Loss Of Gray-white Differentiation Research Articles

Pediatric Multi-System Inflammatory Syndrome With Fatal Cerebral Edema in a Patient With COVID-19

INTRODUCTIONThere are increasing reports of a pediatric multi-system inflammatory syndrome associated with coronavirus disease 2019 (COVID-19) that presents with varying clinical features, but includes features of Kawasaki disease or toxic shock syndrome. Symptoms include fever, rash, abdominal pain, vomiting, and diarrhea. Many patients present without any respiratory symptoms and testing for SARS-CoV-2 is often negative.METHODSA retrospective chart review was performed.RESULTSA 7-year-old previously healthy male presented with 3 days of fevers up to 102.4F, headaches, abdominal pain, and intractable vomiting. Both parents had tested positive for SARS-CoV-2 four weeks prior. Nasopharyngeal swab tested positive for SARS-CoV-2 RNA. Echocardiogram was normal. CT venogram of his head was negative for any pathology. He developed severe neck pain and persistent headache during his hospitalization. Soon after receiving hydroxychloroquine, he developed a facial rash and altered mental status with episodes of aphasia, agitation, and pinpoint pupils. He then became unresponsive with left gaze deviation. A non-contrast head CT and CT angiography were negative. He was given levetiracetam and cefazolin and transferred to the pediatric intensive care unit. An electroencephalogram (EEG) showed no epileptiform activity. Over the following 7 hours, the EEG demonstrated left frontotemporal slowing, which progressed into a loss of fast activity over the right hemisphere with increased delta activity in the left hemisphere, then abruptly changed to generalized voltage attenuation.He rapidly lost brainstem reflexes, developing fixed and dilated pupils. Repeat CT scan revealed diffuse cerebral edema with loss of gray-white differentiation. Lab results then were consistent with severe inflammation. An intracranial pressure monitor revealed pressures greater than 76 mmHg. His exam soon became consistent with brain death. Pathologic evaluation showed diffuse cerebral edema with perivascular mononuclear infiltrates.CONCLUSIONThe cause of this pediatric multi-system inflammatory syndrome is unclear and the mechanism by which SARS-CoV-2 affects the nervous system is unknown. Pediatric patients with COVID-19 and neurologic symptoms should be closely monitored as they can rapidly decline due to fulminant cerebral edema.

Critical Illness Secondary to Synthetic Cannabinoid Ingestion

Synthetic cannabinoids (SCs), commonly known as K2, spice, or fake weed, are cheap, artificially manufactured recreational drugs that have emerged as a major public health threat in various regions of the US. To describe the clinical manifestations of SC intoxication. This case series assessed adults admitted to the intensive care unit from 2014 to 2016 with acute life-threatening complications of SC use. Data analysis was completed in October 2016. Use of SCs such as K2, spice, or other synthetic versions of cannabinoids. Data collected included patient demographic data, medical history, presenting symptoms, physical findings, laboratory and imaging data, and intensive care unit and hospital course. Thirty patients (mean age, 41 years [range, 21-59 years]; 24 men [80%]) with SC ingestion were admitted to the intensive care unit over a 2-year period. Thirteen patients were undomiciled. The majority had a history of polysubstance abuse, psychiatric illness, or personality disorder. The admission diagnoses were coma (10 patients [33%]), agitation (10 patients [33%]), and seizure (6 patients [20%]). Eighteen patients (60%) had acute respiratory failure, and tracheal intubation was required in 21 patients (70%) for either airway protection or acute respiratory failure. Rhabdomyolysis was noted in 8 patients (26%). A man developed transient cerebral edema with loss of gray-white differentiation but had complete recovery. A woman with history of asthma died of acute respiratory distress syndrome. All patients underwent routine toxicology testing, which was unrevealing in 16 cases and revealed coingestion in the remainder. Sixteen patients (53%) left the hospital against medical advice. Ingestion of SCs can lead to life-threatening complications, including severe toxic encephalopathy, acute respiratory failure, and death. Synthetic cannabinoids are undetectable in routine serum and urine toxicology testing but can be suspected on the basis of history and clinical presentation, which may include extreme agitation or coma. Frontline clinicians must be aware of the presentation and be vigilant in suspecting SC intoxication.

