Cranial CT Research Articles

First Admission Neutrophil-Lymphocyte Ratio May Indicate Acute Prognosis of Ischemic Stroke.

ObjectivesOur study aimed to determine the relationship between serum periostin levels, and the neutrophil–lymphocyte ratio (NLR) with ischemic stroke subtypes, clinical stroke scales, and acute prognosis in patients with acute ischemic stroke.Materials and MethodsForty-two ischemic stroke patients and 39 age- and sex-matched healthy volunteers were included in our study. Demographic characteristics including age and gender were recorded. Blood serum periostin and NLR values were evaluated in the first 24 hours after admission. Serum periostin levels were compared with healthy controls of similar age and sex. Lesion localization was determined by cranial CT or diffusion MRI of the patients. Stroke scales were recorded on days 1 and 7 of hospitalization in the study group.ResultsThe mean serum periostin levels were higher than in the control group, but no statistically significant difference was found. There was no correlation between serum periostin levels and prognosis of stroke. First admission NLRs were statistically higher than in the control group. The first admission NLRs were positively correlated with the first admission National Institute of Health Stroke Scale score and the day 7 modified Rankin score.ConclusionOur study is the first study to evaluate both NLR and serum periostin levels in all types of acute ischemic stroke. While our study did not show that first admission serum periostin levels can be used as a biomarker in ischemic stroke, it did indicate that the first admission NLR can be used for acute prognosis of ischemic stroke.

Photo Quiz: A Bag of Marbles in the Nose.

A 51-year-old man presented with nasal congestion, pharyngeal discomfort, and chronic cough which had appeared several months previously. He was immunocompetent, and the only significant history was a moderate factor V deficiency. The patient had no fever, headache, cacosmia, or nasal obstruction. A cranial CT scan showed right maxillary sinusitis potentially associated with a suspected fungus ball surrounded by an inflammatory reaction (Fig. 1A). The nasofibroscopy did not find any particular abnormality. The patient underwent right endoscopic maxillary antrostomy with extraction of the fungus ball. Intraoperative specimens were sent for microbiological and histopathological investigations.

Computed tomographic pattern of stroke among adult patients in north-eastern Nigeria

Stroke and its complications are major health problems in developing countries including Nigeria. It could be a major cause of death or disability especially when only clinical assessment is relied upon for diagnosis. Computed Tomography (CT) is a valuable tool for the diagnosis of stroke. CT pattern of stroke in the North Eastern Nigeria has not been fully described. This was a prospective descriptive study conducted at the Federal Teaching Hospital, Gombe, Nigeria from June 2016 to December 2016. One hundred and eleven patients who presented with clinical features of stroke and were referred to Radiology department for cranial CT were consecutively selected. Data were analysed using SPSS version 16.0 package. A p-value of ≤ 0.05 and confidence interval of 95% were adapted for statistical analysis. The variables were expressed as range, percentage and mean plus standard deviation. All comparison of variables was done applying kappa statistic and point-biserial correlation coefficient for the correlation analysis. There were 69 (62.2%) males and 42 (37.8%) females aged 18-90 years (mean ± SD of 57.49±13.47 years). Ninety-four (94) patients (84.7%) had ischaemic stroke, while the remaining 17 (15.3%) had haemorrhagic stroke. Lobar location was identified as the most common site of ischaemic stroke while thalamo-ganglionic area was the commonest location for haemorrhagic stroke. Age and hypertension were found to be the commonest risk factors associated with stroke. It is evident from this study that ischaemic stroke is the most prevalent stroke subtype. The middle cerebral artery territory was the commonest vascular territory involved in stroke while hypertension and age are common risk factors for both ischaemic and haemorrhagic stroke.

Challenging the Norm: Is Routine Use of Cranial CT in Evaluation of Craniosynostosis Necessary?

