Lucid Interval Research Articles

Imported Human Rabies Cases in Europe, the United States, and Japan, 1990 to 2010: Table 1

Rabies is an irreversible, fatal disease most frequently characterized by acute encephalitis that causes approximately 55,000 deaths annually in Africa and Asia. Disease occurs when rabies virus, a Lyssavirus , is transmitted to a human via the saliva of an infected mammalian carnivore or bat, usually a dog, if it comes in contact with mucous membranes or enters the body via a bite, scratch, or lick on broken skin. Animal reservoirs for rabies exist in all continental areas worldwide. Deaths are presumed to be underreported in areas with poor access to medical facilities. Children are considered to be at a higher risk than adults.1,2 Although the risk of contracting rabies in developed countries is generally low, those who travel to areas with high epizootic endemicity are at increased risk of exposure and death. Steffen and co‐workers evaluated the risk of rabies infection due to animal bites in travelers to developing countries and found an incidence rate per month between 0.1% and 1%.3 An epidemiological study of travelers presenting to GeoSentinel sites worldwide performed by the US Centers for Disease Control and Prevention (CDC) and the International Society of Travel Medicine (ISTM) found that 4.7% of this population required rabies post‐exposure prophylaxis.4 After acquisition of the virus, the incubation period is variable, usually between 20 and 90 d, although occasionally disease develops after only a few days, and, in rare cases, more than a year following exposure. Usually patients develop a furious form of the disease, with episodes of generalized hyperexcitability separated by lucid periods. Encephalitis results from viral replication in the brain. In 20% of cases, a paralytic form of the disease results in progressive immobility. Both forms of rabies, furious and paralytic, are always fatal. One documented case of recovery from symptomatic disease has been reported; … Corresponding Author: Claudius Malerczyk, MD, Novartis Vaccines and Diagnostics GmbH, Emil‐von‐Behring Strase 76, D‐35041 Marburg, Germany. E‐mail: claudius.malerczyk{at}novartis.com

A Case of Delayed Encephalopathy after Carbon Monoxide Poisoning Longitudinally Monitored by Diffusion Tensor Imaging: Fig 1.

A woman with DE after CO poisoning was longitudinally evaluated by DTI, performed during the following periods: at the phase of acute CO poisoning, the lucid interval, neurologic deterioration due to DE, and neurologic recovery. The present case revealed the long-term course of DTI parameters after CO poisoning and the usefulness of DTI for quantifying neurologic damage after CO poisoning.

Sickle Cell Trait-Associated Deaths: A Case Series with a Review of the Literature*,†

This study presents a series of 16 carriers of hemoglobin S (HbS) who died during various circumstances. Many of the cases were associated with mild to moderate exertion. The onset and/or duration of symptoms varied from a few minutes to several hours with many displaying a prolonged lucid interval with stable vital signs. Despite seeking medical treatment, sickle cell trait-related micro-occlusive crisis was never considered in the differential diagnosis. Several cases were associated with sudden death. In those deaths which were delayed, high anion gap and uncompensated metabolic acidosis were typical and were not heat related. Also characteristic were large increases in creatine kinase, alanine aminotransferase, and aspartate aminotransferase along with myoglobinemia. Although the antemortem diagnosis of rhabdomyolysis was made, the underlying cause was never deduced by the clinicians. The sickling found at autopsy is not always a postmortem artifact, and in the right circumstances can be diagnostic.

1H-magnetic resonance spectroscopy indicates damage to cerebral white matter in the subacute phase after CO poisoning

ObjectiveThe authors examined whether 1H-magnetic resonance spectroscopy (MRS) can identify damage to the centrum semiovale in the subacute phase after CO exposure.MethodsSubjects comprised 29 adult patients who were treated with...

Aorto-esophageal fistula: a rare fatal case caused by esophageal malignancy.

Aorto-esophageal fistula: a rare fatal case caused by esophageal malignancy.

