Deep Stupor Research Articles

Essential thrombocythemia complicated by multivessel intracranial dolichoectasia with subarachnoid hemorrhage and recurrent cerebral infarction

BackgroundPatients with essential thrombocythemia (ET) can develop systemic thrombotic and hemorrhagic vascular complications due to increased and dysfunctional platelets.Case presentationWe encountered a 49-year-old Japanese woman with a history of essential ET, cerebral infarction, hypertension, and hyperlipidemia. She had been taking anagrelide (2.5 mg/day) and aspirin (100 mg/day) and had vomited at home. At the time of admission to our hospital, she was in a deep stupor. We thought these symptoms were caused by intracranial hypertension. Head computed tomography showed severe subarachnoid hemorrhage (SAH) at the interhemispheric fissure, hematoma at the corpus callosum, and intraventricular hemorrhages. Digital subtraction angiography demonstrated multiple dilated, stenotic, tortuous intracranial arteries, and a dissecting aneurysm at the right anterior cerebral artery (ACA). The dissecting aneurysm measured 7.7 × 15.5 mm, and a bleb was observed. Our diagnosis was ruptured ACA dissecting aneurysm and diffuse intracranial arterial dolichoectasia (DIADE). We performed stent-assisted coil embolization of the aneurysm. She remained apathetic and manifested unilateral apraxia and alien limb syndrome due to a partial callosal disconnection. Two months thereafter her symptoms gradually improved, her consciousness level and limb function improved, and her modified Rankin scale (mRS) score was 2. However, when we tapered her antiplatelet therapy, she again developed an acute cerebral infarct.ConclusionsThis is the first presentation of a patient with ET complicated by DIADE, both of which can result in ischemic and hemorrhagic vascular complications including SAH. As antithrombotic therapy in patients with DIADE and ET may be associated with higher hemorrhage rates, its effects must be monitored carefully.

The Role of Risk Factor in the Surgical Treatment of Hemorrhagic Stroke

AIM OF STUDY To identify risk factors for adverse outcomes of surgical treatment of patients with HS.MATERIAL AND METHODS A retrospective analysis of the results of surgical treatment of 500 patients operated on at the N.V. Sklifosovsky Institute from 1997 to 2020 for hypertensive intracerebral hematomas. The mean age of the patients was 53.1±12.2 years. There were 335 (67%) men and 165 (33%) women.The level of consciousness before the operation was clear in 176 (35.2%), stupor (11–14 score, GCS) — in 258 (53.6%), sopor (score 9–10, GCS) — in 38 (7.6 %), moderate coma (7–8 score, GCS) — in 10 (2%) patients, deep coma (score 6) — in 7 (1.4%) patients. ICHs were lobar in 218 (43.6%) patients, lateral in 212 (42.4%) patients, thalamic in 10 (2%) patients, mixed in 10 (2%) patients, cerebellar in 50 (10% ) patients. The average volume of ICH was 46.5±25.1 cm3, supratentorial ICH – 49.6±24.5 cm3 (from 4 to 147 cm3), subtentorial — 18.7±6.4 cm3 (from 5 to 36 cm3). The average duration of the surgical intervention was 3.3±2.6 days. The following types of operations were performed: open removal of the ICH in 271 (54.2%) patients, puncture aspiration and local fibrinolysis of the ICH in 98 (19.6%) cases, endoscopic aspiration of the ICG in 131 (26.2%) patients.RESULTS The risk factors for lethal outcome in HT surgery are the age of patients older than 50 years (χ2=13.9, p<0.04), the volume of cerebral hemispheres more than 50 cm3 (χ2=7.8, p<0.01), the total volume of ICH and perifocal edema more than 100 cm3 (χ2=9.1, p<0.01), transverse dislocation of the median structures of the brain more than 5 mm (χ2=32.2, p<0.0001), axial dislocation of the brain (χ2=16 ,1, p<0.02), BP before surgery higher than 160 mm Hg (χ2=21.9, p<0.002), presence of IVH (χ2=36.9, p<0.00001), AOH (χ2=28.0, p<0.0001), surgery time — the first day after hemorrhage (χ2=64.4, p<0.00001), residual volume of ICH after surgery more than 15 cm3 (χ2=4.0, p<0.05) and recurrence of ICH (χ2=33.1, p<0.00001). The outcomes correlate with the severity of the patient’s condition before surgery (R=0.38, p<0.00001), and the risk factor for death is the depression of consciousness to deep stupor and below (χ2=97.2, p<0.00001).CONCLUSION Assessment of risk factors can help clarify the prognosis of the outcomes of surgical treatment and optimize the treatment tactics of patients.

