Normal Level Of Consciousness Research Articles

Status Epilepticus Diagnostic and Management Approach in Emergency Department

Status Epilepticus (SE) is a condition that arises from existing neurological disorders, including epilepsy syndromes. It refers to a state of incessant clinical and/or electrographic seizure activity, or recurrent seizure activity within 5 minutes during which the patient does not recover to a normal level of consciousness between seizures. It is also a medical emergency with a high complication rate. The Medline, PubMed, Embase, NCBI, and Cochrane databases were searched for studies of patient

Effect of implementing bundle care on reducing early Postpartum haemorrhage among primiparous

Background: Postpartum hemorrhage (PPH) is associated with an increased risk of complications after delivery for both the mother and the newborn in postnatal period and later life. Aim: Aim of the study was to assess the effect of implementing bundle care on reducing early postpartum haemorrhage among primiparous.Methods: A quasi-experimental design (nonequivalent control group pretest/posttest) was adopted. Setting: The current study was conducted in the postpartum words of Obstetrics and Gynecology department in Maternity hospital, Portsaid Governorate, Egypt. A purposive sample of 70 primiparous with early PPH was carefully chosen from the nominated setting and dispersed accidentally into two equal groups (study and control group). Two tools were used for collecting the study data: A structured interviewing questionnaire schedule and tool of bundle care of early PPH that consists of three parts.Results: There is a statistically significant difference between the study and control groups in reducing early PPH among primiparous and improve outcomes. The current study results display that the primiparous outcomes improved in study group compared to control group which seemed in mild of bleeding 68.6% in study group, 37.1in control group and conscious level 94.3% in study group, 60% in control group with normal conscious level. The study group have lower complications, compared to complications of the control group. Conclusion: Bundle care was effective in decreasing blood loss complications of early PPH. Recommendations: Bundle care should be recommended as a nursing intervention protocol and should become a fundamental part of the total management of early PPH.

Developing and Implementing Nursing Care Protocol Regarding Management of Postpartum Hemorrhage

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality in developingcountries. PPH is defined as any blood loss >500 ml following vaginal delivery and >1000 ml after cesarean section.It can also be defined as fall in hematocrit >10% or blood loss >15% of total blood volume, or 10% measured perpartum decline in hemoglobin levels. Aim of the study: the aim of this quasi-experimental study was to evaluate theeffect of Developing and implementing Nursing Care protocol regarding management of postpartum hemorrhage onPatients outcomes and complications. Setting: This study was conducted at Assiut Women's Health Hospital,postpartum unit .Sample: Purposive sample with a total of 140 Postpartum Hemorrhage patients was recruited,divided into two groups (control and study) 70 patients for each group Result: this study found that a significantdifference between the routine and designed protocol in nursing management of postpartum hemorrhage . thesefindings show that the patient outcomes improved in study cases when compared with control cases which appearedin stop of bleeding 95.7% in study group, 82.8% in control group and conscious level 87.1%in study group,78.6 incontrol group with normal conscious level Conclusion: This research concluded that nursing care protocol waseffective in reducing postpartum hemorrhage outcome and complications. Recommendations: clearly writtenPostpartum Hemorrhage management protocol, adapted for a particular hospital, should be developed and used inclinical practice.

MRI findings in patients with blunt cervical trauma having a normal level of consciousness and normal CT reports

Objective: This study investigates the possible magnetic resonance imaging (MRI) findings in patients with cervical trauma having a normal level of consciousness and normal CT reports. These patients have tenderness or an uncomfortable feeling in the traumatized area as well. Methods: In this cross-sectional anterograde study, cases were selected among patients referred to the emergency department of Hafte Tir, Iran University of Medical Sciences from 2012 to 2014. Inclusion criteria to select cases were: age above 15, blunt neck trauma, GCS=15, normal CT scan reports of neck, no past medical history of cervical vertebral surgery, and no persistent neurologic lesions. In order to analyse qualitative data, chisquare test was used and for quantitative data t test was applied accordingly. Results: Two hundred eighty patients with chief complaints of neck pain due to trauma entered our study. Among this batch, 264 of them had normal CT scan reports and MRI was done for all of them. According to the results, the maximum injury in MRI was related to intervertebral disc injury (38 cases), ligamentous edema (35 cases), and muscle edema (22 cases), respectively. Neck tenderness from the beginning of the accident and transient neurologic signs had a significant role in MRI results (P < 0.05). Conclusion: In patients with acute cervical trauma having normal CT reports, MRI must be done in those with the average age of 45 or more, tenderness in the neck area, and in those with neurologic transient symptoms.