Testamentary capacity and delirium

With the aging of the population there will be a substantial transfer of wealth in the next 25 years. The presence of delirium can complicate the evaluation of an older person's testamentary capacity and susceptibility to undue influence but has not been well examined in the existing literature. A subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to review how to assess prospectively and retrospectively testamentary capacity and susceptibility to undue influence in patients with delirium. The subcommittee identified questions that should be asked in cases where someone changes their will or estate plan towards the end of their life in the presence of delirium. These questions include: was there consistency in the patient's wishes over time? Were these wishes expressed during a "lucid interval" when the person was less confused? Were the patient's wishes clearly expressed in response to open-ended questions? Is there clear documentation of the patient's mental status at the time of the discussion? This review with some case examples provides guidance on how to consider the question of testamentary capacity or susceptibility to undue influence in someone undergoing an episode of delirium.

Posterior Fossa Extradural Haematomas

Posttraumatic epidural haematoma (EDH) of the temporal region is the most common site of supratentorial extradural bleeding; other locations are considered atypical. We reviewed 24 patients with EDH located in the posterior cranial fossa (PFEDH) treated at two neurosurgical centres between January 2000 and November 2006. In the retrospective study we analysed gender and age distribution, type of injury, clinical presentation, Glasgow Coma Scale (GCS) score on admission, radiological images, interval between trauma and surgery, and outcome. 24 patients with PFEDH constituted 11.5% of 209 surgically treated individuals with EDH. The best outcomes were obtained by patients with GCS scores of 15-14 on admission. Patients in the fourth to seventh decade of life had less favourable outcomes than younger ones. More than half of the patients with PFEDH had associated intradural lesions. Only patients with concomitant brain contusion had a more favourable recovery. The 3 worst levels on the Glasgow Outcome Scale (GOS) were observed in patients suffering from subdural or intracerebral haematoma, or both, associated with the PFEDHs. The majority of patients with concurrent lesions and supratentorial extension of the haemorrhage were in the subgroup undergoing craniotomy between 24 and 72 h after injury. Patients treated in this time interval also had the most unfavourable outcomes. A classical lucid interval was observed only in one patient. The mortality rate in the series was 4.2%. The most significant factors influencing outcome in our patients were GCS on admission, age, and associated intradural lesions.

Factors affecting the prognosis of patients with delayed encephalopathy after acute carbon monoxide poisoning

Objective Delayed encephalopathy after acute carbon monoxide poisoning (DEACMP) is a disease with poor prognosis. The present study was conducted to determine the factors that affect the prognosis of DEACMP patients. Methods In a retrospective study, 46 DEACMP patients were chosen by the following criteria: (1) a clear history of acute carbon monoxide poisoning, a distinct “lucid interval,” and neuropsychologic symptoms; (2) first-time admittance to a hospital (within 1 week of onset of disease); and (3) completion of standard treatment period in our hospital. All patients received hyperbaric oxygen (HBO 2) treatments. Results Fifty percent (23 of 46) of the DEACMP patients showed improvements after HBO 2 treatments. Age, lucid interval, danger–activities of daily living scores (assessed at worst conditions), and complications were related ( P < .05) to the prognosis of DEACMP patients, whereas sex, fundamental diseases, HBO 2 treatment in acute stage, intoxication time, unconsciousness duration, and GM1 ganglioside administration were not ( P > .05) related to prognosis. Conclusion Hyperbaric oxygen treatment appears useful in treating DEACMP patients; and patients with greater age and more complications, but shorter lucid interval and less danger–activities of daily living scores, are more likely to have poor prognosis.

Assessment of damage to cerebral white matter fiber in the subacute phase after carbon monoxide poisoning using fractional anisotropy in diffusion tensor imaging

Chronic neuropsychiatric symptoms after carbon monoxide (CO) poisoning are caused by demyelination of cerebral white matter fibers. We examined whether diffusion tensor imaging can sensitively represent damage to fibers of the centrum semiovale in the subacute phase after CO intoxication. Subjects comprised 13 adult patients with CO poisoning, classified into three groups according to clinical behaviors: group A, patients with transit acute symptoms only; group P, patients with persistent neurological symptoms; and group D, patients with "delayed neuropsychiatric sequelae" occurring after a lucid interval. Median fractional anisotropy (FA) and apparent diffusion coefficient (ADC) of the centrum semiovale bilaterally at 2 weeks were compared between these groups and a control group of ten healthy volunteers. Myelin basic protein (MBP) concentration in cerebrospinal fluid was examined at 2 weeks to evaluate the degree of demyelination in patients. MBP concentration was abnormal or detectable for all group P and group D patients but was undetectable for all patients assigned to group A. Low FA values in groups P and D displaying chronic neurological symptoms clearly differed from those in controls and group A without chronic neurological symptoms, but ADC showed no significant differences between patient groups. MBP concentration at 2 weeks after CO inhalation confirmed a certain extent of demyelination in the central nervous system of patients who would develop chronic neurological symptoms. In these patients, FA sensitively represented damage to white matter fibers in the centrum semiovale in the subacute phase after CO intoxication.