A serious thrombotic event in a patient with immune thrombocytopenia requiring intravenous immunoglobulin: a case report

BackgroundImmune thrombocytopenia is an acquired autoimmune disease. Recently, there has been evidence of thrombotic risk in patients with immune thrombocytopenia, but the mechanism is still inconclusive. Intravenous immunoglobulin infusion therapy is considered an efficient treatment; however, it still is associated with adverse events of fever, chills, and hypotension, as well as serious complications such as thrombosis. We report a case a patient with relapsed immune thrombocytopenia who developed ischemic stroke after an intravenous immunoglobulin infusion.Case presentationA 49-year-old Thai woman with relapsed/refractory immune thrombocytopenia came to our hospital with a large hematoma at the right buttock, and her platelet was decreased to 3 × 109/L. She was admitted to our hospital for intravenous immunoglobulin administration. One hour after completion of intravenous immunoglobulin infusion, the patient’s sister complained that the patient was unconscious and could not move both legs and arms. Emergency computed tomography of the brain showed no abnormal findings, such as brain edema, intracranial hemorrhage, or infarction. One day later, repeat computed tomography of the brain displayed extensive acute ischemic changes and loss of gray-white differentiation of bilateral cerebral hemispheres.ConclusionsWe performed an extensive literature review to determine the possible causes of serious thrombotic events in immune thrombocytopenia between the predictive factors of the disease and intravenous immunoglobulin. Although intravenous immunoglobulin is an effective treatment, thrombotic complications can occur. We emphasize that in patients with atherosclerosis risk factors or thrombophilia, the appropriateness of administering an intravenous immunoglobulin infusion should be carefully evaluated.

Abstract TP56: The Impact of Early Ischemic Changes on Head CT on Hemorrhagic Conversion and Outcomes in Patients With Acute Ischemic Stroke

Background: Early ischemic changes (EIC) on head CT are associated with increased hemorrhagic transformation (HT) following treatment with TPA. We examined the associations between EIC, HT, and outcomes in patients treated and not treated with IV TPA. Methods: We conducted a retrospective review of consecutive acute ischemic stroke (AIS) patients presenting to our CSC from April 2014 to March 2015. Demographic and clinical data, including initial head CT findings (parenchymal hypodensity, loss of gray-white differentiation, sulcal effacement, hyperdense vessel) were collected. HT on repeat neuroimaging, poor functional outcome, as measured by a modified Rankin Scale (mRS) of 3-6, and in-hospital mortality were assessed. Results: A total of 679 patients were included (50.4% men). One hundred and eight patients (15.9%) received IV TPA. EIC were observed in 38.5% of untreated patients and 17.6% in IV TPA treated patients (p<0.0001). For patients treated with IV TPA, EIC was seen more frequently in patients with pre-stroke anticoagulant use (26.3% vs. 6.7%, p=0.010) and less frequently in patients with pre-stroke statin use (15.8% vs. 43.3%, p=0.025). A higher proportion of HT was observed in patients with EIC (12.8% vs. 6.8%, p=0.016 untreated, 36.8% vs. 14.6%, p=0.024 IV TPA) and with hyperdense artery sign (8.2% vs. 3.7%, p=0.022 untreated, 36.8% vs. 15.7%, p=0.035 IV TPA). For untreated patients, EIC was observed in a larger proportion of patients with an NIHSS>14 (14.8% vs. 9.6%, p=0.016), and discharge mRS 3-6 (53.6% vs. 44.5%, p=0.040). For patients treated with IV TPA, in-hospital mortality was more common in patients with EIC (31.6% vs. 10.0%, p=0.013). Conclusions: In untreated patients, EIC may serve as a harbinger for HT on repeat imaging and poor functional outcome at discharge, whereas in patients treated with IV TPA, it is associated with HT and in-hospital mortality. Patients with EIC may be at increased risk of HT and poor outcomes even without thrombolytics.