Walker-Warburg Syndrome: A Case report of Congenital Muscular Dystrophy with Cerebro-Ocular Malformation, a Rare Syndrome in an African Patient

Walker-Warburg Syndrome is a genetically heterogeneous disease with autosomal recessive inheritance presenting with congenital muscular dystrophy with cerebro-ocular malformations since birth or infancy. Literature shows a mutation in Protein O-Mannosyltransferase 1 (POMT1) gene, which results in a defect in O-mannosylation of α-dystroglycan, these proteins are central to the pathogenesis of structural and functional brain abnormalities however, the exact pathophysiology of this disorder is not fully understood. The overall incidence still remains unknown and most cases have been reported from the Western hemisphere. In our setting we report a case of 3 weeks old male baby who was delivered by spontaneous vertex delivery at gestation age of 26 weeks with birth weight of 1900 gm referred to our hospital on the 6th day of life, with complaint of bilateral prominent, protruding eyes and inability to close the eyelids. The parents were non-consanguineous and this was the first child. No ante- natal ultrasound was done during the pregnancy. On further examination, he had macrocephaly 33 cm (>97th centile) with no fusion of the sutures, depressed nasal bridge, low set ears, bilateral dental lamina cyst, bilateral cortical thumb, micrognathia, and scoliosis. Systemic examination revealed a normal conscious level with weak cry, normal facial symmetry, generalized hypotonia and primitive reflex were weak to absent and ocular examination revealed bupthalmos, bilateral megalocornea and glaucoma. Creatine kinase was elevated-522 unit/L (0-25 units/L). Cranial Ultrasound revealed Dandy-Walker cyst in the posterior fossa cyst, with third ventricle dilatation (ventriculomegally), the corpus callosum was normal, Interventricular hemorrhage grade 2 and hyper echogenic eyeballs. Echocardiography revealed Double Outlet Right Ventricle. Management was supportive, aimed to improve growth through optimum feeding, eye padding for protection and diuretics for the underlying congenital heart disease. Conclusion: Overall prognosis of this disease is poor, the baby died in 42 days due to aspiration pneumonia and progressive respiratory failure. Genetic counselling was done to the parents, since in families with one affected child, the risk of having another child with the disease is 25%. A high index of suspicion during a routine antenatal ultrasound could prompt further advanced fetal ultrasonography and magnetic resonance imaging, and aid in timely prenatal diagnosis, management, and counseling.

The practice and predictors of early mobilization of patients post-acute admission to a specialized stroke center

ABSTRACTBackground: Early mobilization (EM) post-stroke is recommended; however, the ideal timing and nature of EM, and factors that may influence EM practice are unclear.Objectives: The primary objective was to describe the type and extent of mobilization 0–48 h post-stroke admission to acute hospital care. A secondary objective was to evaluate whether pre-stroke functional level, stroke severity, tissue plasminogen activator (tPA) administration, and level of consciousness (LOC) predicted any passive, any active, and out-of-bed mobilization (i.e. sitting at edge-of-bed, standing, or ambulation) 0–24 h post-admission.Methods: A quantitative, cross-sectional, retrospective review of health records of patients admitted to a specialized acute stroke center in 2016 was conducted.Results: Data from 296 eligible health records were abstracted. Median age was 73 years, and 87% of patients had sustained an ischemic stroke. Active, passive, and out-of-bed mobilization occurred in 91.6%, 57.1%, and 24.3% of patients by 12 h post-admission, respectively, and 99.3%, 78.4%, and 77.4% of patients by 48 h post-admission, respectively. Administration of tPA, stroke severity, and impaired LOC, were each associated with any passive mobilization, and no tPA administration, stroke severity, and normal LOC were each associated with out-of-bed mobilization 0–24 h post-admission (p < 0.05).Conclusions: Almost all patients receive active mobilization by 12 h post-admission whereas out-of-bed mobilization is infrequent. In the first 24 h post-admission, clinicians may prioritize passive over out-of-bed mobilization when patients have received tPA, present with severe stroke, and have impaired LOC. This conservative approach is unsurprising given the lack of clear practice recommendations for these situations.

