociated encephalopathy. Conclusions: Children under 5 years of age with influenza are prone to combine neurological complications and have a higher mortality rate. Significant elevations in ALT, AST, LDH, and CSF proteins predict death from influenzaassociated encephalopathy in children.

Parameters Indicating Development of Influenza-Associated Acute Necrotizing Encephalopathy: Experiences from a Single Center.

BackgroundInfluenza-associated acute necrotizing encephalopathy (IANE) can be lethal and disabling and have a sudden onset and deteriorate rapidly but lacks early diagnostic indicators. We aimed to examine the early clinical diagnostic indicators in children with IANE.Material/MethodsAcute influenza patients were grouped according to their clinical manifestations: flu alone (FA), flu with febrile seizure (FS), influenza-associated encephalopathy (IAE), and IANE. The clinical features, biomarkers, neuroelectrophysiological results, and neuroimaging examination results were compared.ResultsA total of 31 patients were included (FA (n=4), FS (n=8), IAE (n=14), and IANE (n=5)). The IANE group, whose mean age was 3.7 years, was more likely to show rapid-onset seizure, acute disturbance of consciousness (ADOC), Babinski’s sign, and death/sequela. More patients in the IANE group required tracheal intubation mechanical ventilation and received intravenous immunoglobulins (IVIG) and glucocorticoids. The alanine aminotransferase (ALT), aspartate transaminase (AST), and lactate dehydrogenase (LDH) levels in the IANE group were significantly higher than in the FS and IAE groups. The aquaporin-4 (AQP-4) antibody and malondialdehyde (MDA) levels in the serum and cerebrospinal fluid (CSF) were notably higher in IANE patients in the acute stage compared with FS and IAE patients. All patients in the IANE group had positive neuroimaging findings.ConclusionsEarly clinical warning factors for IANE include rapid-onset seizures in patients under 4 years of age, ADOC, and pathological signs. Increased AQP-4 antibodies and MDA levels in CSF might contribute to early diagnosis. Early magnetic resonance venography (MRV) and susceptibility-weighted imaging (SWI) sequences, or thrombelastography to identify deep vein thrombosis, might indicate clinical deterioration.

Characteristics and Mortality Risk Factors of Influenza-Associated Encephalopathy/Encephalitis in Children in a Tertiary Pediatric Hospital in China, 2016-2019

Background: Seasonal influenza associated neurological complications had high mortality and morbidity rates in children. In this study, we aimed to investigate the clinical characteristics and mortality risk factors in children with influenza-associated encephalopathy. Methods: Retrospectively analyze the clinical data, laboratory tests, and imaging examinations of 68 children diagnosed with influenza-associated encephalopathy from January 2016 to December 2019 at Guangzhou Women and Children’s Medical Center, and the cases were divided into survival and non-survival groups by disease outcome and analyzed between two groups. Chi-square test or Mann-Whitney rank sum test was used for comparison between groups, and multivariate Logistic regression analysis was used for the analysis of risk factors for death. Results: Among the 68 children with influenza-associated encephalopathy, 40 were male, and 28 were female, aged from 3 months to 13 years, of which 66.18% (45/68) were under 5 years old. Pathogenetic tests showed that influenza virus type A accounted for 63.24% (43/68), and influenza virus type B accounted for 36.76% (25/68). Typical brain MRI changes in childhood influenza-associated encephalopathy were bilateral symmetrical lesions of the thalamus, basal ganglia, brainstem, and cerebellum. 68 patients had a mortality rate of 20.59% (14/68), with a significantly higher proportion of fever peak > 39°C, Acute Disturbance of Consciousness (ADOC), and cardiac arrest in the non-survival group than in the survival group (P Conclusions: Children under 5 years of age with influenza are prone to combine neurological complications and have a higher mortality rate. Significant elevations in ALT, AST, LDH, and CSF proteins predict death from influenza-associated encephalopathy in children.

Influenza-Associated Encephalopathy and Acute Necrotizing Encephalopathy in Children: A Retrospective Single-Center Study.

