Normal Lumbar Puncture Research Articles

Serotonin Syndrome Following Low-Dose Sertraline: A Case Report

IntroductionSerotonin syndrome is a potentially life-threatening condition that is precipitated by the use of serotonergic medications, Selective Serotonin Reuptake Inhibitors (SSRIs) and Monoamine Oxidase Inhibitors (MAOIs). It usually occurs when high doses of serotonergic drugs are prescribed. It is a medical emergency that requires prompt recognition, cessation of offending drugs and supportive therapy.ObjectivesWe present a case of serotonin syndrome that occurred in a patient who was prescribed a low dose of sertraline, and aim to highlight the importance of early detection of this severe condition.MethodsDetails of the case were described. Information was gathered based on medical records.Results Patient M was a 29-year-old Malay male with a history of major depressive disorder, who was previously trialed on fluvoxamine 100mg every night but subsequently switched to and maintained on sertraline 75mg every night in 2020. He then defaulted follow up appointments. In 2023, he presented to the emergency services for a suicide attempt and was diagnosed with major depressive disorder with psychotic features. He was restarted on sertraline 50mg every night and risperidone 0.5mg every night was newly started. Two days later, sertraline was increased to 100mg every night. Two days following this increase, he was noted to have altered mental state, fever of 39.3-degree celcius, tachycardia of 120 beats per minute, ocular clonus and generalized hyperreflexia. Sertraline and risperidone were immediately stopped. Blood tests including creatine kinase, lumbar puncture and magnetic resonance imaging (MRI) of the brain did not show any abnormalities. After stopping of the medications, the patient’s symptoms resolved within 24 hours. Based on clinical symptoms and a normal creatine kinase level, neuroleptic malignant syndrome (NMS) was ruled out. Subsequently, he was restarted on risperidone 0.5mg and mirtazapine 7.5mg every night. He developed symptoms of serotonin syndrome with a low dose of sertraline. Symptoms resolved after the discontinuation of the SSRI.Conclusions In this case, differential diagnoses of serotonin syndrome were also considered, such as NMS, encephalitis, meningitis and thyroid storm. NMS was less likely due to the rapid onset of onset and resolution of symptoms. Encephalitis and meningitis were unlikely in view of normal MRI brain and lumbar puncture findings.There have been case reports of serotonin syndrome developing with lower doses of an SSRI in the pediatric population. There is, however, a lack of literature describing serotonin syndrome with low doses of SSRI in the adult population. To avoid a missed diagnosis, clinicians should monitor closely for SSRI toxicity, including serotonin syndrome, even when low doses of serotonergic drugs are used.Disclosure of InterestNone Declared

A - 94 A Case of New Onset Refractory Status Epilepticus (NORSE) Associated with COVID-19.

New Onset Refractory Status Epilepticus (NORSE) is a rare condition of prolonged medication-refractory seizures potentially due to elevated inflammatory molecules in the brain. NORSE can be triggered by a viral infection and is a documented neurologic consequence of COVID-19. A 74-year-old, left-handed, Hispanic male was in his usual state of health until experiencing 1-2weeks of speech decline, which culminated in an episode of altered mental status (disorientation and mumbling speech). He presented to the Emergency Department with drowsiness and complaints of a "funny feeling" on the left side of his head. Upon arrival, he was found to be COVID-19 positive and hyperglycemic with normal CT, MRI, lumbar puncture, and bloodwork. An EEG showed "focal temporal activity" and he was diagnosed with non-convulsant status epilepticus. Hospitalization and medical sedation lasted 2months followed by 8months of inpatient rehabilitation. The patient was discharged shortly before presenting for neuropsychological evaluation. Neuropsychological evaluation showed weaknesses in learning and free recall, visuospatial skills (due to disorganization and poor attention to details), processing speed, and executive functioning. The patient reported elevated anxiety symptoms. Collateral report indicated severe declines in executive organizational abilities, as well as mild memory and divided attention declines. Results suggest frontal cortical and subcortical impairments affecting multiple areas of cognition and functional decline consistent with a diagnosis of major neurocognitive disorder. Similar to the literature, status epilepticus was attributed to inflammatory meningoencephalitis triggered by the prior COVID-19 infection. Interdisciplinary care was an integral factor in this case.