Functional Activity of the Autonomous Nervous System at Different Levels of Consciousness in Patients with a Brain Damage

The purpose of the study — assessment of the level of consciousness in patients with a brain damage on the basis of electrophysiological examination of the functional state of the autonomous nervous system by recording parameters of the heart rate variability (HRV). Materials and Methods . The study included 77 patients on Day 20—50 after a traumatic brain injury, anoxic injury, consequences of acute cerebral circulation disorders. The following parameters of the HRV for a 5-minute recording were accepted as criteria of norm and pathology of the autonomous nervous system (ANS) activity: (1) parasympathetic hyperactivity (hypervagal state) values with 95% confidence intervals were recorded within the accepted values for (a) SDNN (standard deviation of normal to normal R-R intervals), [41.5 —149.3 ms]; (b) rMSSD (root-mean-square of the successive normal sinus R—R interval difference in ms), [42.4—175.0 ms];(c) pNN50% (percentage of successive normal sinus RR intervals >50 ms), [8.14—54.66%]; (d) SI (Baevsky stress index), [0—80 normalized units, n. u.]; (2) the sympathetic hyperactivity recordered within the range of values for (a) SDNN [4.54—13.30 ms]; (b) rMSSD [2.25— 5.77 ms]; (c) pNN50% [0—0.109%]; (d) SI >900 n. u.; (3) the normal value of ANS parameters were recordered within the range of values for (a) SDNN [13.31—41.4 ms]; (b) rMSSD [5.78—42.3 ms]; (c) pNN50% [0.110—8.1%]; (d) SI [80—900 n. u.]. For verification of the hypervagal state, sympathetic hyperactivity or normal state, at least 3 of 4 parameters should be within the specified limits. Results . In 40 (51.9%) of 77 patients examined after a brain damage, ANS functional activity parameters were within the range of pathological values. The sympathetic hyperactivity was identified in 34 patients, and in 6 cases the hypervagal state was diagnosed. Pathological parameters of HRV were found in 80% of patients with severe forms of unconsciousness (vegetative state, coma), and only in 20% of patients with normal consciousness. Conclusion .The computer analysis of the HRV is a necessary element of examination of patients with different levels of consciousness after a brain damage of a traumatic and non-traumatic genesis. The frequency of pathological changes in the functional state of the autonomous nervous system increases significantly in groups of patients from the normal level of consciousness to the state of minimal consciousness, vegetative state, and coma. The sympathetic hyperactivity is the main type of ANS pathology in the groups of patients with minimal consciousness, in the vegetative state, and coma.

Breakdown in the temporal and spatial organization of spontaneous brain activity during general anesthesia.

Which temporal features that can characterize different brain states (i.e., consciousness or unconsciousness) is a fundamental question in the neuroscience of consciousness. Using resting-state functional magnetic resonance imaging (rs-fMRI), we investigated the spatial patterns of two temporal features: the long-range temporal correlations (LRTCs), measured by power-law exponent (PLE), and temporal variability, measured by standard deviation (SD) during wakefulness and anesthetic-induced unconsciousness. We found that both PLE and SD showed global reductions across the whole brain during anesthetic state comparing to wakefulness. Importantly, the relationship between PLE and SD was altered in anesthetic state, in terms of a spatial "decoupling." This decoupling was mainly driven by a spatial pattern alteration of the PLE, rather than the SD, in the anesthetic state. Our results suggest differential physiological grounds of PLE and SD and highlight the functional importance of the topographical organization of LRTCs in maintaining an optimal spatiotemporal configuration of the neural dynamics during normal level of consciousness. The central role of the spatial distribution of LRTCs, reflecting temporo-spatial nestedness, may support the recently introduced temporo-spatial theory of consciousness (TTC).