A CASE REPORT ON PRADHAMANA NASYA: AN AYURVEDIC POWDER INHALATION

Nasal medication known as Nasya (medication through nasal route) is one among the Panchakarma (five internal bio-cleansing therapies) procedures which delivers drugs through the nasal route to cure ailments related to head and neck. Ayurvedic classics explain management of Sanyasa (coma) with immediate administration of most Tikshna (high potency) Nasya (medication through nasal route) and Pradhamana/Dhmapana Nasya (Nasya therapy by medicated powder insufflations). The present case report attempts to disclose the significance of an Ayurveda treatment modality Pradhamana/Dhmapana Nasya in an unanticipated medical condition (deep stupor) happened to a patient admitted to National Ayurveda Research Institute for Panchakarma (NARIP) Cheruthuruthy for the treatment of low back pain. On examination of the case, it was found that the patient was in deep stupor (Grade III state of awareness as per Grady coma Scale- and score seven on Glasgow coma scale GGCS). In this case, Rasnadi Choorna was selected for Pradhamana Nasya. The medicine was administered after placing the medicinal powder in a fine thin cotton cloth and a Pottali was made and it was just introduced into patent’s nostrils. Immediately after the administration of Pradhamana/Dhmapana Nasya the patient wake up from deep stupor state and became alert. This case report is an attempt to reveal the effect of Nasya in an unexpected medical condition and it also gives a new ray of hope to conditions of disturbed consciousness through nasal route of drug delivery.

A Case Report on a Patient with Intracerebral Hemorrhage with Intraventricular Hemorrhage Suffering from Deep Stupor to Semi-coma Treated by Korean Traditional Medicine

A Case Report on a Patient with Intracerebral Hemorrhage with Intraventricular Hemorrhage Suffering from Deep Stupor to Semi-coma Treated by Korean Traditional Medicine

Interobserver variability of the measurement of the mortality probability models (MPM II) in the assessment of severity of illness.

To assess the interobserver variability of the measurement of the MPM II system. Random sample of an inception cohort. Fifteen adult medical and surgical intensive care units (ICUs) in Spain. A 5% random sample (n = 119) of 2332 patients consecutively admitted in the ICU, aged 18 years or older. Prospective data collection during the stay of the patient in the ICU. Repeated data collection, after the patient's hospital discharge. Demographic information, length-of-stay and vital status at both ICU and hospital discharge, as well as all variables necessary for computing the MPM II system were measured. Interobserver variability for categorical variables was measured computing the kappa index. For interval variables the interobserver variability was assessed by the intraclass correlation coefficient, the paired t-test, and linear regression. In the MPM II0 index, the variables coma, heart rate, systolic blood pressure, chronic renal insufficiency, metastatic neoplasm, acute renal failure, cardiac dysrhythmia and cardiopulmonary resuscitation, showed moderate or low levels of agreement. In the MPM II24 index, the variables coma or deep stupor, PaO2 and prothrombin time showed low or moderate interobserver agreement. Agreement for the MPM II probability of death was high, although the external observer obtained a lower estimation than the hospital observer. The MPM II severity system showed a high level of stability when used in groups of patients. Nevertheless, the observed variability in some variables means that it should be used with caution for individual patients.

Safety, Tolerability, and Pharmacokinetics of the N -Methyl- d -Aspartate Antagonist Dextrorphan in Patients With Acute Stroke

Dextrorphan hydrochloride is a noncompetitive N-methyl-D-aspartate antagonist that is neuroprotective in experimental models of focal brain ischemia. The purpose of this study was to determine the maximum loading dose and maintenance infusion of dextrorphan hydrochloride that are well tolerated in patients with an acute stroke. An intravenous infusion of dextrorphan or placebo was begun within 48 hours of onset of a mild-to-moderate hemispheric stroke. Initially, patients were treated with either placebo (n = 15) or dextrorphan (n = 22) using a 1-hour loading dose (60 to 150 mg) followed by a 23-hour ascending-dose maintenance infusion (maximum total dose, 3310 mg). Subsequently, 29 patients were treated with dextrorphan in an open trial using a 1-hour loading dose (145 to 260 mg) followed by an 11-hour constant rate (30 to 70 mg/h) infusion. Transient and reversible adverse effects, including nystagmus, nausea, vomiting, somnolence, hallucinations, and agitation, commonly occurred in dextrorphan-treated patients. Loading-dose escalation was stopped because of rapid-onset, reversible, symptomatic hypotension in 7 of 21 patients treated with doses of 200 to 260 mg/h. At the highest rates of maintenance infusion (> 90 mg/h), 3 patients developed deep stupor or apnea. The maximum tolerated loading dose was 180 mg/h, and the maximum tolerated maintenance infusion was 70 mg/h. Maximum plasma levels of 750 to 1000 ng/mL were obtained in 9 patients. There was no difference in neurological outcome at 48 hours between the dextrorphan-treated and placebo-treated patients. The highest doses of dextrorphan administered were associated with serious adverse experiences in some patients. Lower doses (loading doses of 145 to 180 mg, maintenance infusions of 50 to 70 mg/h) were better tolerated and rapidly produced potentially neuroprotective plasma concentrations of dextrorphan. These doses were associated with well-defined pharmacological effects compatible with N-methyl-D-aspartate receptor antagonism.

