Lucid Interval Research Articles

Extradural haematoma in children Primary and secondary lucid intervals

Twenty-six cases of extradural haematoma in children were reviewed over a 10-year period. The incidence of extradural haematoma was 3.3/1000 patients admitted to hospital with head injuries. Of 26 patients, 23% had no skull fracture and, in a further 8%, the fracture was not radiographically detectable. Twenty-three per cent of patients showed papilloedema, and 50% exhibited a fixed dilated ipsilateral pupil. In 62% of patients, there was no initial loss of consciousness; in a further 19%, impairment of consciousness was brief or doubtful. The lucid interval lasted three hours or less in one-third of patients; 24 hours after injury, the level of consciousness had declined in 73% of patients. Of particular interest was the occurrence of a secondary lucid interval, definite and dramatic in 8% of patients, and definite, but slight, in a further 12%. All patients made a good recovery, except one, who died from massive pulmonary fat embolism.

Delayed neurologic sequelae in carbon monoxide intoxication.

Of 2,360 victims of acute carbon monoxide intoxication examined between 1976 and 1981, delayed neurologic sequelae were diagnosed in 65 (2.75% of the total group, 11.8% of those admitted). There were 25 men and 40 women. Ages ranged from 34 to 80 years (mean, 56.1 years), with the peak incidence in the sixth and seventh decades. The lucid interval before appearance of neurologic sequelae varied from two to 40 days (mean, 22.4 days). The most frequent symptoms were mental deterioration, urinary or fecal incontinence, gait disturbance, and mutism; the most frequent signs were masked face, glabella sign, grasp reflex, increased muscle tone, short-step gait, and retropulsion. There were no important contributory factors except age and the severity of anoxia. Previous associated disease did not hasten the development of sequelae. Of 36 patients followed up for two years, 27 (75%) recovered within one year.

Thrombosis of the Internal Carotid Artery Due to Blunt Trauma

Thrombosis of the internal carotid artery (ICA) due to blunt trauma is more common than generally appreciated. Mortality is high (about 50%) and so is the morbidity in those that survive. Because of the varied clinical picture and the frequent lucid interval, a definitive diagnosis is often made too late for curative intervention. Our experience with a successfully treated case provided the stimulus for a review of the subject.

Benign post-traumatic encephalopathy syndrome in young people. Critical review of the literature

A trivial head injury can transiently render a child lethargic or even comatose. There have been several isolated reports concerning such conditions. Critical analysis disclosed that all these reports had certain factors in common: 1) they occurred in young people, 2) after head injury, 3) with several minutes to hours of lucid period; 4) neurological signs and symptoms were transient, and 5) complete recovery was usual. On closer checking, however, these syndromes could be categorized into three groups, i.e., nonconvulsive, convulsive, and brain swelling types. A typical non-convulsive type was the juvenile head trauma syndrome (Haas et al.). Injuries were usually trivial. After a short time, nausea, vomiting, lethargy, headache, cortical blindness, hemiparesis, and/or brain stem signs occurred. Not only a similarity of the manifestations with the periodic syndrome and migraine attacks but also the presence of migraine diathesis was frequently reported. Altogether 50 cases of the convulsive type were collected from the literature. Most of them were young children with minor head injury. Some became stunned, or received skull fractures. Convulsions were mostly focal motor. The third type consisted of 23 cases of diffuse brain swelling in children with a lucid period reported by Bruce et al. Vomiting, headache, disturbed consciousness from lethargy to coma, pupillary changes, apnea, and/or convulsive seizure were noted. CT scans disclosed small ventricles and effacement of the perimesencephalic cistern. All recovered without deficits except one who died from delayed brain swelling. In the first and second types of patients, no brain swelling was documented. Two patients who, after a minor head injury, convulsed and died of severe brain swelling have been separately reported. Three cases of the first type and one case of the second type recently experienced by the authors showed normal CT scans in the acute stage. All these three types might have a common underlying mechanism and they might be collectively termed as ‘benign post-traumatic encephalopathies in young people’, modified from Guthkelch. Children and young adults must have low thresholds against external force or more specifically either to increased extracellular potassium or to cerebral vasospasm. The relationship with migraine diathesis was noted only in the first type, which probably indicates a lower threshold in such predisposed youngsters.