Clinical Presentation, Investigation Findings, and Treatment Outcomes of Spontaneous Intracranial Hypotension Syndrome

Spontaneous intracranial hypotension (SIH) is a highly disabling but often misdiagnosed disorder. The best management options for patients with SIH are still uncertain. To provide an objective summary of the available evidence on the clinical presentation, investigations findings, and treatment outcomes for SIH. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline-compliant systematic review and meta-analysis of the literature on SIH. Three databases were searched from inception to April 30, 2020: PubMed/MEDLINE, Embase, and Cochrane. The following search terms were used in each database: spontaneous intracranial hypotension, low CSF syndrome, low CSF pressure syndrome, low CSF volume syndrome, intracranial hypotension, low CSF pressure, low CSF volume, CSF hypovolemia, CSF hypovolaemia, spontaneous spinal CSF leak, spinal CSF leak, and CSF leak syndrome. Original studies in English language reporting 10 or more patients with SIH were selected by consensus. Data on clinical presentation, investigations findings, and treatment outcomes were collected and summarized by multiple observers. Random-effect meta-analyses were used to calculate pooled estimates of means and proportions. The predetermined main outcomes were the pooled estimate proportions of symptoms of SIH, imaging findings (brain and spinal imaging), and treatment outcomes (conservative, epidural blood patches, and surgical). Of 6878 articles, 144 met the selection criteria and reported on average 53 patients with SIH each (range, 10-568 patients). The most common symptoms were orthostatic headache (92% [95% CI, 87%-96%]), nausea (54% [95% CI, 46%-62%]), and neck pain/stiffness (43% [95% CI, 32%-53%]). Brain magnetic resonance imaging was the most sensitive investigation, with diffuse pachymeningeal enhancement identified in 73% (95% CI, 67%-80%) of patients. Brain magnetic resonance imaging findings were normal in 19% (95% CI, 13%-24%) of patients. Spinal neuroimaging identified extradural cerebrospinal fluid in 48% to 76% of patients. Digital subtraction myelography and magnetic resonance myelography with intrathecal gadolinium had high sensitivity in identifying the exact leak site. Lumbar puncture opening pressures were low, normal (60-200 mm H2O), and high in 67% (95% CI, 54%-80%), 32% (95% CI, 20%-44%), and 3% (95% CI, 1%-6%), respectively. Conservative treatment was effective in 28% (95% CI, 18%-37%) of patients and a single epidural blood patch was successful in 64% (95% CI, 56%-72%). Large epidural blood patches (>20 mL) had better success rates than small epidural blood patches (77% [95% CI, 63%-91%] and 66% [95% CI, 55%-77%], respectively). Spontaneous intracranial hypotension should not be excluded on the basis of a nonorthostatic headache, normal neuroimaging findings, or normal lumbar puncture opening pressure. Despite the heterogeneous nature of the studies available in the literature and the lack of controlled interventional studies, this systematic review offers a comprehensive and objective summary of the evidence on SIH that could be useful in guiding clinical practice and future research.

Etiology, Risk Factors, Mortality and Morbidity of Status Epilepticus in Children: A Retrospective Cross-Sectional Study in Tehran, Iran