Recurrent decrease level of consciousness as first manifestation of high grade glioma

Objective and method: Paroxysmal and recurrent alteration of the level of consciousness is a diagnostic given by multiple causes, being sometimes the first sign of a systemic or central nervous system disease. We report a case of a 9-year-old patient with a recurrent decrease in the level of consciousness. Results: He was admitted at PICU with acute fever, vomiting, headache and decreased of the level of consciousness. Analysis, urine toxics and CT, normals. CSF showed 10 cells without germ. Eeg slowed activity. Acute meningoencephalitis was suspected and treated with cefotaxime and acyclovir. Excellent improvement, recovery of the level of consciousness in the first 24 h and discharged at home at 7 day. That day reentered by similar episode with agitation psychomotor, aggressiveness requiring intubation. Another craneal CT normal and CFS showed 13 cells and hyperproteinorraquia. Two craneal NMR and another CT were normal. Autoimmune encephalitis was suspected and initiating Methylprednisolone. NMDA antibodies in CSF, oligoclonal bands, GADs, lactic, ammonium, and PCR herpes were negatives. Extubated on the 3rd day with normal level of consciousness, discharged at 11 days, persisting bradypsychia. Readmited to the 14 days by similar episode and convulsive crisis and papillary effacement. We measured the pressure of the CSF. We treated of HTC, with sharp decreases in the level of consciousness with response to SSH3%. ICP monitoring showed 60 cm H2O placing VDVP. Clinical improvement being discharged, restless legs and ataxia. Cranio-medullary MRI showed germinoma hypothalamic-pineal disease with leptomeningeal carcinomatosis. Moved to Childhood Oncology Unit, being death on a month Conclusions: A systematic and oriented study of recurrent alteration of the level of consciousness, without forgetting that the normality of tests not discard our suspicion. In our case the late syndrome of restless legs, was the key. The request for pathological anatomy in CSF could help before.

The initial time-course of headache in patients with spontaneous subarachnoid hemorrhage

BackgroundIf acute severe headache disappears early after its onset, the question arises whether subarachnoid hemorrhage (SAH) should still be ruled out. We studied the initial time-course and minimal duration of headache in a consecutive series of neurologically intact patients with spontaneous SAH. MethodsWe included patients admitted between 2012 and 2015 within 48h after spontaneous SAH with a normal level of consciousness and no focal deficits. We retrieved data on headache severity, measured with a Numeric Rating Scale (NRS), <48h after ictus. We analyzed the proportion of patients with a first NRS 0 and NRS <3 within 48h after ictus and minimal headache duration. Patients were censored in case of a decrease in level of consciousness, aneurysm treatment, or early discharge. ResultsWe included 106 patients (62 aneurysmal SAH, 33 perimesencephalic hemorrhage, 11 other spontaneous SAH). All patients were treated with analgesics. Within 48h after ictus, a first NRS 0 was reported by 9 patients (8%;95%CI:3%–14%) and a first NRS <3 by 22 patients (21%;95%CI:13%–28%). Shortest time lapse until NRS 0 was 10h in a patient with aneurysmal SAH who had been on acetaminophen and tramadol since 2:35h after ictus. ConclusionsIn a cohort of SAH patients with a normal level of consciousness and no focal deficits who all used analgetics, headache disappeared in around 10% within 48h after ictus. Our data indicate that a diagnostic work-up for SAH is also needed in patients using analgesics in whom headache has disappeared after 10h.

Bilateral paramedian thalamic infarctions in a young woman with patent foramen ovale

Background: Simultaneous bilateral thalamic infarctions are rare and in most cases associated with typical clinical pattern which, beside other things, include neuropsychological changes. Case report: We report a case of a 37- year-old woman with acute onset ofdiplopia from skew deviation, right-sided central facial nerve palsy, left hemihypesthesia, ataxia, with normal level of consciousness and without any neuropsychological disturbances except minor memory deficit. She was diagnosed with bilateral thalamic infarction due to the cardioembolisation via patent foramen ovale. Conclusion: In cases of bilateral thalamic infarction one can presume the existence of rare anatomic variant of thalamic perfusion commonly known as the artery of Percheron, single artery trunk that branches to irrigate both paramedian territories of thalamus. The cause of infarction can be cardioembolism trough the patent foramen ovale, especially in young adults. Our case represents a combination of two specific pathological conditions - patent foramen ovale and bilateral thalamic infarction. Clinical presentation in this case was unusual for the bithalamic paramedian infarction.