Posterior fossa epidural hematoma

CT demonstrated posterior fossa epidural hematoma in three patients with head trauma in whom this diagnosis was not clinically apparent. No patient was in stupor or coma and no patient experienced a lucid interval. Only one patient had signs referable to the posterior fossa. Two patients had occipital skull fracture disclosed by plain radiographs. CT revealed a unilateral biconvex hematoma in two cases, and a bilateral hematoma with supratentorial extension in the third. All patients underwent suboccipital craniectomy and recovered. Therapeutic success in these cases was facilitated by early CT and the rapid disclosure of the unsuspected posterior fossa lesions. CT showing contiguous hematoma below and above the tentorium cerebelli after posterior head trauma is highly suggestive of epidural hematoma arising from the posterior fossa.

Diffuse axonal injury due to nonmissile head injury in humans: an analysis of 45 cases.

Forty-five cases of diffuse axonal injury (DAI) brought about by nonmissile head injury in humans are analyzed and compared with 132 cases of fatal head injury without DAI. All cases were subjected to a comprehensive neuropathological study. In the patients with DAI a statistically significant lower incidence of lucid interval, fracture of the skull, cerebral contusions, intracranial hematoma, and evidence of high intracranial pressure were found, with a higher incidence of head injury due to road traffic accident. Brain swelling and hypoxic brain damage were not statistically different in the two groups. The features of DAI in humans are compared with the DAI that has been produced in subhuman primates by pure inertial loading brought about by angular acceleration of the head. The available evidence indicates that DAI in human beings occurs at the time of head injury and is not due to complicating factors such as hypoxia, brain swelling, or raised intracranial pressure.

Middle meningeal artery trauma

We present the case of a patient who had the symptoms of a subarachnoid hemorrhage but was subsequently found to have an unusual combination of a separate traumatic pseudoaneurysm and a traumatic arteriovenous fistula of the middle meningeal artery. A review of the literature revealed a difference in the clinical course of patients with traumatic pseudoaneurysms compared to that of patients with arteriovenous fistulas. Patients who were found to have traumatic pseudoaneurysms of the middle meningeal artery frequently manifested signs of delayed hemorrhage. This mechanism may account for the prolonged lucid intervals exhibited in some patients subsequently found to have epidural hematomas.

Traumatic primary intraventricular hemorrhage

Two patients with primary intraventricular hemorrhage following mild head injury are presented. Both patients experienced a rapid loss of consciousness after a lucid interval following the head injury. Conray ventriculography or computerized tomography revealed intraventricular hematoma originating in the third ventricle and causing an obstructive hydrocephalus. Both patients made good recoveries promptly after ventricular drainage.

Cardiac arrest from gas embolism in scuba diving

The case of a scuba diver who suffered a cardiac arrest is presented. The history of a short, lucid interval after surfacing followed by cardiac arrest, the finding of hemoptysis, and the characteristic response to recompression therapy are consistent with the diagnosis of gas embolism. The clinical presentation and pathophysiology of gas embolism are discussed, and an approach to emergency stabilization and definitive management of gas embolism is reviewed, with emphasis on cardiac arrest.

Rabbit model of phlyctenulosis and catarrhal infiltrates.

Phlyctenules and catarrhal infiltrates of the human cornea have been described in association with staphylococcal blepharitis. Rabbits immunized and boosted with phenol-inactivated Staphylococcus aureus had a fourfold or greater increase in antibody titer to S aureus and delayed hypersensitivity to S aureus. After topical challenge with viable S aureus, the rabbits in this model had vascularized, elevated, nodular infiltrates of the cornea resembling phylctenules in humans and peripheral corneal infiltrates running parallel to the limbus and separated from it by a lucid interval resembling catarrhal infiltrates in humans. The nodular corneal infiltrates were found in a subepithelial location and were composed of vessels, polymorphonuclear leukocytes and mononuclear cells, including lymphocytes, plasma cells, and macrophages. The peripheral corneal infiltrates separated from the limbus by a lucid interval were found in the anterior stroma beneath the corneal epithelium and were composed of polymorphonuclear leukocytes and mononuclear cells.

Diffuse cerebral swelling following head injuries in children: the syndrome of "malignant brain edema".