Cranial CT is routinely taught to be the gold standard for diagnosis of craniosynostosis and used by craniofacial teams for suspected nonsyndromic single suture craniosynostosis. Given the risks associated with infant CTs, do these scans provide significantly enhanced diagnostic accuracy compared to the physical exam when performed by an experienced clinical provider? A retrospective chart review was performed for children who underwent corrective surgery for nonsyndromic, single-suture craniosynostosis over an 11 year period by a single craniofacial team. Ages at presentation and surgery, preoperative clinical diagnosis and imaging, co-existing radiographic findings, and correlation with the intraoperative diagnosis were analyzed. A total of 138 patients were included in this study. The mean age was 4.2 months at initial craniofacial evaluation, and 8.0 months at time of surgery. Twenty-seven patients received imaging prior to our clinic. Of those, 21 had plain radiography and 6 had CT scans. Of the remaining 111 patients referred without imaging, craniosynostosis was clinically diagnosed in 102 (92%), whereas 9 (8%) had an unclear clinical diagnosis. Of these 9, 1 (1%) was diagnosed clinically at follow-up exam, and the remaining 8 (7%) were diagnosed using radiography (3 CT scans, 5 plain radiographs). In all patients, the preoperative diagnosis was confirmed during intraoperative assessment. Cranial CT was not needed by experienced craniofacial providers in 93% of nonsyndromic, single-suture craniosynostosis. Imaging obtained before craniofacial clinic referral may have been unnecessary. These findings question the classic teaching that preoperative cranial CT is the gold standard for diagnosis in infants with nonsyndromic, single-suture craniosynostosis.

Systematic review and cumulative meta-analysis of the diagnostic accuracy of glial fibrillary acidic protein vs. S100 calcium binding protein B as blood biomarkers in observational studies of patients with mild or moderate acute traumatic brain injury.

Traumatic brain injuries (TBIs) and sports-related concussions (SRCs) are the leading causes of hospitalization and death in subjects <45 years old in the USA and Europe. Some biomarkers (BMs) have been used to reduce unnecessary cranial computed tomography (CCT). In recent years, the astroglial S100 calcium-binding B protein (S100B) has prevented approximately 30% of unnecessary CCTs. Glial fibrillary acidic protein (GFAP) has also been studied in direct comparison with S100B. The aim of our cumulative meta-analysis (cMA) is to compare- in the context of hospital emergency departments or SRC conditions- the differences in diagnostic accuracy (DA), sensitivity (Se) and specificity (Sp) of GFAP and S100B. The main cMA inclusion criterion was the assessment of both BMs in the included subjects since 2010, with blood samples drawn 1-30h from the suspected TBI or SRC. The risk-of-bias (RoB) score was determined, and both the publication bias (with the Begg, Egger and Duval trim-and-fill tests) and sensitivity (with the box-and-whiskers plot) were analyzed for outliers. Seven studies with 899 subjects and nine observations (samples) were included. The diagnostic odds ratios (dORs) with their prediction intervals (PIs), Se and Sp (analyzed with a hierarchical model to respect the binomial data structure) were assessed, and a random-effects MA and a cMA of the difference in the BMs dOR natural logarithms (logOR(G-S)) between the BMs were performed. The cMA of dOR(G-S) was significant (5.78 (CI 2-16.6)) probably preventing approximately 50% of unnecessary CCTs. Further work is needed to standardize and harmonize GFAP laboratory methods.

Risk factors for cerebral complications after type A aortic dissection surgery: single center's experience.

The objective of this study was to retrospectively review the rate and risk factors of cerebral complications (CC) after type A aortic dissection (TAAD) surgery. A total of 746 TAAD patients who underwent hypothermic circulatory arrest (HCA) surgery were enrolled. Postoperative CC were defined as intracranial hemorrhage or ischemic infarct stroke as confirmed by cranial CT scan. Multivariable logistic regression analysis was used to investigate the risk factors for CC and mortality. To identify the risk role of arch repair methods and flow rate in antegrade cerebral perfusion (ACP), propensity-score matching studies were performed (conservative vs. total arch replacement, n=135; low vs. normal flow rate, n=148). Thirty-five patients developed CC (6 with intracranial hemorrhage and 29 with ischemic stroke). Thirty-day mortality (34.3%) among patients with CC was significantly higher than that among patients without CC (12.2%). Multivariable logistic regression analysis identified preoperative cerebral ischemia, limb ischemia, end-stage renal disease, and salvage surgery as risk factors for postoperative CC. CAR (P=0.044; odds ratio, 4.587; 95% CI: 1.045-20.130) and low flow rate ACP (P=0.046; odds ratio, 2.139; 95% CI: 1.014-4.515) had protective roles. In the propensity-score matching studies, the CAR group (0.7% and 9.6%, P=0.005 and 0.175, respectively) and the low flow rate ACP group had lower rates of mortality (8.8% and 5.4%, P=0.067 and 0.012, respectively) and CC. CC are common and lethal after TAAD surgery. Low-flow ACP could be a safer and suitable antegrade perfusion method for cerebral protection.