Pediatric MRI of the Brain: A Primer

1. Kamakshya P. Patra, MD* 2. Jeffrey D. Lancaster, MD* 3. Jeffery Hogg, MD† 4. Jeffrey S. Carpenter, MD† 1. *Department of Pediatrics, Section of Hospital Pediatrics, West Virginia University Children’s Hospital, Morgantown, WV. 2. †Department of Neuroradiology, West Virginia University Health Sciences Center, Morgantown, WV. * Abbreviations: ADHD: : attention-deficit/hyperactivity disorder CSF: : cerebrospinal fluid CT: : computed tomography DWI: : diffusion-weighted magnetic resonance imaging FLAIR: : fluid-attenuated inversion recovery fMRI: : functional magnetic resonance imaging MRI: : magnetic resonance imaging MRV: : magnetic resonance venography NAA: : N -acetylaspartate SDH: : subdural hematoma Because of recent advances in magnetic resonance imaging (MRI) techniques, pediatricians should be aware of the different modalities and their unique advantages and appropriateness in different clinical situations. After completing this article, readers should be able to: 1. Understand the pros and cons of MRI and computed tomography of the brain. 2. Know the basic principles of MRI and its different image modalities. 3. Be aware of the appropriateness of different modalities in specific clinical situations. Magnetic resonance imaging (MRI) is based on the absorption and emission of radiofrequency energy by hydrogen protons whose spin is influenced by changing magnetic fields (0.3 to 1.5 T). Unlike computed tomography (CT), there is no radiation exposure. T1-weighted images cause fat (eg, myelin in white matter) to appear bright and water (eg, cerebrospinal fluid [CSF] or edema) to appear dark on this sequence. The gray-white interfaces of the brain are well depicted on these sequences, especially if with the images are thinly sliced. T2-weighted images cause water (eg, CSF and edema) to appear bright and fat to appear dark. The MRI-based intravenous contrast agents (eg, gadolinium) are frequently used in T1-weighted images (Fig 1A and B) to make serum appear bright. The blood-brain barrier typically serves to limit the passage of many molecules out of the blood vessels. If disease processes break down this barrier (such as infection, tumors, or inflammation), intravenous contrast agents can cross into the brain, causing areas of contrast entry to appear very bright. Figure 1. T1-weighted image at the level of midbrain. A. The cerebrospinal fluid (CSF) appears dark. B. The CSF appears bright. Note the gray and white matter differentiation …

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Case Reports: Spontaneous pneumocephalus is rare in infants, and is most often associated with trauma and central nervous system instrumentation. In adults, occasional cases have been reported associated with middle ear infections and mixed anaerobic central nervous system infections. We report a neonate with extensive pneumocephalus caused by Citrobacter koseri meningitis in the absence of any other predisposing factors. A three week old male, delivered vaginally at 34 weeks after a preterm labor complicated by prolonged rupture of membranes, presented with lethargy, hypothermia and feeding difficulties. Physical examination was remarkable for a tense anterior fontanel, poor capillary refill, tachycardia, pallor and severe hypotension. He was intubated and received intravenous ampicillin and gentamicin. He also required maximal vasopressor support for septic shock. Cerebrospinal fluid (CSF) revealed severe leukocytosis, low glucose and elevated protein, and gram negative organisms on smear. Portable computed tomography of the brain was performed and revealed extensive diffuse pneumocephalus, micro abscesses and loss of gray-white differentiation. Meropenem was added and gentamycin was changed to amikacin due to concern for more invasive organisms. Blood, respiratory and CSF cultures grew Citrobacter koseri within 24 hours. Unfortunately, he died within 36 hours of admission secondary to multi-organ failure. Autopsy of the brain demonstrated generalized edema, extensive hemorrhage and diffuse cortical necrosis. Microscopy revealed bacteria laden macrophages in the leptomeninges. Discussion: Citrobacter species accounts for 4 percent of neonatal meningitis with a 30 percent mortality rate despite prompt treatment. Most affected infants are less than 6 weeks of age and one third are born premature. Citrobacter species are facultative anaerobic gram negative bacilli that can hydrolyze urea and ferment glucose, resulting in production of gas. Cerebral ischemia may also contribute by hindering the absorption of the gas produced. This case emphasizes the severe nature of Citrobacter infection and the importance of considering Citrobacter in the differential diagnosis of spontaneous pneumocephalus in neonates.