Time-dependent test characteristics of neck stiffness in patients suspected of nontraumatic subarachnoid haemorrhage

BackgroundNeck stiffness can be the only diagnostic clue for subarachnoid haemorrhage (SAH) at neurological examination in patients with a clinical suspicion of nontraumatic SAH who present with a normal level of consciousness and no focal neurologic deficits. Since the clinical impression is that neck stiffness may take several hours to develop, we determined time-dependent test characteristics of neck stiffness. MethodsWe retrieved the presence of neck stiffness from the medical records of consecutive patients presenting between 2005 and 2013 with a clinical suspicion of SAH, a normal level of consciousness and no focal neurologic deficits. Test characteristics with corresponding 95% confidence intervals (CIs) were calculated for the evaluation of neck stiffness ≤6h and 6–72h after symptom onset for the diagnosis of nontraumatic SAH. In a secondary analysis, multiple imputation was used to account for missing values. Results114 of 247 included patients were diagnosed with nontraumatic SAH. Neck stiffness at neurological examination performed ≤6h after symptom onset had a positive predictive value (PPV) of 90% (95% CI: 78%–97%) and negative predictive value (NPV) of 69% (95% CI: 59%–78%). Between 6 and 72h after symptom onset the PPV was 76% (95% CI: 58%–89%) and NPV 91% (95% CI: 78%–98%). Multiple imputation to account for missing values yielded similar results. ConclusionIn patients with a normal level of consciousness without focal neurologic deficits the presence of neck stiffness is helpful but not pathognomic for the diagnosis of SAH. Moreover, the absence of neck stiffness does not rule out SAH, especially when evaluated ≤6h after symptom onset.

CT within 6 hours of headache onset to rule out subarachnoid hemorrhage in nonacademic hospitals.

To investigate whether staff radiologists working in nonacademic hospitals can adequately rule out subarachnoid hemorrhage (SAH) on head CT <6 hours after headache onset. In a multicenter, retrospective study, we studied a consecutive series of patients presenting with acute headache to 11 nonacademic hospitals. Inclusion criteria were (1) normal level of consciousness without focal deficits, (2) head CT <6 hours after headache onset and reported negative for the presence of SAH by a staff radiologist, and (3) subsequent CSF spectrophotometry. Two neuroradiologists and one stroke neurologist from 2 academic tertiary care centers independently reviewed admission CTs of patients with CSF results that were considered positive for presence of bilirubin according to local criteria. We investigated the negative predictive value for detection of SAH by staff radiologists in nonacademic hospitals on head CT in patients scanned <6 hours after onset of acute headache. Of 760 included patients, CSF analysis was considered positive for bilirubin in 52 patients (7%). Independent review of these patients' CTs identified one patient (1/52; 2%) with a perimesencephalic nonaneurysmal SAH. Negative predictive value for detection of subarachnoid blood by staff radiologists working in a nonacademic hospital was 99.9% (95% confidence interval 99.3%-100.0%). Our results support a change of practice wherein a lumbar puncture can be withheld in patients with a head CT scan performed <6 hours after headache onset and reported negative for the presence of SAH by a staff radiologist in the described nonacademic setting.