BackgroundAlthough influenza primarily affects the respiratory system, it can cause severe neurological complications, especially in younger children, but knowledge about the early indicators of acute necrotizing encephalopathy (ANE) is limited. The main purpose of this article is to summarize the clinical characteristics, diagnosis, and treatment of neurological complications of influenza in children, and to identify factors associated with ANE.Material/MethodsThis was a retrospective study of children with confirmed influenza with neurological complications treated between 01/2014 and 12/2019 at Guangzhou Women and Children’s Medical Center. A receiver operating characteristics curve analysis was performed to determine the prognostic value of selected variables.ResultsSixty-three children with IAE (n=33) and ANE (n=30) were included. Compared with the IAE group, the ANE group showed higher proportions of fever and acute disturbance of consciousness, higher alanine aminotransferase, higher aspartate aminotransferase, higher creatinine kinase, higher procalcitonin, higher cerebrospinal fluid (CSF) protein, and lower CSF white blood cells (all P<0.05). The areas under the curve (AUCs) for procalcitonin and CSF proteins, used to differentiate IAE and ANE, were 0.790 and 0.736, respectively. The sensitivity and specificity of PCT >4.25 ng/ml to predict ANE were 73.3% and 100.0%, respectively. The sensitivity and specificity of CSF protein >0.48 g/L to predict ANE were 76.7% and 69.7%, respectively. Thirteen (43.3%) children with ANE and none with IAE died (P<0.0001).ConclusionsHigh levels of CSF protein and serum procalcitonin might be used as early indicators for ANE. All children admitted with neurological findings, especially during the influenza season, should be evaluated for influenza-related neurological complications.

Temporal Changes in Brain Perfusion in Neuronal Intranuclear Inclusion Disease.

We herein report a patient with neuronal intranuclear inclusion disease (NIID) who presented with encephalitis-like episodes. A neurological examination revealed a disturbance of consciousness without any evidence of encephalitis or epilepsy on laboratory tests. Brain perfusion single-photon emission computed tomography revealed an elevated cerebral blood flow during the encephalitis-like episode and reduced cerebral blood flow in the chronic phase with clinical recovery. This report suggests that the cerebral blood flow of patients with NIID can change over the clinical course. Encephalitis-like episodes of NIID should thus be considered in the differential diagnosis of acute disturbance of consciousness.

Prolonged mild disturbance of consciousness and acute encephalopathy.

Acute encephalopathy (AE) is defined by the Japanese guidelines as the acute disturbance of consciousness (Glasgow coma scale [GCS] score ≤11) that persists for >24h. We have often encountered, however, cases of prolonged mild disturbance of consciousness (PMDC) with GCS score >11, meaning that they do not fit the guideline definition of AE. The reports of these cases have been relatively sparse, and the nosological position, prognosis, and other characteristics remain unknown. To clarify the characteristics of PMDC we compared cases of PMDC with cases of AE. This study was a retrospective observational study at a tertiary children's hospital in Japan. We studied children with a diagnosis of AE or PMDC between January 2011 and August 2016. Thirteen cases of PMDC and 19 cases of AE were identified during the study period. PMDC patients more frequently had hyponatremia (P < 0.01), paradoxical arousal response on electroencephalogram (P = 0.010), normal computed tomography (CT; P = 0.025), and normal magnetic resonance imaging (MRI; P < 0.01) than the AE patients. Sequelae were more frequently observed in AE than in PMDC patients (P = 0.011). PMDC has different characteristics to AE with regard to hyponatremia, paradoxical arousal response, CT or MRI findings, and prognosis. Despite the differences, PMDC might also be regarded as being a milder member of the wide variety of AE and related diseases.

Pharmacotherapy for Delirium in the Intensive Care Units

Delirium is defined as an acute disturbance of consciousness with inattention difficulties, changes in cognition or perceptual disturbance, which can develop over hours to days. Delirium is common in the medical and surgical intensive care units (ICU) and associated with many negative outcomes such as increased mortality, ICU and hospital length of stay, and cognitive impairment. A large number of studies have been conducted on various nonpharmacologic and pharmacologic strategies for prevention or treatment of delirium. The purpose of this article was to review the non- pharmacologic and pharmacologic agents used for delirium and review current studies on each strat- egy. Nonpharmacologic delirium managements using early mobilization and spontaneous awakening Review Article

Cerebral Lipiodol Embolism in Hepatocellular Carcinoma Patients Treated with Transarterial Embolization/Chemoembolization.

Background and PurposeLiver cancer is the third leading cause of cancer mortality worldwide. The aim of this study was to investigate the frequency and characteristics of cerebral lipiodol embolism (CLE) in patients with hepatocellular carcinoma (HCC) receiving transarterial embolization/chemoembolization (TAE/TACE).MethodsWe reviewed all HCC patients who received TAE/TACE during the period of 2007 and 2013 at a university medical center. The frequency of CLE per procedure and the clinical manifestations of CLE, including the review of previous reported cases (n = 24), were analyzed.ResultsDuring the study period, a total of 7855 TAE/TACE procedures were conducted on 3277 patients. There were 8 patients (mean age 59±11 years; 5 males and 3 females) who developed CLE. The frequency of TAE/TACE-related CLE was 1.02 (95% CI, 0.44–2.01) per 1000 procedures. Acute disturbance of consciousness and respiratory distress after TAE/TACE were the most common presentations of CLE. All patients had disseminated infarcts involving both the anterior and posterior cerebral circulations. For 3 patients with shunting between the tumor feeding artery and the pulmonary vein, a specific imaging pattern of coexisting scattered hyperdense spots was found. Furthermore, combined with our 8 cases, the total of 32 cases indicated that old age and female sex were the two risk factors for poor outcome after CLE.ConclusionsCLE is a rare but potentially serious complication in HCC patients receiving TAE/TACE. The clinical characteristics of CLE summarized in our study would help facilitate the ability of clinicians to provide timely diagnosis and management.