A rare case report: concurrent COVID-19 and acute cerebrovascular ischemic stroke in a patient with Sheehan’s syndrome

Introduction: SARS-Corona Virus-2 (SARS-CoV-2/COVID-19) is a novel member of coronaviridae family. This new disease first appeared in China in December 2019, and can cause severe respiratory failure in advanced cases. COVID-19 was announced as a pandemic in March 2020 by WHO. It has infected 76 million people and has caused the death of more than 1.5 million people until December 2020. Common symptoms of this disease are mostly fever, cough, shortness of breath, anosmia, and fatigue. But atypical presentations have also being reported. Here, we present a COVID-19 patient with an unusual neurological symptom. Case: 82-years-old female patient with a history of hypertension and Sheehan’s syndrome came to the emergency room with the complaint of fever, shortness of breath and left hemiplegia. Although nasopharyngeal swab PCR test was negative (twice), acute phase reactants were elevated and chest CT revealed typical findings of COVID-19 pneumonia, so the patient was diagnosed as COVID-19. Since the patient had left hemiplegia, a cranial CT and diffusion-weighted MRI were performed to see whether a central neurological pathology was present. Both imaging revealed the findings of acute ischemic stroke (AIS). Afterwards, the patients was hospitalized and was started on Hydroxychloroquine, acetylsalicylic acid (ASA), favipiravir and methylprednisolone. At the 7th day of follow up, the nasopharyngeal swab PCR test was reperformed and found as positive. On the 10th day of treatment, the symptoms and acute phase reactants regressed. Left hemiplegia of the patient also regressed and she was discharged from the hospital at the 12th day of admission without a sequelae. Discussion and conclusion: Since there has been a recent evidence of strong relationship between COVID-19 and acute ischemic pathologies due to pathophysiology of COVID-19, we should be suspicious of acute ischemic stroke in a COVID-19 patient with neurological symptoms, especially when the patient had a history like Sheehan’s Syndrome disease may aggravate or hide the symptoms.

Hemodynamics-based analysis of factors associated with aneurysm rupture in different sides of the internal carotid artery

Objective: To explore the influence of hemodynamics, morphological and clinical characteristics on rupture risk of the dorsal and non-dorsal internal carotid artery aneurysms (ICAAs). Methods: A total of 111 patients diagnosed with aneurysm by digital subtraction angiography (DSA) or surgery, underwent cranial CT angiography (CTA) were retrospectively collected from January 2010 to December 2016 at the Department of Diagnostic Radiology, Jinling Clinical College of Xuzhou Medical University (General Hospital of Eastern Theater Command). Among them, 41 were males and 70 were females, ranging in age from 32 to 83 (56±11) years old. The patients were divided into the ruptured group (n=54) and unruptured group (n=57) based on the hemorrhagic manifestation on non-enhanced CT images or DSA or surgery of the head. Demographics and the morphological characteristics of the aneurysms were evaluated. Hemodynamic parameters, including wall share stress, wall share stress gradient, and others were obtained in overall using computational fluid dynamics simulation technique. Characteristics were compared between the ruptured and unruptured groups. Logistic regression analysis was applied to evaluate the independent risk factors for rupture, and the hemodynamic characteristics associated with dorsal and non-dorsal aneurysms were analyzed, respectively. Results: Compared with the unruptured group, patients in the ruptured group were younger ((54.2±11.4) years and (58.3±9.9) years, P=0.033), mostly female (74.1% vs 52.6%, P<0.05), with a higher proportion of hypertension (46.3% vs 22.8%, P=0.009). The ruptured internal carotid artery aneurysms (ICAAs) were more frequently located at the dorsal of an arterial arch (57.4% vs 36.8%, P<0.05), and the flow of the blood was more complex, concentrated, unstable, and with a smaller impingement zone (68.5% vs 33.3%,55.6% vs 10.5%,72.2% vs 26.3% and 79.6% vs 36.8%, respectively, all P<0.05). Logistic regression demonstrated that women, hypertension, dorsal, concentrated flow pattern, and unstable flow pattern were an independent risk factors for ICAAs rupture [OR=3.551 (1.080-11.679), 3.900 (1.172-12.976), 4.966 (1.504-16.401), 51.893 (7.913-340.296) and 50.015 (8.423-296.985), respectively, all P<0.05]. The ruptured ICAAs located at non-dorsal had more concentrated, unstable, and with smaller impingement zone (P<0.05), while those at dorsal had more complex, concentrated, and unstable flow patterns, and with smaller impingement zone (all P<0.05). Conclusion: Women, hypertension, dorsal concentration, and unstable flow pattern are independent risk factors for the rupture of ICAAs. The dorsal locations of ICAAs could have a higher risk of rupture.