Black Serial Poetics: An Introduction to Ed Roberson

Black Serial PoeticsAn Introduction to Ed Roberson Brent Hayes Edwards (bio) This special section is the first collection of criticism devoted to the work of Ed Roberson, one of the most quietly dazzling poets writing in English today. This year marks the fortieth anniversary of the publication of Roberson's first book, When Thy King Is a Boy, as well as the upcoming appearance of his latest (ninth) volume, To See the Earth Before the End of the World, and given the extraordinary layers and depths of this body of work, its incisive attention to the complexities of black life in the United States, and its singular formal complexity—in overlapping syntax and unsettling enjambment designed to suggest multivalence and multivocality—it would be an understatement to say that this initial scholarly attention is long overdue. The essays and interviews assembled here are intended both as a first foray and as an attempt to provide source materials, conceptual framing, and methodological approaches that will inspire further consideration of Roberson's unique oeuvre.1 While critical interpretation has been slow to come to terms with Roberson's accomplishment, it is not that he has been overlooked. He won the Grand Prize in the Atlantic Monthly poetry contest as a college student in 1962, and has been recognized with numerous honors and awards over the years, especially in the last decade and a half. When Thy King Is a Boy was one of the selections for the Pitt Poetry Series in 1970 (along with Michael S. Harper's first book, Dear John, Dear Coltrane), and Roberson's collection Voices Cast Out to Talk Us In was a winner of the Iowa Poetry Prize in 1995. He received a Lila Wallace-Reader's Digest Writers Award in 1998, and his book Atmosphere Conditions was selected for the National Poetry Series the same year and then nominated for the Academy of American Poets' Lenore Marshall Award in 2000.2 In 2008, Roberson was awarded the prestigious Shelley Memorial Award of the Poetry Society of America (presented to a living American poet "selected with reference to genius and need"), and the citation praised the "meticulous design and lasting emotional significance" of his writing (Wright and Hejinian). The reviews of When Thy King Is a Boy were emphatic in suggesting that the book marked the emergence of a major talent. In the Saturday Review, for example, Robert Spector discusses Roberson's volume with works by Daniel Berrigan and Denise Levertov as examples of innovation in recent poetry. "The quiet fierceness of Ed Roberson's poetry terrifies," Spector writes, "as it comes out from a controlled if unconventional verse form that seems an amalgam of Charles Olson and E. E. Cummings." For Spector, Roberson's poems were "like ominous icebergs, seven-eighths invisible and threatening beyond their placid surface appearance" (51). A few months later in Prairie Schooner, Charles Peek reviewed Roberson's book alongside Michael S. Harper's debut and Edward Kamau Brathwaite's Islands, the final volume in his magisterial "Arrivants Trilogy," and concluded that [End Page 621] where Harper startles with his vigor and his ability to contain that vigor in his poetry and Brathwaite's ability to mellow his passion in poetry calls for respect, Ed Roberson overwhelms one with genius. One might return to any of these books a second time, but he would return to When Thy King Is a Boy first. … Anyone interested in black poetry, in modern poetry, in literature with life, should read these books. The first two will be memorable books; the last, an unforgettable one. (84, 85) These kind of notices make it all the more puzzling that Roberson's second book, Etai-Eken, hardly made a ripple when it was published in 1975. It would be nearly another decade before friends of Roberson in Pittsburgh raised funds to publish a limited edition of the remarkable Lucid Interval as Integral Music (1984), and another decade after that until Voices Cast Out to Talk Us In (1995), the larger volume of which Lucid Interval comprises the first half, was chosen for the Iowa Poetry Prize. The critical establishment, especially in the world of African American poetry...