Background:Risk factors identification associated with status epilepticus is valuable in order to prevent morbidity and mortality in children. This study aimed to consider the etiology, risk factors, morbidity and mortality in children with status epilepticus.Methods:This retrospective cross-sectional study was performed on 119 patients aged from one month old to 15 years old. Patients’ data were recorded, including basic demographic, etiology and clinical information. The different risk factors correlated to morbidity and mortality were evaluated in this study.Results:The most common etiologies were acute symptomatic and febrile status epilepticus by 32.8% and 22.7%, respectively. Abnormal brain imaging results were reported far more frequently in patients with a history of neurodevelopmental delay and previous status epilepticus (p<0.001). The overall morbidity and mortality rates were 18.9% and 10.9%, respectively; while these rates in patients with delayed development (45.16% and 18.42%, respectively) were significantly higher than patients with normal development (8% and 7.4%, respectively). The morbidity rates in patients with previous seizures and previous status epilepticus were remarkably higher than those without previous history of seizure (26.41% vs 11.32%; p=0.047) and without previous status epilepticus (36.36%versus14.28%; p=0.018). The length of hospital stay in patients with mortality was considerably longer than patients without mortality (12.30 ± 16.1 days vs 7.29 ± 6.24 days; p=0.033). The mortality rate in patients with normal Lumbar Puncture result was notably lower than those with abnormal LP result (2.9% vs 50%). The morbidity rate in patients with abnormal brain imaging results (p<0.001) was significantly greater than those in patients with normal results. The mortality rate was relatively higher in patients with abnormal imaging results compared to those normal results. Etiology was an important predictor of mortality and morbidity rates; acute symptomatic (32.8%), febrile status epilepticus (22.7%) and remote symptomatic (16.8%) etiologies were the most common underlying causes of S.E. While in children less than 3 years old, the acute symptomatic etiology and febrile status epilepticus etiologies were estimated as the most common, in most patients older than 3 years old the most common etiology of status epilepticus was unknown. Congenital brain defects etiology had the highest mortality (36.36%) and morbidity (42.85%) rate. The lowest morbidity (3.84%) and mortality (0%) rates were for patients with febrile status epilepticus etiology.Conclusion:Age, developmental delay, history of previous status epilepticus, the length of hospital stay, abnormal brain imaging results and the underlying etiology of status epilepticus were associated with increased morbidity and mortality among children with status epilepticus.

Validity evidence of a task trainer for normal and difficult lumbar puncture: A cross-sectional study.

Validation of the anatomically complex configurations of the Lumbar Puncture Simulator II (KYOTO KAGAKU CO., LTD., 15 Kitanekoya-cho Fushimi-ku Kyoto, Japan 612-8388) have not been reported. Previous validation of the normal anatomic configuration has been reported. This study aims to evaluate evidence for construct and content validity of 4 interchangeable lumbar puncture (LP) complex anatomic configurations of this simulator.We performed a cross-sectional study between April 2018 and May 2019. Novice volunteer medical students and expert physicians who had performed over 30 LP procedures performed sequential LP procedures on each of 4 simulated interchangeable anatomic LP puncture blocks (normal, obesity, geriatric, combined geriatric/obesity). Primary outcome measures compared between groups for each LP procedure were return of cerebrospinal fluid within 5 minutes and a calculated performance score. Subjective face validity and content validity 5-point Likert questionnaires were completed by participants.35 novice (n = 19) and expert (n = 16) subjects completed 140 procedures. Significant differences were found between novice and expert groups for both cerebrospinal fluid success rates and performance scores for normal (P = .001/P = .001) geriatric (P = .005/P = .002) and obesity (P = .003/P = < .001) configurations. There were no differences for the geriatric/obesity configuration. Expert median score of simulator realism (face validity) was 4 (range 3–4); median score of utility as a training tool (content validity) was 4 (range 4–5).We provide evidence for construct validity for each of the complex LP configurations, except combined geriatric/obesity. Expert physicians found the simulator sufficiently realistic to effectively teach LP skills.

091 Cerebellar oedema in fulminant adult leigh syndrome

IntroductionWe report a case of adult Leigh syndrome resulting in rapidly fatal cerebellar oedema.CaseA 19-year-old female presented with a five-week history of hyperventilation, generalised weakness, dysarthria and bilateral ptosis. Brain Magnetic resonance imaging (MRI) findings and the presence of a mitochondrial mutation (NC_012920.1(MT-ATP6):m.9176T&gt;C) in blood and urine with approximately 97% heteroplasmy, confirmed a diagnosis of Leigh syndrome.Two-days after a normal lumbar puncture, opening pressure 8cm water, her conscious level rapidly declined. CT revealed marked cerebellar oedema with brainstem compression. Despite immediate decompression, she did not recover consciousness and died six-weeks after symptom onset.ConclusionAdult Leigh syndrome is a progressive untreatable inherited mitochondrial disorder typically of infants and children. Adult cases are rare and described mostly in single case reports. There is marked phenotypic and genotypic variability. Over 83% of Leigh’s syndrome is identified by the age of 2 years, however, there have been cases reported in patients up to 74 years old. There are over 60 mutations described in Leigh syndrome, which are identified in only half of reported cases. Classic MRI changes include bilateral symmetric T2 hyper-intensities in the basal ganglia and brainstem. To our knowledge, this is the first reported case resulting in fulminant cerebellar oedema. A challenge of diagnosis remains the marked heterogeneity in presenting symptoms including cognitive decline, behavioural change and ophthalmoparesis. Typically, this syndrome has been confirmed by histopathology at autopsy. Advances in genetics and imaging have allowed earlier accurate diagnosis, potentially paving the way for improved therapeutics.