Portal vein thrombosis associated with ChAdOx1 nCov-19 vaccination

A 41-year-old man with an unremarkable medical history presented to the emergency department with a headache that woke him and persisted despite painkillers. He had no neurological symptoms. The initial evaluation revealed severe thrombocytopenia (64 000 per μL) and increased D-dimer (42 028 μg/L). Cranial CT identified no findings of haematoma or ischaemia, and there was no sign of dural venous thrombosis on CT angiography. Thorax CT showed peripheral pulmonary emboli in the right lower lobe. There were no clinical signs of COVID-19, and upper abdominal organs were normal.

Evaluation of Intracranial Hypertension in Traumatic Brain Injury Patient: A Noninvasive Approach Based on Cranial Computed Tomography Features.

Background: Our purpose was to establish a noninvasive quantitative method for assessing intracranial pressure (ICP) levels in patients with traumatic brain injury (TBI) through investigating the Hounsfield unit (HU) features of computed tomography (CT) images. Methods: In this retrospective study, 47 patients with a closed TBI were recruited. Hounsfield unit features from the last cranial CT and the initial ICP value were collected. Three models were established to predict intracranial hypertension with Hounsfield unit (HU model), midline shift (MLS model), and clinical expertise (CE model) features. Results: The HU model had the highest ability to predict intracranial hypertension. In 34 patients with unilateral injury, the HU model displayed the highest performance. In three classifications of intracranial hypertension (ICP ≤ 22, 23–29, and ≥30 mmHg), the HU model achieved the highest F1 score. Conclusions: This radiological feature-based noninvasive quantitative approach showed better performance compared with conventional methods, such as the degree of midline shift and clinical expertise. The results show its potential in clinical practice and further research.

Structural Imaging Characteristic, Clinical Features and Risk Factors of Cerebral Venous Sinus Thrombosis: A Prospective Cross-Sectional Analysis from a Tertiary Care Hospital in Pakistan.

Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke that accounts for 0.5–1.0% of all strokes. Clinical presentation, predisposing factors, neuroimaging findings, and outcomes of CVST are extremely diverse, which causes a high index of suspicion in diagnosis. Therefore, early diagnosis of CVST is crucial for prompt treatment to prevent morbidity and mortality. Objective: The purpose of this prospective study is aimed at assessing the clinical characteristics, potential risk factors, and neuro-radiological features along with the topography of venous sinus involved in CVST patients in a tertiary care hospital, Lahore, Pakistan. Material and Methods: Consecutive patients enrolled in this study had a computed tomography (CT) scan, magnetic resonance imaging (MRI), and magnetic resonance venography (MRV) along with a clinical presentation to confirm the diagnosis of CVST. Categorical data were presented as percentages. Continuous variable and categorical data were compared (parenchymal lesions vs. non-parenchymal lesions) using the Student’s t-test and Chi-square test, respectively. Results: A total of 3261 patients with stroke were presented during the study period. Out of all patients, 53 confirmed patients with CVST (1.6%) were recruited; the predominant population was female (84.91%), having a male to female ratio of 1:4. Mean age of the cohort was 28.39 ± 7.19 years. Most frequent symptoms observed were headache (92.45%) followed by vomiting (75.47%), seizures (62.26%), papilledema (54.72%), visual impairment (41.51%), and altered consciousness disturbance (52.83%). The presumed risk factors associated with CVST were puerperium (52.83%), use of oral contraceptives (13.21%), antiphospholipid syndrome (7.55%), elevated serum levels of protein C and S (5.66%), and CNS infection (3.77%). On cranial CT scans, 50 patients (94.33%) showed abnormalities while 32 patients exhibited various parenchymal lesions. Seizures were more frequent in CVST patients with parenchymal lesions compared with subjects lacking parenchymal lesions. Seventy-two sinuses, either single or in combination, were involved in CVST patients, being more common in patients with parenchymal lesions than those without parenchymal lesions. The most frequent locations of CVST were the superior sagittal and transverse sinus. Conclusion: In short, non-contrast CT brain may be used as a first line investigation in suspected cases of CVST. Our study also demonstrates some regional differences in the clinical features, risk factors, and neuroimaging details of CVST as described by some other studies. Therefore, care must be taken while diagnosing and predicting the outcome of the CVST.