"The Umbilicate Ear": Audition in Ed Roberson's Lucid Interval as Integral Music

"The Umbilicate Ear": Audition in Ed Roberson's Lucid Interval as Integral Music

Lightening up before death

A lightening, or clearing, of the mental state in the hours or days before death, particularly in those delirious, is occasionally noted by those caring for the dying. Similar phenomena have been described in the natural world and in classical literature. This brief period of lucidity is generally followed by a rapid terminal decline. The author reports on his experience with six cases illustrating this phenomenon. The increasing use of palliative sedation may diminish the possibility of lightening up before death occurring. The theoretical concepts of Hughlings Jackson may provide an explanation for this phenomenon.

Koma nach luzidem Intervall – schwere sekundäre Bewusstseinseinschränkung nach Polytrauma

A 71-year-old man sustains multiple fractures in an accident; after a lucid interval he deteriorates neurologically and becomes comatose. Intracranial hemorrhage, status epilepticus, adverse drug reactions, toxic-metabolic, ischemic or infectious causes are subsequently ruled out. Development of petechiae and thrombopenia raises the possibility of fat embolism syndrome, which is confirmed in a MRI of the head 72 hours after the accident. We discuss current aetiologic concepts as well as diagnosis and clinical course of the cerebral fat embolism syndrome.

Epidural hematoma revealed by exophthalmia, two cases reports

Epidural or extradural hematoma is a well known entity, usually a complication of severe traumatic head injury. The clinical presentation is most commonly a decline in consciousness and new neurological deficits. Fewer than 20% of patients demonstrate the classic presentation of a lucid interval between the initial trauma and subsequent neurological deterioration. The association of an epidural hematoma with a subperiostal intraorbital hematoma is rare, where exophthalmia is the only presenting sign. We report on two cases of frontal epidural hematoma revealed by an exophthalmia after a minor head trauma. On reporting our cases we aim to increase the awareness of this association each time a head or facial trauma is associated with exophthalmia.

Carotid artery thrombosis and delayed stroke associated with the use of a shoulder belt in a teenager

Blunt carotid artery injury caused by shoulder belts is rare and requires a high index of suspicion to diagnose before the onset of neurologic sequelae. Neurologic abnormalities may be erroneously attributed to concomitant head trauma, and the onset of neurologic abnormalities may be delayed for hours or days. The case of a young, teenaged driver with a “seatbelt sign” and presentation of signs and symptoms of carotid artery thrombosis 13 days after injury is described. Occult vascular injury should be suspected if neurologic deterioration occurs after a lucid interval and/or computed tomography of the head is inconsistent with neurologic findings. Screening criteria and possible screening modalities are discussed.

Psychosis in the Elderly

Ms. A, an 85-year-old Caucasian woman, was hospitalized for increased paranoia, visual hallucinations, and agitation. According to her son, Ms. A had had "strange thoughts" for as long as he could remember. For example, for a time, Ms. A would eat only foods that were white. Still, in her adult life, she had actively participated in developing and running a successful family business with her husband and had raised two sons. When her husband died 5 years ago, Ms. A developed a major depressive disorder, single episode, severe with psychotic features. She moved to an assisted living facility and did well there until she was hospitalized 2 years ago with agitation. At that time, she was diagnosed with late-onset Alzheimer's type dementia with delusions, depressed mood, and behavioral disturbance. She returned to the assisted living facility and was stable until a few months before her current hospitalization, which was precipitated by gradually worsening paranoid delusions, visual hallucinations, severe restlessness, and difficulty in being redirected. At admission, Ms. A's responses to questions were largely irrational or irrelevant to the topic at hand. In a more lucid moment, Ms. A conveyed that she had pain, gesturing to her stomach. Her vital signs were stable; she was afebrile and normotensive. Initial mental status examination revealed Ms. A to be an unkempt, distraught, elderly woman with poor eye contact and poor attention span. She was restless and would intermittently grasp imaginary objects in the air, uttering brief phrases or nonspecific sounds in response to questions. Her thought processes were disorganized as she conveyed vague thoughts with themes of fears of dying and of being harmed. She was irritable and had a labile affect and clouded sensorium that fluctuated between periods of lucidity and of obtundation. Her insight and judgment were severely impaired. Ms. A's psychotropic medications at the time of admission included 400 mg of quetiapine daily in divided doses for delusions, hallucinations, and agitation; 500 mg of divalproex daily for mood instability and agitation; 100 mg of sertraline daily for depression and agitation; and 4-6 mg of lorazepam daily in divided doses for anxiety and agitation. Her medical history was significant for hypothyroidism, coronary artery disease, atrial fibrillation, hypertension, hypercholesterolemia, and gastroesophageal reflux disease. For these conditions, she was taking 25 μg of levothyroxine daily, 0.125 mg of digoxin daily, 40 mg of enoxaparin daily, 325 mg of aspirin daily, 50 mg of metoprolol twice daily, 40 mg of simvastatin daily, and 40 mg of pantoprazole daily. Ms. A also had a history of recurrent urinary tract infections, chronic constipation, frequent falls, and osteoporosis. She had no known drug allergies.