Acute Isolated Dysarthria Is Associated with a High Risk of Stroke

Background: Isolated dysarthria is an uncommon presentation of transient ischemic attack (TIA)/minor stroke and has a broad differential diagnosis. There is little information in the literature about how often this presentation is confirmed to be a TIA/stroke, and therefore there is debate about the risk of subsequent vascular events. Given the uncertain prognosis, it is unclear how to best manage patients presenting to the emergency department (ED) with isolated dysarthria. The objective of this study was to prospectively identify and follow a cohort of patients presenting to EDs with isolated dysarthria in order to explore their natural history and risk of recurrent cerebrovascular events. Specifically, we sought to determine early outcomes of individuals with this nonspecific and atypical presentation in order to appropriately expedite their management. Methods: Patients with isolated dysarthria having presented to 8 Canadian EDs between October 2006 and April 2009 were analyzed as part of a prospective multicenter cohort study of patients with acute neurological symptoms as assessed by emergency physicians. The study inclusion criteria were age ≥18 years, a normal level of consciousness, and a symptom onset <1 week prior to presentation without an established nonvascular etiology. The primary outcome was a subsequent stroke within 90 days of the index visit. The secondary outcomes were the rate of TIA, myocardial infarction, and death. Isolated dysarthria was defined as slurring with imprecise articulation but without evidence of language dysfunction. The overall rate of stroke in this cohort was compared with that predicted by the median ABCD2 score for this group. Results: Between 2006 and 2009, 1,528 patients were enrolled and had a 90-day follow-up. Of these, 43 patients presented with isolated acute-onset dysarthria (2.8%). Recurrent stroke occurred in 6/43 (14.0%) within 90 days of enrollment. The predicted maximal 90-day stroke rate was 9.8% (based on a median ABCD2 score of 5 for the isolated dysarthria cohort). After adjusting for covariates, isolated dysarthria independently predicted stroke within 90 days (aOR: 3.96; 95% CI: 1.3-11.9; p = 0.014). Conclusions: The isolated dysarthria cohort carried a recurrent stroke risk comparable to that predicted by the median ABCD2 scores. Although isolated dysarthria is a nonspecific and uncommon clinical presentation of TIA, these findings support the need to view it first and foremost as a vascular presentation until proven otherwise and to manage such patients as if they were at high risk of stroke in accordance with established high-risk TIA guidelines.

Noninvasive ventilation in withdrawal from mechanical ventilation.

Patients with chronic airflow obstruction and difficult or prolonged weaning are at increased risk for prolonged invasive mechanical ventilation (IMV). Several randomized controlled trials mainly conducted in patients who had pre-existing lung disease have shown that the use of noninvasive ventilation (NIV) to advance extubation in patients with difficult and prolonged weaning can result in reduced periods of endotracheal intubation, complication rates, and improved survival. Patients in these studies were hemodynamically stable, with a normal level of consciousness, no fever, and a preserved cough reflex. The use of NIV in the management of mixed populations with respiratory failure after extubation, including small proportions of chronic respiratory patients did not show clinical benefits included. By contrast, NIV immediately after extubation is effective in avoiding respiratory failure after extubation and improving survival in patients at risk for this complication, particularly those with chronic respiratory disorders, cardiac comorbidity, and hypercapnic respiratory failure. Finally, both continuous positive airway pressure and NIV can improve clinical outcomes in patients with postoperative acute respiratory failure, particularly abdominal and thoracic surgery.

An Eye-Tracking Assistive Device Improves the Quality of Life for ALS Patients and Reduces the Caregivers’ Burden

ABSTRACT. Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disease. In some cases, patients with ALS retain a normal level of consciousness but disease progression eventually results in generalized paralysis, which first impedes and then prevents oral communication. This communication obstacle can generate a great deal of stress for the patient, family, and caregiver. Here the authors ask whether the use of an eye-tracking assistive device can improve quality of life for ALS patients and relieves burden of their primary caregivers. Subjects were divided into two groups depending on whether they used (n = 10) or did not use (n = 10) an eye-tracking assistive device. The authors assessed patients’ quality of life and severity of depression using the ALS Specific Quality of Life Instrument–Revised and the Taiwanese Depression Questionnaire, respectively. The Caregiver Burden Scale was used to assess the burden on caregivers. Our study shows that the eye-tracking assistive device significantly improved patients’ quality of life, as compared with patients in the nonuser group (p <.01). The assistive device also reduced the burden on caregivers (p <.05). This is likely a result of the improvement of patient's autonomy and more effective communication between patient and caregiver.