Calcium Channel Subunit α2δ-1 as a Potential Biomarker Reflecting Illness Severity and Neuroinflammation in Patients with Acute Ischemic Stroke

BackgroundVoltage-gated calcium channels (VGCCs) dysfunction is involved in the development of acute ischemic stroke (AIS). As a subunit of VGCC complexes, we detected the levels of α2δ-1 subunit in serum and cerebrospinal fluid (CSF) specimens from AIS patients. MethodsThe study included 105 patients with first-ever AIS, who were admitted within 48 hours after stroke onset. The serum and CSF levels of α2δ-1 were measured with ELISA and the severity of AIS patients was evaluated according to the National Institutes of Health Stroke Scale (NIHSS) score. The cerebral infarct volume was calculated through the Pullicino formula based on the cranial CT or MRI scan. C-reactive protein (CRP) and serum amyloid A (SAA) were measured using the latex-enhanced immunoturbidimetric assay. ResultsCompared to the control subjects, the serum α2δ-1 level was significantly increased in AIS patients with large infarct volume and in severe AIS cases with high NIHSS score, which correlated positively with the inflammatory markers CRP and SAA. Furthermore, the concentration of α2δ-1 in CSF was elevated with the infarct volume, which was higher in severe AIS patients. ConclusionOur study suggests that the increased α2δ-1 levels in serum and CSF specimens may be used as a potential marker for reflecting VGCCs dysfunction, illness severity and neuroinflammation in AIS patients.

Do computed tomography findings agree with traditional osteological examination? The case of porous cranial lesions

ObjectiveThe current study evaluates the feasibility of using clinical cranial computed tomography (CT) scans for assessing the presence and morphology of porous cranial lesions (cribra orbitalia, porotic hyperostosis). MethodsObservers (n = 4) conducted three independent evaluations of porous cranial lesions based on photographs, 2-D CT, and 3-D CT scans of archaeological crania. Evaluations of the crania from each viewing scenario were compared to findings from direct macroscopic observation. MaterialsTwenty-two complete adult crania from the Peruvian sites of Pachacamac and Chicama. ResultsWe found that lesion visibility differed by location: vault lesions with porosity larger than the resolution of the CT scan were identifiable across all viewing scenarios, but orbital lesions were identifiable only when extensive porosity was accompanied by widening of the inter-trabecular spaces. Lesions in stages of advanced remodeling were not visible on CT. ConclusionsPaleopathological criteria applied to head CTs from clinical cases of suspected cranial fracture can reliably identify moderate to severe porous cranial lesions in living individuals. SignificanceThis validation study opens the door to broader study of porous cranial lesions in living individuals that can address open questions about the causes and consequences of these commonly reported skeletal indicators of stress. LimitationsPerformance of all viewing scenarios was evaluated relative to assessment data from direct observation of skeletal remains, but direct observation is itself subject to error. Suggestions for Further ResearchThe increasing resolution of routine CTs makes it increasingly possible to explore skeletal lesions in clinical contexts.

The Value of Cranial CT Imaging in Patients With Headache at the Emergency Department.

Background: Headache is among the most prevalent complaints in patients presenting to the emergency department (ED). Clinicians are faced with the difficult task to differentiate primary (benign) from secondary headache disorders, since no international guidelines currently exist of clinical indicators for neuroimaging in headache patients.Methods: We performed a retrospective review of 501 patients who presented at the ED with headache as a primary complaint between April 2018 and December 2018. Primary outcomes included the amount of diagnostic imaging, the different conclusions provided by diagnostic imaging, and the clinical factors associated with abnormal imaging results.Results: About half of the patients were diagnosed with a primary headache disorder. Cranial CT imaging at the ED was performed regularly (61% of the patients) and led to the diagnosis of underlying pathology in 1 in 7.6 patients. In a multivariate model, factors significantly associated with abnormal cranial CT results were age 50 years or older, presentation within 1 h after headache onset, clinical history of aphasia, and focal neurological deficit at examination.Conclusions: As separate clinical characteristics have limited value in detecting severe underlying headache disorders, cranial imaging is regularly performed in the ED. Clinical prediction model tools applied to headache patients may identify patients at risk of intracranial pathology prior to diagnostic imaging and reduce cranial imaging in the future.