Assessing the Damage in Iraq

The bombs that ripped apart Iraq's military war machine and civilian infrastructure sent shockwaves through the Arab world, leaving no one unaffected or indifferent. Some, who had loathed Saddam as regional bully and domestic tyrant, now rallied to his support in defeat, disgusted by the overkill of the allied campaign. Others, who had placed their hopes in Saddam's promise to liberate them from foreign rule, first rhapsodized about Iraqi military victories that had gone strangely unreported in the international media, only to sink into a deep stupor once the extent of the debacle became evident. Still others, who had admired Iraq's temerity in standing up to a coalition of the world's most powerful nations, quietly took down the posters and packed away the other mementos of a promise unfulfilled, storing their hopes somewhere deep inside until a future, more propitious, day. The signs were everywhere, as I traveled through Jordan, Iraq, and the occupied territories between March and May on a mission for the Bostonbased Physicians for Human Rights. In a quiet middle-class residential neighborhood of Amman, I visited the home of an Iraqi exile-clearly no friend of the Ba'athist regime. On her doormat she had sewn a small American flag. We discussed the situation in Baghdad where her relatives still live. She had received no news, and was very concemed. Since I was about to travel to Iraq, I took down the necessary addresses, and promised to look up

Basilar artery migraine

The case of a 40-year-old woman with a 24-year history of basilar artery migraine is described. She was admitted to the hospital after suffering a large cerebellar infarction causing hydrocephalus and deep stupor during an attack of migraine. She recovered after ventricular shunting and removal of the infarct.

Predicting the Outcome of Intensive Care Unit Patients

Abstract Statisticians are being asked with increasing frequency to develop models for occurrences in medical environments. Until recently, only subjective models were available to predict mortality for patients in an intensive care unit (ICU). These models were based on variables and associated weights determined by panels of medical “experts.” This article shows how multiple logistic regression (MLR) can be used to develop an objective model for prediction of hospital mortality among ICU patients. An MLR model to be applied when a patient is admitted to the ICU was developed on 737 ICU patients. The final model is based on the following variables: presence of coma or deep stupor at admission, emergency admission, cancer part of present problem, probable infection, cardiopulmonary resuscitation (CPR) prior to admission, age, and systolic blood pressure at admission. To validate this model, a new cohort of 1,997 consecutive ICU patients was entered into the study. Information was collected for the variabl...

Nonconvulsive Status Epilepticus in a Patient With Leptomeningeal Cancer

A 56-year-old man sought medical assistance because of recurrent nonconvulsive status epilepticus without a history of prior seizure activity. Examination of the cerebrospinal fluid disclosed leptomeningeal cancer. To our knowledge, the association of partial complex status epilepticus and leptomeningeal cancer has not been reported previously. If the results of computed tomographic and magnetic resonance imaging studies are normal, examination of cerebrospinal fluid should be considered in patients with nonconvulsive status epilepticus.

Encéphalite herpétique postopératoire. Intérêt de la méthode diagnostique de Klapper

A case of a 51 year old female with herpes encephalitis is reported. She underwent surgery for chronic pancreatitis with pseudocyst formation. On the third postoperative day, she developed a severe vesicular nasolabial eruption associated with a deep stupor. Anti- Herpes simplex viral (HSV) antibodies were found in both blood and cerebrospinal fluid. Klapper's anti-HSV antibody ratio was calculated and agreed with the hypothesis of herpes encephalitis. The patient was given nucleoside analogues. She rapidly improved and was discharged from the intensive care unit without any sequelae. The frequency of HSV infection in intensive care patients and the use of Klapper's index for the diagnosis of herpes encephalitis in these patients are then discussed.

Correlation of cerebral blood flow with outcome in head injured patients.