The commonest initial computerized tomography (CT) finding in head-injured children is bilateral diffuse cerebral swelling. Cerebral blood flow and CT density studies suggest that this swelling is due to cerebral hyperemia and increased blood volume, not to edema. The clinical history, course, and outcome of 63 children with this CT pattern are reviewed. Fourteen children had a Glasgow Coma Scale score of greater than 8; all made a complete recovery and follow-up CT scans were normal. Forty-nine children had Glasgow Coma Scale scores of 8 or less. Fifteen had a history of a lucid period following the initial unconsciousness. One of these children died of delayed brain swelling, the others recovered well with minimal neurological deficit. Thirty-four children were rendered immediately and continuously unconscious. There was a high incidence of second lesions on the CT scan, 50% of this group developed intracranial hypertension and five died. All of the others were in coma for periods ranging from weeks to months. Follow-up CT scans showed an extracerebral collection with a density of cerebrospinal fluid in 27% of the patients, and ventriculomegaly with large sulci in 35%, whereas this pattern was seen only once in those with a lucid period. The difference between those with and without a lucid period is related to the degree of primary diffuse impact injury to the white matter.

Delirium updated

The new classification of organic mental disorders in Diagnostic and Statistical Manual of Mental Disorders, 3 ed (DSM-III) 1 features delirium as one of the seven organic brain syndromes. Acute failure of integrated cerebral functioning, due to a wide range of possible noxious factors, is manifested at the behavioral level by the syndrome of delirium. 2 Although well described by numerous writers since antiquity, delirium is still often misdiagnosed, and confusion about its essential features persists. For example, a recent report on lithium toxicity describes a patient as distractible, fully disoriented, and visually hallucinated, but curiously concludes that, “Despite the similarity of this illness to an acute delirium with occasional lucid intervals, the patient had no clouding of consciousness.“ 3 To counteract such diagnostic and related errors, an update of the diagnosis, pathogenesis, and management of delirium is presented, which supplements a previous extensive review. 4

Lucid Interval and Acute Subdural Hematoma

To the Editor.— In his recent article Acute Subdural Hematoma With a Lucid Interval (240:2284,1978), Volker K. H. Sonntag, MD, states that the occurrence of a lucid period in patients with acute subdural hematoma has not been stressed in any of the recent stories published and implies that it is uncommon. However, several recent studies have shown that a lucid interval occurs in patients with acute subdural hematoma. In a series cited by the authors, Jamieson and Yelland 1 reviewed 553 cases of surgically treated traumatic subdural hematomas and found that a lucid interval occurred in 13% of the patients. They compared this with the 12% incidence of lucid interval in their earlier review of extradural hematomas. 2 Richards and Hoff 3 reviewed 100 surgical patients with acute subdural hematoma; 37% had a lucid interval. Therefore, although a lucid interval after head trauma is classically associated with epidural hematoma, it

Marginal Corneal Ulcers with Acute Beta Streptococcal Conjunctivitis and Chronic Dacryocystitis

A 73-year-old woman had right dacryocystitis, intense conjunctival hyperemia and chemosis, marginal corneal ulcers, and abscesses and conjunctival cultures that were positive for beta hemolytic streptococci. A distinct lucid interval separated the peripheral corneal ulcers and infiltrates from the corneoscleral limbus. Gram stain of corneal scrapings revealed polymorphonuclear leukocytes but no bacteria, and corneal cultures were negative for bacteria. The peripheral corneal ulcers and abscesses in our patient with the lacrimal conjunctivitis of Morax clinically resembled the catarrhal ulcers found with staphylococcal blepharitis. A hypersensitivity or toxic reaction to streptococci or their products may have played a role in the development of the marginal ulcers in this patient.

Acute Subdural Hematoma With a Lucid Interval

THE LUCID interval following head trauma and unconsciousness is described classically in epidural hematomas. The historic emphasis placed on the lucid interval in cases of extradural hematoma has made this one of the best-remembered signs of the syndrome. Initial unconsciousness is thought to be due to the concussive effect of the blow to the head. The lucid period is the time required for the clot to grow to proportions great enough to produce compression of the brain. The percentage of patients with epidural hematoma who have lucid intervals varies in different reports from 10%¹to 72%.²Although the occurrence of a lucid period in patients with acute subdural hematoma has been mentioned in previous literature, it has not been stressed in any of the recent series published.^2-3My patient had an acute subdural hematoma in which head trauma and initial unconsciousness were followed by a lucid interval, then

Acute subdural hematoma with a lucid interval

Acute subdural hematoma with a lucid interval

Extradural haematoma. Report of 132 cases.