Intracranial hypertension presenting with severe visual failure, without concurrent headache, in a child with nephrotic syndrome

BackgroundIdiopathic intracranial hypertension is a condition typically characterised by headache, normal level of consciousness, papilloedema and raised cerebrospinal fluid pressure. Children often present with visual loss and atypical features of raised pressure, posing a diagnostic and management challenge. A range of renal disorders can predispose to developing this raised intracranial pressure syndrome. We present a case of severe visual failure in a child with nephrotic syndrome, with no headache when elevated pressure was proven. In nephrotic syndrome, visual failure related to elevated intracranial pressures without concurrent headache symptoms has not been reported previously.Case presentationWe discuss a 5-year-old Caucasian girl with steroid sensitive nephrotic syndrome who went on to become a late non-responder and presented with intracranial hypertension. Following initial response to steroids, she had a relapse of her nephrotic syndrome; her proteinuria did not resolve on steroid treatment, requiring addition of cyclosporine therapy to manage her nephrotic syndrome. Three months following this, she presented with visual failure in the right eye with bilateral central scotoma and papilloedema. At the time of presentation of visual impairment, she was otherwise well, with no symptoms of a raised intracranial pressure syndrome or associated systemic illness. Medical management was initiated following confirmation of a raised intracranial pressure. Her intracranial pressure remained elevated requiring serial therapeutic lumbar punctures before some improvement in visual acuity was observed. Later in the clinical course, she presented with worsening of her visual impairment with further deterioration of the vision in the left eye, again associated with elevated intracranial pressure. An urgent surgical cerebrospinal fluid diversion procedure was performed. At review, three years after presentation our patient has severe visual impairment with no perception of light in her right eye and 6/36 Snellen acuity in the left secondary to optic atrophy.ConclusionOur case demonstrates the occurrence of intracranial hypertension in nephrotic syndrome, highlighting the atypical presentation of severe visual failure without concurrent headache at presentation. This demonstrates the management complexities and the need for clear guidelines for ophthalmological surveillance to aim to reduce permanent visual impairment.

Isolated unilateral IIIrd nerve palsy as the only sign of chronic subdural haematoma

Subdural haematoma (SDH) is the collection of blood below the inner layer of the dura but external to the brain and the arachnoid membrane. It is the most common type of traumatic intracranial mass lesion seen. Chronic subdural haematoma (CSDH) usually presents with headache, fluctuating level of consciousness, falls, seizures, focal or transient neurological deficits and hemiparesis1 (Table 1). Isolated third nerve palsy is a common presentation of intracranial aneurysms, diabetes mellitus, trauma and in chronic lymphocytic meningeal infiltration. Subdural haematomas presenting with an isolated unilateral oculomotor paralysis, without any other notable signs or symptoms, except for mild headache, however, are very unusual. To the best of our knowledge it has been reported only thrice earlier in literature.2–4 Table 1 Presentations of chronic subdural haematoma.1 Here we report one such rare case of CSDH in a relatively young individual who presented with unilateral complete third nerve palsy as the only presenting sign and a normal level of consciousness.

Accuracy of the S100β protein as a marker of brain damage in traumatic brain injury

Introduction: This study tested the hypothesis that S100β is a useful screening tool for detecting intracranial lesion (IL) in patients with a normal level of consciousness after traumatic brain injury (TBI).Methods: One hundred and forty-three post-TBI patients without a decrease in consciousness (GCS = 15) and with at least one neurological symptom (e.g. transitory loss of consciousness, amnesia, headache, dizziness or vomiting) were prospectively included. A blood sample was drawn at 6-hours post-TBI. A routine CT scan was obtained within 24 hours post-injury. Diagnostic properties of S100β for IL prediction in CT scan findings were tested using ROC-analysis.Results: A total of 15 patients (10.5%) had IL. Serum levels were significantly higher in these patients. Significant differences were found between S100β levels and CT scan findings (p = 0.007). ROC-analysis showed that S100β is a useful tool for detecting the presence of IL in CT scans (p = 0.007). In this series, the best cut-off for S100β is 0.130 µg L−1, with 100% sensitivity and 32.81% specificity.Conclusion: Within the first 6 hours post-TBI, serum S100β seems to be an effective biochemical indicator of IL in patients without a decrease in consciousness. These results indicate that higher S100β cut-off values substantially improve the clinical relevance of this protein.

Predicting influenza A and 2009 H1N1 influenza in patients admitted to hospital with acute respiratory illness

ObjectiveTo create a clinical decision tool for suspected influenza A (including 2009 H1N1) to facilitate treatment and isolation decisions for patients admitted to hospital with an acute respiratory illness from...