P.025 Magnetic resonance imaging in pediatric recurrent ophthalmoplegic cranial neuropathy

Background: Recurrent ophthalmoplegic cranial neuropathy (ROCN), previously called ophthalmoplegic migraine, is characterized by recurrent episodes of headache and ophthalmoplegia of unclear etiology. Characteristic neuroimaging findings can support the diagnosis. Methods: A case report and review of the literature. Results: We present a 6-year-old girl with a past history of migraine headaches associated with retroorbital pain since 4 years of age. Family history is positive for migraine. She presented with a half a day history of left eye ptosis, 10 days post a resolved gastroenteritis which was associated with headaches. Examination showed only a left eye ptosis, pupil-sparing with no exotropia or diplopia. There was no headache. The rest of the neurologic examination was normal. Investigations showed normal blood tests and lumbar puncture. MRI head showed on thin cuts asymmetric nodular thickening (4mm) of the origin of the cisternal segment of the left oculomotor nerve, with corresponding homogeneous enhancement post gadolinium infusion. Clinical resolution occurred spontaneously within 48 hours. A review of the literature highlights focal thickening and enhancement of the affected cranial nerve, with resolution of enhancement post-acute phase. Conclusions: Focal thickening and enhancement of affected cranial nerve is seen in the majority of pediatric ROCN. These findings are best seen with thin MRI cuts and gadolinium infusion.

Influenza Encephalitis in a Collegiate Baseball Player

HISTORY: A 20 year old male, NCAA Division I baseball player presents to athletic trainer with a chief complaint of a severe headache. Associated symptoms included numbness in bilateral fingertips and lips, disoriented and look tired and fatigued. Athlete could answer questions asked but could not recall details of the morning prior to presenting to the athletic trainer. He had a previous history of headaches, coughing and congestion over past few months. Previous headaches were treated with over the counter medications and sleep. Athlete also had a medical history of ADHD and surgical history of tonsillectomy and adenoidectomy 2013. PHYSICAL EXAM: No obvious deformity and no visible sites of trauma. Full strength in upper extremities bilaterally; normal sensation bilaterally except for fingertips and lips. Deterioration of mental status over the following hour and was unable to understand simple commands or reply verbally. Athlete was transported to the Emergency Department. Upon arrival, athlete became combative due to disorientation and was intubated for his safety. DIFFERENTIAL DIAGNOSIS: 1. Migraine Headache 2. Intracranial Hemorrhage 3. Meningitis TESTS & RESULTS: Complete Blood Count Test- mild elevated white blood cell count (13.4) Comprehensive Metabolic Panel- within normal limits Urine Toxicology- within normal limits CT Scan- normal MRI- normal Lumbar Puncture- elevated with white blood cell count Influenza Test- positive for influenza b FINAL/WORKING DIAGNOSIS: Influenza Encephalitis TREATMENT & OUTCOMES: • Intubated and admitted to the ICU • Hospital day #2 was extubated • Treated with Tamiflu for influenza b • Discharged to go home and follow up with athletic training staff • No residual symptoms, feeling well • Athlete successfully participated in 2015 baseball season

Pseudotumor Cerebri in a Child with Idiopathic Growth Hormone Insufficiency Two Months after Initiation of Recombinant Human Growth Hormone Treatment.