Common and Expected Postmortem CT Observations Involving the Brain: Mimics of Antemortem Pathology

Postmortem imaging with CT or MR is emerging as an effective technique to augment forensic autopsy. Expected findings on postmortem imaging of the brain may mimic pathologic processes in the living brain, leading to potential misdiagnosis. The purpose of this study is to describe the array of CT findings that can be expected to be present within the brain after death. A retrospective review was performed using an anonymized data base of 33 postmortem head CTs with no evidence of trauma to the face or scalp. Head CTs were assessed for 1) loss of gray-white differentiation, 2) effacement of the ventricles and cisterns, 3) postmortem intravascular blood distribution, 4) presence of intracranial or intravascular air, and 5) an irregular appearance of the falx. Imaging findings were correlated with autopsy findings. Visualization of the basal ganglia was noted in 30 (91%) subjects, and the cortical ribbon was appreciated in 14 (42%). The ventricles and cisterns were effaced in 19 (58%) cases. An "expected postmortem blood distribution" was seen in 27 (82%) instances. Intravascular air was present in 14 cases (42%). A "lumpy" falx was present in 20 cases (61%). In 4 cases of subdural or subarachnoid hemorrhage noted on autopsy, but not on CT, retrospective review confirmed that a true discrepancy between the radiology and pathology findings persisted. Recognition of expected postmortem patterns is required before pathology can be accurately diagnosed. A limitation of CT virtual autopsy is the possibility of missing small blood collections.

Abnormal Neuroimaging is Associated with Early In-Hospital Seizures in Pediatric Abusive Head Trauma

Abusive head trauma (AHT) is a common condition in children. Little is known in this condition regarding the frequency of seizures, the factors associated with increased risk of seizures, or the association of seizures with outcome. We sought to determine frequency and risks for in-hospital seizures after AHT. This was a single-center, retrospective chart review study at a 270 bed tertiary care referral pediatric hospital. A total of 54 cases of AHT were identified during the study period. During the first week following hospital admission, 33% of patients were observed to have clinical seizures. The occurrence of clinical seizures after admission was associated with findings on initial CT including midline shift, cerebral edema, and loss of gray white differentiation. MRI findings associated with clinical seizures after admission included midline shift, cerebral edema, infarction, and restricted diffusion. The presenting complaint of seizures or acute mental status changes well as a variety of abnormal imaging findings including gray white blurring, infarction, and edema were associated with short-term outcomes. Specific neuroradiologic findings identify children at greater risk for seizures, both clinical and subclinical, following AHT. Clinical and subclinical seizures are common in the initial hospitalization for AHT.

Posterior-to-anterior circulation access using the Penumbra Stroke System for mechanical thrombectomy of a right middle cerebral artery thrombus