The Effect of Mental Illness on Language Regression to the Mother Tongue in Bilingual Teenagers

The Effect of Mental Illness on Language Regression to the Mother Tongue in Bilingual Teenagers

Classic Text No. 74 `How Fury and Lucid Intervals may be Proven' by Sir George Mackenzie of Rosehaugh

In Scots law, adults are presumed to have legal capacity to enter into contracts and to dispose of their property as they see fit. That presumption may be rebutted where an individual's mental condition impairs that capacity. This has been the legal position for some time. The text reproduced here is taken from the written pleadings drawn up by an eminent seventeenth-century advocate for a client who sought to resist a claim on his deceased sister's estate. It was argued by the other side that she had been incapacitated by mental illness before her death and at the time that she had made provision. The pleading expounds Scottish seventeenth-century notions of insanity in a particular context, and argue for a way of determining whether a person had the necessary capacity by using and drawing on earlier Continental texts. It is notable that there is use of medical evidence almost a century prior to the first recognized use of medical testimony as to mental disorder in English courts.

The nature of shaken baby syndrome injuries and the significance of a “Lucid Interval”

The possibility of shaking an infant sufficiently violently to cause brain damage by head rotational acceleration remains controversial and the nature of the anticipated injuries poorly defined. Animal studies of whiplash injuries have revealed two modes of injury; subdural haemorrhage (SDH) and cortex surface injury (CSI). CSI can be induced without SDH with a suitable whiplash impulse, suggesting independent mechanisms. Experimental whiplash injury has been found to bring an immediate cessation of cerebral function (coma) with a threshold approximating to peak velocity (applied accelerationxapplied time). Tangential forces producing brain acceleration are transferred across the subarachnoid space by trabeculae. Their total cross-sectional area is much less than that of the arachnoid and pia surfaces, producing high stress concentrations where trabeculae bond with the pia mater. That CSI occurs within the pia-glia formation when astrocytes linking the pia below trabeculae to the cortex fail under the high local stress concentrations. The pia may be locally pulled off the neural tissue, dragging neural tissue with it. Axons will be stretched or broken, thereby immediately disrupting interneuron communications (coma). In contrast to such immediate mechanical injuries, chemical (e.g. hypoxic) insults take time to develop, described as a "lucid interval". Crying requires recognition of a noxious stimulus, and coordination of respiratory and vocal muscles, showing that the infant is not in a coma but in a lucid interval. Therefore, when crying can be heard on 999 or 911 tape recordings the initial event could not have been shaking.

Shaken baby syndrome: the quest for evidence

Shaken baby syndrome (SBS), characterized by the triad of subdural haemorrhage, retinal haemorrhage, and encephalopathy, was initially based on the hypothesis that shaking causes tearing of bridging veins and bilateral subdural bleeding. It remains controversial. New evidence since SBS was first defined three decades ago needs to be reviewed. Neuropathology shows that most cases do not have traumatic axonal injury, but hypoxic-ischaemic injury and brain swelling. This may allow a lucid interval, which traumatic axonal injury will not. Further, the thin subdural haemorrhages in SBS are unlike the thick unilateral space-occupying clots of trauma. They may not originate from traumatic rupture of bridging veins but from vessels injured by hypoxia and haemodynamic disturbances, as originally proposed by Cushing in 1905. Biomechanical studies have repeatedly failed to show that shaking alone can generate the triad in the absence of significant neck injury. Impact is needed and, indeed, seems to be the cause of the majority of cases of so-called SBS. Birth-related subdural bleeds are much more frequent than previously thought and their potential to cause chronic subdural collections and mimic SBS remains to be established.