Purpose. To report a rare case of pseudotumor cerebri (PTC) in a child two months after receiving treatment with recombinant human growth hormone (rhGH) and to emphasize the need of close collaboration between ophthalmologists and pediatric endocrinologists in monitoring children receiving rhGH. Methods. A 12-year-old boy with congenital hypothyroidism started treatment with rhGH on a dose of 1,5 mg/daily IM (4.5 IU daily). Eight weeks later, he was complaining of severe headache without any other accompanying symptoms. The child was further investigated with computed tomography scan and lumbar puncture. Results. Computed tomography scan showed normal ventricular size and lumbar puncture revealed an elevated opening pressure of 360 mm H2O. RhGH was discontinued and acetazolamide 250 mg per os twice daily was initiated. Eight weeks later, the papilledema was resolved. Conclusions. There appears to be a causal relationship between the initiation of treatment with rhGH and the development of PTC. All children receiving rhGH should have a complete ophthalmological examination if they report headache or visual disturbances shortly after the treatment. Discontinuation of rhGH and initiation of treatment with acetazolamide may be needed and regular follow-up examinations by an ophthalmologist should be recommended.

Diagnosing RCVS Without the CV: The Evolution of Reversible Cerebral Vasoconstriction Syndrome.

This is a case of a 52-year-old man with a past medical history of 2 episodes of coital thunderclap headaches as well as recent cocaine, marijuana, and pseudoephedrine use, who presented with sudden, sharp, posterior headache associated with photophobia and phonophobia. His initial magnetic resonance imaging (MRI) of the brain, magnetic resonance angiography (MRA) of the head, and magnetic resonance venography (MRV) of the head were all normal as well as a normal lumbar puncture. Given the multiple risk factors for reversible cerebral vasoconstriction syndrome (RCVS), the patient was treated for suspected RCVS, despite the normal imaging. Repeat MRI brain 3 days after hospital admission demonstrated confluent white matter T2 hyperintensities most prominent in the occipital lobes, typical of posterior reversible encephalopathy syndrome (PRES). Repeat MRA of the head 1 day after discharge and 4 days after the abnormal MRI brain showed multisegment narrowing of multiple arteries. This case demonstrates that RCVS may present with PRES on MRI brain and also exemplifies the need to treat suspected RCVS even if imaging is normal, as abnormalities in both the MRI and the MRA may be delayed.

The Effect of Traumatic Lumbar Puncture on Hospitalization Rate for Febrile Infants 28 to 60 Days of Age

The authors measured the effect of a traumatic or unsuccessful lumbar puncture (LP) on the management of febrile infants. This was a 10-year retrospective cross-sectional study of low-risk infants by the "Boston" criteria 28 to 60days of age presenting to the emergency department for evaluation of fever. "Normal LP" infants had cerebrospinal fluid (CSF) WBC < 10×10(6) cells/L. "Traumatic" or "unsuccessful LP" infants had CSF red blood cell count ≥ 10×10(9) cells/L or no CSF cell counts obtained, respectively. A serious bacterial infection (SBI) was defined as growth of a bacterial pathogen from culture. The hospitalization and SBI rates were compared between infants with normal versus traumatic or unsuccessful LPs. Of the 929 study infants, 756 (81.4%) had normal LPs, and 173 (18.6%) had traumatic or unsuccessful LPs. Infants with traumatic or unsuccessful LPs had a higher hospitalization rate (72.3% traumatic or unsuccessful LP vs. 18.1% normal LP; difference= 54.1%; 95% confidence interval [CI] = 46.4% to 60.8%), but a similar SBI rate (2.9% vs. 4.1%; difference= 1.2%; 95% CI = -2.7% to 3.6%). No infant had proven bacterial meningitis (0% risk, 95% CI = 0 to 0.3%). Low-risk infants aged 28 to 60days with traumatic or unsuccessful LPs are more frequently hospitalized, although SBI rates were similar to those of infants with normal LPs.