Hyperthyroidism and Immune Thrombocytopenia (ITP) Overlap Presenting as Hypoxic Ischemic Encephalopathy in a 38-Year-Old Filipino Female: A Case Report

Background: The coexistence of these two conditions can mimic severe sepsis in critically ill patients which may leave severe thyrotoxicosis unrecognized. Its higher incidence in Asian population suggests a possible genetic propensity. Clinical Case: A 38-year-old Filipino female sought consult due to changes in behavior. Two months prior, patient had persistent heavy menstrual bleeding but refused work-up. There was progressive weakness and pallor in the interim but no consult was done until she had an aggressive behavior hitting everyone she sees. Patient has Graves disease, maintained on methimazole 15 mg/day and propranolol 30 mg/day. Patient was advised to undergo radioactive iodine therapy but was lost to follow-up for 2 years. Likewise, no medication adjustment nor monitoring of biochemical parameters was done during the same period. On admission, patient was disoriented, tachycardic and febrile. She was generally pale with petechiae on the extremities and blood clots on her lips. Internal examination of the introitus revealed fresh blood with clots. Pregnancy test was negative. Initial laboratory evaluation revealed severe anemia (3.3 g/dl) and thrombocytopenia (3000/uL). Peripheral smear showed mild anisocytosis of red blood cells with no blasts nor atypical lymphocytes and platelet clumps seen. Patient received 1 unit platelet apherese and 2 units packed red blood cells (PRBC) and was started on broad spectrum antibiotic. Neurologic evaluation was negative for craniopathies. Baseline cranial CT scan was not done due to absence of lateralizing signs and was managed as a case of hypoxic ischemic encephalopathy from severe blood loss. Patient was biochemically hyperthyroid with TSH 0.065 uIU/ml, FT4 2.67 ng/dl and 10-fold elevated anti-TPO. Methimazole was then resumed at 20 mg/day and propranolol at 30 mg/day. Neck ultrasound showed an enlarged thyroid with diffuse parenchymal disease. Furthermore, patient had negative Coombs test, normal fibrinogen and procalcitonin. Patient was weakly positive for ANA at 1:160 dilution but negative for other markers in the lupus panel. Consistent with ITP, patient was started on IV hydrocortisone. In the interim, patient had less vaginal bleeding but with persistent bicytopenia which required multiple platelet and PRBC transfusions. A bone marrow biopsy was contemplated. However, on the 7th hospital day, patient had sudden onset of right sided paresthesia with dysarthria and hematomas on extremities. MRI of the brain revealed a large intraparenchymal hemorrhage and patient eventually succumbed to it. Conclusion: Bone marrow dysfunction secondary to the hyperthyroid state may explain the lack of response to standard therapy of ITP. There is short platelet lifespan, which is rather metabolic in nature, from increased reticuloendothelial phagocytic activity by upregulation of Fc receptor activity in patients with hyperthyroidism.

Panhypopituitarism Presenting as Progressive Visual Acuity Deterioration Secondary to Suprasellar Germinoma

Background: Overall the incidence of germ cell tumors worldwide is 0.1% with 60% comprising of germinomas. These may present in the suprasellar region a third of the time and thus impart variability in its presenting characteristics. Clinical Case: A 27-year male presented with progressive blurring of vision with incongruent visual acuity and refraction grade with optic disc pallor assessed with normal angiography. Patient also presented with increasing docility, sluggishness and more withdrawn behavior paired with polyuria, polydipsia and cold intolerance. Progressive worsening of vision led to cranial CT revealing an enhancing hyper density in the right caudate head later elucidated via MRI with several interspersed non-enhancing foci in the right caudate nucleus, both internal capsules with associated mild mass effect. The largest component located in the right capsular region with measurement of 21 x 21 x 16 mm with enhancing lesions in the hypothalamus and pituitary stalk. Endocrine evaluation revealed low serum cortisol at 91.03nmol/L (NV 138-685 nmol/L), responsive to ACTH stimulation test (65.94nmol/L to 387nmol/L), high prolactin at 856.9 mIU/L (42.4-296.8mIU/L) and low FT4 8.62pmol/l (9.01-19.05 pmol/L) despite normal TSH 1.528uIU/ml (0.35-4.94 uIU/mL). Optic nerve atrophy was now attributed to compressive intracranial mass. Secondary adrenal insufficiency was managed with hydrocortisone 50mgIV every 8 hours, and central hypothyroidism was managed with levothyroxine 75mcgtab 1tab once a day. Increased urinary output assessed as diabetes insipidus was given desmopressin 60mcg/tab ½ tab 2x a day at this time. Stereotactic biopsy of the brain revealed a germinoma of the right caudate lobe. Given the nature of the intracranial mass with high sensitivity to chemotherapeutic and radiotherapy, a multidisciplinary approach to treatment was taken with radiotherapy, hormonal and steroid replacement. Patient underwent external beam radiation therapy of the brain and spine for a total of 51 treatments allowing for improvement of visual acuity to counting, with polyuria less than 2-3 diaper changes per day. Conclusion: Optic disc pallor is a clinical sign that indicates optic nerve atrophy reflective of the optic tract. This may be an important clinical sign to increase clinical suspicion for intracranial mass lesion especially with correlation to manifestation of pituitary hormone deficiencies.