Nonconvulsive status epilepticus in neurological emergencies

According to the 2010 neuroresuscitation guideline, status epilepticus (SE) is a critical condition that causes respiratory and circulation dysfunction, including "acute consciousness disturbance" and "elevated intracranial pressure." There are two types of SE: general convulsive SE (GCSE) and nonconvulsive SE (NCSE). GCSE is easily diagnosed because the patients show continuous convulsions. In contrast, NCSE can only be diagnosed by electroencephalography (EEG), which can delay diagnosis. Moreover, GCSE and NCSE occasionally manifest in the same patient and alternate. Here, we describe the case of a 64-year-old male patient who experienced losses of consciousness mimicking stroke. We could not diagnose these episodes as NCSE until the patient had a general continuous convulsion. In this case, the delayed diagnosis of NCSE resulted in uncontrollable GCSE that required intensive management, including mechanical ventilation under sedation. It is important to recognize that NCSE can cause consciousness disturbance and to initiate treatment as soon as possible to improve patient prognosis. This could be achieved by performing an EEG earlier, such as at the scene of emergencies.

Diagnosis and Treatment of Post-Stroke Delirium

Delirium is an acute disturbance of consciousness and cognition with fluctuating course over a short period of time. Recognition of delirium in post-stroke patients is important because of its association with a longer stay in the hospital, a poor functional outcome, an increased risk of deteriorated cognition, and a higher mortality rate. It is occasionally under-recognized due to the fluctuating course and the neurological deficits that are caused by the stroke. Disturbance of several neurotransmitter systems including not only acetylcholine and dopamine but also serotonin, noradrenaline and gamma amino butyric acid have been implicated for the possible pathophysiology of delirium. Numerous potential precipitating and predisposing factors have been proposed such as comorbid condition, age, acute medical insults and environmental issues. In view of the complex multifactorial causes of delirium, multicomponent non-pharmacological approaches for risk factors are the most effective strategy for prevention of delirium. Preventive interventions such as frequent reorientation, early and recurrent mobilization, pain management, adequate nutrition and hydration, reducing sensory impairments, and ensuring proper sleep patterns have all been shown to reduce the incidence of delirium, regardless of the care environment. Pharmacologic interventions and physical restraints should be reserved for patients who are a threat to their own safety or the safety of others. This review describes epidemiology, pathophysiology, risk factors, diagnostic methods, and management of delirium in post-stroke patients. (Brain & NeuroRehabilitation 2015; 8: 59-64)

Delirium Superimposed on Dementia and Mild Cognitive Impairment

Dementia is an illness that progressively affects cognition, emotion, and functional status. It can be complicated by delirium, an acute disturbance of consciousness and cognition that develops over a short course with fluctuating symptoms. Patients with dementia who experience delirium tend to have slower resolution of symptoms, more adverse events, and poorer outcomes. There are significant health care expenditures associated with delirium. Many health care providers fail to recognize and diagnose delirium. The confusion assessment method is a suggested tool for diagnosing delirium. Delirium is multifactorial, occurring in an individual who has a predisposing factor (dementia is the number 1 risk factor) and is exposed to further precipitating risk factors that are often preventable. The main focus of treatment and management of delirium should be on prevention, which can be achieved through assessing patients for predisposing and precipitating factors. If a patient does develop delirium, a reassessment of precipitating factors is the first step in treatment, and then nonpharmacologic or pharmacologic treatment can be considered. The use of antipsychotics or melatonin to treat delirium in dementia is considered off-label.