In a consecutive unselected series of 132 cases of acute extradural haematoma among 9,600 patients who sustained a head injury and were admitted without delay to a regional neurosurgical department during the years 1964 to 1975 the overall mortality was 23 per cent. Associated intradural lesions, the relative infrequency of the lucid interval, sustained loss of consciousness from the time of admission, lack of the classical pupillary changes, and the rapid rise in intracranial pressure in some patients are factors of importance for the prognosis. It should be possible to improve the results and lower the mortality if due consideration is taken of these factors.

Lecithin: Cholesterol Acyl Transferase Deficiency Presenting as Visual Impairment, with Hypocholesterolaemia and Normal Renal Function

A 20-year-old male of Indian extraction presented with visual impairment principally due to bilateral diffuse punctate corneal infiltration, with peripheral ring opacities. The diagnosis of LCAT deficiency was eventually confirmed by tissue and serum analysis together with enzyme studies, but there were some unusual features, notably persistent hypocholesterolaemia with normal range triglycerides but reduced levels of VLDL, LDL, and particularly HDL, without anaemia or detectable impairment of renal functions. This presentation has occasionally been described, and it is not clear whether it represents an early stage in the disease or whether a distinct sub-entity is involved. The corneal lesions differed from typical arcus in that the inner borders of the ring opacities were diffuse, and in particular outer lucid intervals were not apparent. Previous mild trachomal involvement was not considered to be responsible for these differences. The degree of visual affect was such that unilateral full-thickness ke...

The use of long acting lithium carbonate (Micalith) in patients with affective psychoses.

Many investigators in the West have cited disturbing figures illustrating how patients fail to take the proper dose described: 45% of patients with schizophrenia do not in fact take the medicine prescribed for them on discharge from hospital [i], and of those in hospital and under the supervision of the staff, only 80% take everything prescribed [2]. Patients with manic-depressive psychosis taking lithium salts during "lucid intervals" also frequently reduce the daily dose or omit treatment for several days in succession. The motives differ in such cases: If the effects are good and affective phases are absent for a long time the patient considers that he is "cured" and does not need preventive treatment; patients who have not yet shown distinct improvement consider that taking the medicine is a waste of time, unless their faith in it is supported by frequent conversations with the physician; often the patients are afraid of the consequences of taking medicine for such a long time, and are put off by the advice given to them by nonspecialist practitioners to "give the body a rest." If the course of the disease before the beginning of prophylactic treatment was sufficiently progressive, the patient's relatives will have more faith in the medicine than the patient himself. In such cases, reducing the number of doses to be given each day, possibly to once a day, in the morning or evening, makes supervision of the patients easier. According to our own observations only 88 to 250 patients with affective psychoses taking prophylactic doses of lithium for periods ranging from 1 to 8 years always strictly followed the physician's advice (the number is approximate and was obtained on the basis of the patients' own declarations, observations by the physician of fluctuations in the patients' conditions, and suggestions made by relatives [3]). The introduction of long-acting preparations reducing the frequency of dosage into psychiatric practice goes a long way toward overcoming the difficulties mentioned above.

TRAUMATIC SPREADING DEPRESSION SYNDROME

From 1476 hospital admissions with head injury, 37 patients were selected on the basis of distinctive clinical features which appeared to share a single and benign aetiology. In head injuries of this type, transient neurological disorders resulted from trivial or rather mild head injuries. These disorders, which included headache, nausea and vomiting, pallor, somnolence, irritability and restlessness, stupor, hemiparesis and aphasia, appeared after a lucid interval which was usually less than two hours; then the patient either recovered, or went on to develop convulsive attacks. Recovery without convulsions was usual in children and adolescents; convulsions occurred both in infants and younger children. The symptoms were not attributable to cerebral compression but were probably due to a self-limiting cortical phenomenon. It appears that convulsive attacks occurring within a few hours of this type of head injury may not be significant as precursors of post-traumatic epilepsy. It is suggested that there is a close relation between the convulsive attacks and the non-convulsive symptoms seen in this type of injury and that both are based on a common process which has the characteristics of the spreading depression of Leão. This type of head injury should be classified as a distinct clinical entity, in which no surgical treatment is required and the prognosis is good.