A Case of Giant Prolactinoma Characterized by a Nasopharyngeal Extension and Diagnosed by Nasal Cavity Biopsy

Abstract Introduction: Giant prolactinomas represent 2-3% of all prolactinomas and less than 0.5% of all pituitary lesions. Uncommon extensions of giant pituitary adenomas to areas such as nasopharynx or paranasal sinuses are even rarer. There are about 50 cases described in the literature. Here, we report a giant prolactinoma case diagnosed by biopsy from the nasal cavity. Case: A 40-year-old male patient applied to the emergency room after falling on ice. Cranial CT revealed a giant sellar mass destroying the clivus and the sphenoid bone corpus. The patient has had frontotemporal headache for 5 years, and also loss of libido and erectile dysfunction. He had right superolateral visual field defect and right-sided ptosis. Pituitary MRI showed a T2-hyperintense sellar mass measuring 58x58x70 mm, with extension to the nasopharyngeal wall, right cavernous sinus, right petrous apex and ethmoid spaces at the base of the skull. A punch biopsy was taken from the vascular mass located in the right nasal cavity, in between the middle concha and the septum. Pathological examination revealed a neoplasm that showed strong diffuse immunostaining with PRL and CK8, and focal staining with GH. Ki-68 proliferation index was 2%. Serum PRL level was 11881 ng/mL, FSH: 1.5 mIU/mL, LH: 1.3 mIU/mL, testosterone: 35.7 ng/dL, GH: 0.5 ng/mL, IGF-1: 520 ng/mL, ACTH: 73 pg/mL, cortisol: 12 mcg/dL, TSH: 0.04 uIU/mL, fT4: 14.2 pmol/L, fT3: 4.9 pmol/L and electrolytes were normal. Five days later, a right pterygonal craniotomy was performed. The mass showed the same immunostaining characteristics as the earlier biopsy specimen, and also included fibrin, monotonous cells with ischemic necrosis and distorted architecture of the reticulin pattern. According to the post-operative MRI, the right cavernous and clival part of the mass was reduced in size. Cabergoline (0.5 mg/w), levothyroxine (100 mcg/d) and testosterone propionate (250 mg/m) were started. The patient received conventional radiotherapy in a total dose of 1250 Gy, because of the residual mass. Sixth months after radiotherapy, the nasopharyngeal part of the tumor was not visualized. Cabergoline was up-titrated to a maximum dose of 3 mg/w. Prolactin levels decreased to 136 and 22 ng/mL at the third and sixth months of the treatment, respectively. Superolateral right-sided visual field defect persisted. Five years after surgery, secondary hypocortisolism has emerged, and 5 mg/day prednisolone was added to the therapy. Eight years after diagnosis, MRI revealed significant reduction in the size of the heterogeneous residual mass lesion. Discussion: Giant macroadenomas extending to nasopharynx are mostly prolactinomas, but other functional or non-functional pituitary adenomas may also have the same presentation. These lesions tend to be surgically hard to excise due to uncommon localizations, as in our case, and radiotherapy may be needed to control the residual mass.

Investigating the effects of the COVID-19 pandemic on the reasons for application to the emergency department in patients with neurological symptoms.

ObjectiveTo investigate whether the COVID-19 pandemic had an effect on the emergency department admission complaints of patients with neurological symptoms.MethodsA total of 976 patients admitted to the emergency department of our hospital and had undergone neurology consultation during a 6-month period were evaluated. The reasons for consultation, the number of patients consulted, hospitalization counts, and imaging studies for neurological assessment including computerized tomography (CT) and magnetic resonance imaging (MRI), were recorded and compared.ResultsCompared to the pre-pandemic period, there were significant decreases in the number of neurological consultations requested by the emergency department (overall and related to stroke, seizure and other reasons) and the number of patients hospitalized in the neurology department. We also found that the number of orders for cranial CT and MRI images during the pandemic period had decreased significantly.ConclusionRestrictions, social isolation measures and patients’ reluctance to apply to hospitals to avoid contact with possibly infected people may have led to a decrease in the number of patients with neurological symptoms admitted to the emergency department and the number of hospitalized patients.