Temperature Variability during Delirium in ICU Patients: An Observational Study

IntroductionDelirium is an acute disturbance of consciousness and cognition. It is a common disorder in the intensive care unit (ICU) and associated with impaired long-term outcome. Despite its frequency and impact, delirium is poorly recognized by ICU-physicians and –nurses using delirium screening tools. A completely new approach to detect delirium is to use monitoring of physiological alterations. Temperature variability, a measure for temperature regulation, could be an interesting component to monitor delirium, but whether temperature regulation is different during ICU delirium has not yet been investigated. The aim of this study was to investigate whether ICU delirium is related to temperature variability. Furthermore, we investigated whether ICU delirium is related to absolute body temperature.MethodsWe included patients who experienced both delirium and delirium free days during ICU stay, based on the Confusion Assessment method for the ICU conducted by a research- physician or –nurse, in combination with inspection of medical records. We excluded patients with conditions affecting thermal regulation or therapies affecting body temperature. Daily temperature variability was determined by computing the mean absolute second derivative of the temperature signal. Temperature variability (primary outcome) and absolute body temperature (secondary outcome) were compared between delirium- and non-delirium days with a linear mixed model and adjusted for daily mean Richmond Agitation and Sedation Scale scores and daily maximum Sequential Organ Failure Assessment scores.ResultsTemperature variability was increased during delirium-days compared to days without delirium (βunadjusted=0.007, 95% confidence interval (CI)=0.004 to 0.011, p<0.001). Adjustment for confounders did not alter this result (βadjusted=0.005, 95% CI=0.002 to 0.008, p<0.001). Delirium was not associated with absolute body temperature (βunadjusted=-0.03, 95% CI=-0.17 to 0.10, p=0.61). This did not change after adjusting for confounders (βadjusted=-0.03, 95% CI=-0.17 to 0.10, p=0.63).ConclusionsOur study suggests that temperature variability is increased during ICU delirium.

Management of acute hydrocephalus due to pregnancy with ventriculoperitoneal shunt

IntroductionThe ventriculoperitoneal (VP) shunt is an effective andmainstay of treatment for hydrocephalus. Although VPshunt reduces the morbidity and mortality of hydrocepha-lus considerably, it often malfunctions due to complica-tions such as obstruction, breakage, migration and infection[1, 2]. In pregnant women, shunt malfunction occurs due toincreasing abdominal pressure associated with enlargementof the uterus and other organs [3]. We present a case inwhich the patient presented an acute VP shunt malfunctionin the third trimester of pregnancy, and the externaldrainage of cerebrospinal fluid (CSF) management relievedher symptoms, so that she was able to successfully deliver ahealthy infant vaginally.Case reportAn 18-year-old female, who was at 30 weeks of gestation,was admitted to our emergency room due to acute distur-bance of consciousness. A computed tomography (CT)scan showed dilation of the ventricles (Fig. 1d).Previously, about 2 years ago, the patient had a pro-gressive visual impairment. Magnetic resonance images(MRIs) of the head indicated obstructive hydrocephalusdue to the rupture of an epidermoid cyst in the fourthventricle (Fig. 1b). Since the content of the epidermoidcyst had flowed to all ventricles and total resection of thecyst was impossible (Fig. 1a), a ventriculoperitoneal (VP)shunt was placed in the right lateral ventricle. Her visionreturned back to normal with rare headaches. A CT scanafter the procedure confirmed the relief of hydrocephalus(Fig. 1c).In the emergency room, the patient was not able to openher eyes spontaneously and showed flexion to pain with noverbal response (Glasgow Coma Scale, GCS 5 E1V1M3).A quick but systematic evaluation was made by bothneurosurgeons and obstetricians. The shunt catheter was inthe right lateral ventricle. The pressure of the shunt valvewas high, but the flexibility was good. The heart rate of thefetus was around 140 beats per minute. The reason for theVP shunt malfunction was due to increased intra-abdominalpressure because of the pregnancy. An external drainage inthe left ventricles was done immediately under generalanesthesia.After the procedure, approximately 60 ml of clear CSFwas drained per day and the CSF analyses were normal.The patient’s neurological condition was graduallyimproved (GCS8 E1V1M6) with a better flowing ventriclesystem that was confirmed by the CT scan (Fig. 1d). Twodays after the external drainage, premature rupture of themembrane was detected and vaginal delivery was per-formed successfully without epidural analgesia but underclose surveillance by neurosurgeons and obstetricians. Theinfant was healthy with an Apgar score of ten. The externaldrainage catheter was removed 2 days later on the condi-tion that VP shunt reverted functioning, confirmed byanother CT scan (Fig. 1f). The patient was discharged18 days after surgery.

Delirium in ICU patients is associated with increased temperature variability

Delirium is an acute disturbance of consciousness and cognition. It is a common disorder in the ICU and associated with impaired long-term outcome [1,2]. Despite its frequency and impact, delirium is poorly recognized by ICU physicians and nurses using delirium screening tools [3]. A completely new approach to detect delirium is to use monitoring of physiological alterations. Temperature variability, a measure for temperature regulation, could be an interesting parameter for monitoring of ICU delirium, but this has never been investigated before. The aim of this study was to investigate whether temperature variability is affected during ICU delirium.