In order to determine the relationship of cerebral blood flow (CBF) to the clinical outcome of head injury, serial determinations of CBF were performed by the intravenous Xenon technique in 24 patients. The patients were of mixed injury severity and were classified into four groups depending on the neurological exam at the time of each CBF study. All eight patients who were lethargic on admission demonstrated increases in their minimally depressed CBF as they improved to normal status. Eleven patients in deep stupor or coma ultimately recovered. Ten of these patients initially had moderate to profound decreases in CBF which improved as recovery occurred. The single exception was an adolescent whose initial CBF was high but became normal at recovery. Five comatose patients died. In four of these, already depressed CBF fell even lower, while one adolescent with initially increased CBF developed very low CBF preterminally. The data presented in this report demonstrated a good correlation between CBF and clinical outcome. In every one of the adult survivors, depressed CBF increased as the patient recovered to normal status. All adults who died showed a deterioration of CBF as the neurological status worsened. The only exceptions were two adolescents who initially showed high CBF values. In the adolescent who died, CBF dropped to low levels while in the survivor a normal CBF was achieved. Thus in adults a traumatic brain injury was associated with depressed CBF which increased with recovery or decreased further with deterioration while the reaction to injury was quite different in the younger brain.

Continuous anesthesia by subcutaneous injection of magnesium sulphate in nephrectomized animals

In the paper dealing with the anesthesia produced in animals by subcutaneous injection of magnesium salts Meltzer and Auer stated that animals which urinated frequently had the better chance for recovery, and that urination probably carries off some of the salt and prevents its fatal accumulation in the blood. On the basis of this assumption a series of experiments were carried out in which the anesthetic effects of subcutaneous injections of magnesium sulphate were studied in nephrectomized rabbits. The results briefly stated were as follows: A dose of 0.8 gram of the salt per kilo of rabbit is sufficient to put the animal within a short time into deep anesthesia. This is less than half the dose that is required to anesthetize a normal rabbit. Furthermore, the nephrectomized rabbits thus anesthetized remained in a more or less comatose, paralyzed state until death, which did not occur earlier than in the control nephrectomized animal; in other words the animals remained in a state of anesthesia lasting sometimes two days and longer. Frequently the animals recovered slightly some hours after the injection, to sink soon again, however, into a deep stupor which lasted until death. The described effect was the same whether the above mentioned quantity of salt was given in one dose or was administered in fractions. These facts demonstrate that elimination of the injected magnesium salt occurs mainly through the kidneys and that the elimination begins pretty soon after the injection. Hence when the kidneys are absent and practically no elimination takes place a smaller dose is sufficient to bring on the anesthesia, and it makes no difference whether the quantity is given at once or in small doses at varying intervals. Furthermore, the anesthesia is long lasting and continuous, as the salt cannot leave the body.

Treatment of Hernia Cerebri.

Coronado, Cal., July 6, 1895. <h3>To the Editor:</h3> —Moved by a very interesting and instructive paper, recently published in theJournal, on brain surgery, in which Volkmann's treatment of fungus cerebri by the curette is mentioned, I wish to report a case successfully treated, in my first year of practice, by a different process. In July, 1838, my father (University of Pennsylvania, 1809) was called several miles in the country to a child about 3 years old, who had been kicked by a horse, and I went with him. We found a tumor over the left parietal, the child in deep stupor, and other indications of compression. The knife was given to me and I made a crucial incision, brain and clots of arterial blood following the knife. The dura was much torn and was trimmed after eleven pieces of bone were removed. Fearing erysipelas few sutures were used and

1.—German Retrospect

The State of the Eye During Sleep.—Dr. W. Sander (“Archiv,” ix. Band, 1 Heft), observes that with some care and practice the eye may be opened during sleep, and its condition examined. The view commonly given in the text books is that during sleep the eyeballs are turned inwards and upwards. This, I think, was first taught by Sir Charles Bell. According to Sander's experiments, the eyes are in a middle position, the axes parallel to one another, as when looking at a far object. In falling asleep, the eyeballs are converged and turned upwards, and the same thing takes place when the sleep is disturbed through raising of the lids. We then can see the eyes slowly moving upwards and inwards, as if to avoid the light, and seek protection from the covering eyelids. It is this condition which has been mistaken for the permanent one during disturbed sleep. Divergent positions of the eyes were seldom observed, and Dr. Sander is inclined to regard them as the result of disease, or deep stupor.

1.—German Retrospect

The State of the Eye During Sleep.—Dr. W. Sander (“Archiv,” ix. Band, 1 Heft), observes that with some care and practice the eye may be opened during sleep, and its condition examined. The view commonly given in the text books is that during sleep the eyeballs are turned inwards and upwards. This, I think, was first taught by Sir Charles Bell. According to Sander's experiments, the eyes are in a middle position, the axes parallel to one another, as when looking at a far object. In falling asleep, the eyeballs are converged and turned upwards, and the same thing takes place when the sleep is disturbed through raising of the lids. We then can see the eyes slowly moving upwards and inwards, as if to avoid the light, and seek protection from the covering eyelids. It is this condition which has been mistaken for the permanent one during disturbed sleep. Divergent positions of the eyes were seldom observed, and Dr. Sander is inclined to regard them as the result of disease, or deep stupor.