Background Mechanical thrombectomy devices rely on the ability of an operator to directly access a thrombus with the device. The authors demonstrate the first reported posterior-to-anterior circulation approach using the Penumbra Stroke System (Penumbra, Inc, Alameda, CA) for thrombectomy in acute stroke. Case Description A 53-year–old man presented 5 hours and 15 minutes after onset of left homonymous hemianopia, left facial droop, left upper extremity plegia, and left lower extremity paresis (NIHSS = 15). Computed tomography of the head revealed hyperdense material in the right M1 to M2 segments without loss of gray-white differentiation in the right cerebral hemisphere. Cerebral angiography at 6 hours and 50 minutes revealed occlusion of the right ICA at its origin. Injection of the left vertebral artery demonstrated clot in the right M1 segment with no anterograde flow. An Excelsior 1018 (Boston Scientific, Natick, MA) microcatheter was used to access the right PCOM and subsequently the right ICA and right MCA. A joint decision was made with the stroke neurology service to bury the microcatheter within the right MCA clot and administer 13 mg of tPA. A triaxial system using the Penumbra 041 catheter, Excelsior SL-10 microcatheter, and Synchro2 (Boston Scientific) guidewire was used to traverse the left vertebral and basilar arteries, the right PCOM, and the right ICA to the thrombosed right M1 segment. Aspiration using the Penumbra 41 catheter and 41 Separator was performed, resulting in a TIMI-2 result with minimal residual superior right M2 thrombus. Conclusion In patients with proximal vascular occlusion, mechanical thrombectomy with relatively stiff thrombectomy systems can be achieved through collateral pathways in the circle of Willis. Although the diameter mismatch between the Penumbra 41 catheter and a microguidewire may make sharp turns challenging, the use of an SL-10 microcatheter as a functional obturator may afford access.

Baseline computed tomography changes and clinical outcome after thrombolysis with recombinant tissue plasminogen activator in acute ischemic stroke.

Intravenous recombinant tissue plasminogen activator (rt-PA) is the only therapy of proven value for patients with acute ischemic stroke (AIS). Controversy exists with regard to the prognostic significance of early computed tomography (CT) changes in patients receiving rt-PA for AIS. The authors retrospectively reviewed all cases of AIS who received intravenous rt-PA for AIS in University of South Alabama hospitals between January 1996 and May 1999. A neuroradiologist, blinded to clinical outcomes, reviewed all baseline CT scans for the presence of the following signs: hyperdense middle cerebral artery (HMCA), loss of gray-white differentiation (LGWD), insular ribbon sign (IRS), parenchymal hypodensity (PH), and sulcal effacement (SE). Modified Rankin Scale (mRS) score was recorded 90 days after thrombolysis, and clinical outcome was dichotomized as favorable (0-1) or unfavorable (2-6). The authors performed both univariate and multivariate analyses to investigate the relationship between early CT signs, baseline clinical variables, and functional outcome as measured by the 90-day mRS scores. Any one early CT finding was detected in 23(64%) patients. The frequency of specific findings were as follows: SE in 13 patients (36%), LGWD in 12 patients (33%), PH in 9 patients (25%), HMCA in 4 patients (11%), and IRS in 3 patients (8%) patients. There was no statistically significant association between the occurrence of these imaging findings and subsequent functional outcome after thrombolysis. The data suggest that the presence of subtle acute CT changes in AIS patients is not predictive of clinical outcome following administration of rt-PA as per National Institute of Neurological Disorders and Stroke protocol.

Long-term outcome in infants with the shaking-impact syndrome.

Nonaccidental injury accounts for nearly one quarter of all hospital admissions for head injury in infancy, and is associated with significant morbidity and mortality. Long-term outcome in survivors, however, has been incompletely studied. In this series, 84 infants 2 years of age and younger with the shaking-impact syndrome consecutively admitted to a single hospital between 1978 and 1988 were identified. A questionnaire detailing current medical, developmental, and behavioral status was developed, and attempts were made to locate the 62 children surviving the acute injury. Family instability and strict confidentiality restrictions precluded locating the majority of children, but 14 children with demographic and injury characteristics similar to those of the overall group were contacted at an average of 9 years after injury. Seven children were severely disabled or vegetative, 2 were moderately disabled, and 5 had a good outcome. Of the latter group, 3 had repeated grades and/or required tutoring. Acute factors associated with poor outcome included unresponsiveness on admission, need for intubation, age less than 6 months, and bilateral or unilateral diffuse hypodensity on CT scan. All children with bilateral diffuse hypodensity and loss of gray-white differentiation on CT scan remained blind, retarded, nonverbal, and nonambulatory in spite of aggressive medical and surgical management. This study suggests that the majority of children surviving the shaking-impact syndrome suffer major permanent morbidity, and that acute factors predicting long-term outcome may help guide aggressiveness of care.