Evaluation of the relationship between NIRS (near-infrared spectroscopy) and optic nerve sheath diameter measurement in children with increased intracranial pressure: a pilot study

BackgroundThe increased intracranial pressure (ICP) syndrome may emerge depending on many different neurological factors and the early diagnosis and treatment are important for the prevention of neurologic damage and related mortality. In recent years, the follow-up of increased ICP with non-invasive methods has been rising. In this study, our objective was to determine the significance and any possible correlation between Optic Nerve Sheath Diameter (ONSD) and Near Infrared Spectroscopy (NIRS) in children with increased ICP.MethodsPatients who were hospitalized in our pediatric ICU at Çukurova University Medical Faculty between June 2018 and June 2019 due to the suspicion of increased ICP were included in this study. The demographic characteristics of patients, diagnosis at admission, results of the cranial CT and MRI examinations, and results of the simultaneous ONSD and NIRS measurements were recorded.ResultsA total of 36 patients were included in our study. With respect to the diagnosis, non-traumatic causes were at the forefront in 30 patients (83.3%), and the most common causes were meningoencephalitis (n = 9; 25%) and non-traumatic bleeding (n = 7; 19.4%). Six of the patients were under the age of one year (16.7%), and the mean values of ONSD and NIRS were 4.8 ± 0.7 mm and 71.1 ± 12.4% respectively in this group. Fourteen patients were in the one to ten year age group and the mean values of ONSD and NIRS were 6.1 ± 0.6 mm and 72.7 ± 9.3% respectively. Sixteen patients were over ten years of age (44.4%), and the mean values of ONSD and NIRS were 5.6 ± 0.7 mm and 74.2 ± 16% respectively. There was no correlation between the ONSD and NIRS values (r:0.307; p = 0.068).ConclusionOur study showed that ONSD measurements were helpful in children with increased ICP and reflected the increase in ICP. However, our study also demonstrated that ONSD was not in correlation with the NIRS monitoring. We believe that there is a need for further studies focused on the use of ONSD and NIRS in the monitoring of increased ICP.

Management of Traumatic Epidural Hematoma in Infants Younger than One Year: 50 Cases – Single Center Experience

Aim and Background: Traumatic epidural hematoma (EDH) is a rare but possibly fatal complication of head trauma in infants. In this study, infants who were younger than 1 year and followed up and treated for TEDH in our clinic were evaluated. Our series is the largest series consisting only infantile cases in the literature. Material and Methods: There were 50 patients younger than 1 year followed up and treated in our hospital between January 2011 and December 2019. Their age, gender, hospital admission signs and symptoms, trauma type, localization and thickness of the hematoma, and accompanying skull fracture were noted from their hospital files. Decisions for conservative or surgical treatment were made according to neurological status, Children Coma Scale (CCS) score, and EDH thickness, degree of the midline shift on cranial computerized tomography (CT), and presence of additional intracranial pathology. Results: Patients’ age ranged from 0 day to 12 months (7 months as median), and their male/female ratio was 30/20. Falling from a height (<1 m) was the most frequent trauma mechanism, with a 96% rate. The most common finding was irritability and unusual crying (88%). The CCS score was 5–15 (median 13). The hematoma was located most frequently in the parietal region (48%) and least frequently in the posterior fossa (2%). Linear fracture was observed in 62% of the cases. Thirty-nine (78%) patients were treated conservatively (hematoma thickness ≤17 mm). Eleven (22%) cases were surgically treated (hematoma thickness was between 15 and 40 mm (26.3 ± 6.6 mm, mean ± standard deviation [SD]). The midline shift in the operated cases was between 1.8 and 11.8 mm (6.4 ± 3 mm, mean ± SD). One of them with a hematoma thickness of 15 mm was operated for associated open depression fracture above the hematoma. Other 10 patients were operated for primarily hematoma evacuation. None of the patients treated conservatively worsened neurologically or required operation during or after hospitalization. Two patients died (4%) during hospitalization, and both of them were anisocoric on admission. The hospital stay was between 1 and 10 (median 3) days, and the follow-up period of the living patients was between 1 month and 6 years (median 24 months). All of the living patients were neurologically normal on their last controls. Conclusions: Because the symptoms and signs in infants are nonspecific, it is difficult to diagnose EDH clinically. Cranial CT should be performed in cases with irritability, swelling of the scalp, pallor, deterioration of consciousness, and anisocoria after head trauma. Traumatic EDHs with normal neurological examination, high CCS score, hematoma thickness below 20 mm, no apparent shift, and without associated brain pathology can be treated conservatively. None of those patients treated conservatively required operation after that.