HIV-Associated Disseminated Emmonsiosis, Johannesburg, South Africa

HIV-Associated Disseminated Emmonsiosis, Johannesburg, South Africa

Higher Orexin A levels in lumbar compared to ventricular CSF: A study in idiopathic normal pressure hydrocephalus

Orexin A (ORX-A) is implicated in the regulation of various physiological processes, including sleep/wake cycles and reward/motivation. The hypothalamic ORX-A neurons project throughout the brain and spinal cord. In the present study we established and compared ORX-A levels in lumbar and ventricular cerebrospinal fluid (CSF) samples, drawn from idiopathic normal pressure hydrocephalus (INPH) patients, during respectively, lumbar puncture and shunt placement. Ventricular and lumbar CSF levels of total protein and of the dopamine, serotonin and norepinephrine metabolites HVA, 5-HIAA and MHPG respectively, were also estimated. ORX-A was quantified using a commercially available radioimmunoassay kit. Neurotransmitter metabolites were quantified by high performance liquid chromatography. Expectedly, HVA and 5-HIAA levels were significantly higher and total protein levels lower in ventricular compared to lumbar CSF while there were no differences in MHPG levels. However, in contrast to HVA and 5-HIAA and similar to total protein, lumbar ORX-A levels were significantly higher than ventricular levels. The higher lumbar compared to ventricular ORX-A levels may reflect elevated contributions from the spinal cord. The finding of a ventriculo-lumbar difference for ORX-A should be considered in studies utilizing its CSF levels in assessing Orexin system status.

Primary sudden onset severe headache: Prognosis and factors influencing it

Sudden onset severe headache, so called thunderclap headache, is a common condition that sometimes indicates a life-threatening conditions such as subarachnoid haemorrhage (SAH). Little is known about the prognosis of primary sudden onset severe headache (PSOH). Objectives To investigate the recurrence rate of sudden onset severe headache with normal brain imaging and lumbar puncture and factors associated with its recurrence.

371 Rare Presentation of Acute Demyelinating Encephalomyelitis in A Child with Excessive Fatigue and Sleepiness

The encephalopathic child is a paediatric emergency and presents a considerable challenge.We present a 4 year old boy who was admitted with 3 week history of excessive fatigue and sleepiness,...

CSF abnormalities can be predicted by VEP and MRI pathology in the examination of optic neuritis

Optic neuritis (ON) is linked to multiple sclerosis (MS). The presence of white matter lesions on cerebral magnetic resonance imaging (MRI) predicts the risk of MS after ON with considerable accuracy. Oligoclonal bands (OCB) are present in 95 % of MS patients, and a lumbar puncture can also be valuable in the evaluation of patients with ON. We analyzed CSF findings in patients referred with ON in the context of MRI and visual evoked potential (VEP) pathology. We assessed the possible contributory role of a lumbar puncture and weigh this against disadvantages of the procedure. Between February 2003 and November 2011, 505 patients were referred by ophthalmologists to the Clinic of Optic Neuritis, Glostrup Hospital, University of Copenhagen. None had MS prior to referral. A total of 437 were included in the study, and all underwent MRI, a lumbar puncture and VEP. Patients with other organic causes of their symptoms and patients with >3 months between onset and tests were excluded. All files were reviewed retrospectively. CSF leukocytes and the IgG index were elevated in 33 and 41 %, respectively, and OCBs were detected in 61 % of patients. CSF abnormalities correlated strongly with VEP and MRI (p < 0.0001). Patients with normal VEP and MRI had a 96 % probability of a normal lumbar puncture. The contributory role of a lumbar puncture in the evaluation of ON seems negligible when patients have a normal VEP and MRI. We suggest that all patients should be evaluated with VEP and MRI before deciding on a lumbar puncture.

Index of Suspicion in the Nursery

Twins are born at 37-5/7 weeks gestation to a 41-year-old G4P2 woman who had unremarkable serology results. The delivery is via cesarean section because of a nonreassuring fetal heart rate. Twin B appears to be acrocyanotic and initially requires positive-pressure ventilation for 30 seconds before being able to maintain her oxygen saturation on her own. Apgar scores are 7 and 8 at 1 and 5 minutes, respectively. She also appears to be “jittery,” and her screening glucose concentration is 24 mg/dL (1.3 mmol/L). She consumes 20 mL of infant formula and a 10% dextrose (D10) infusion is begun at a rate of 60 mL/kg per day. Three hours after birth, a follow-up glucose evaluation measures 30 mg/dL (1.7 mmol/L), prompting administration of a 4-mL/kg bolus of D10 over 20 minutes and increase of the maintenance infusion rate to 100 mL/kg per day. Six hours after birth, glucose measures 80 mg/dL (4.4 mmol/L), and the infusion rate is decreased to 60 mL/kg per day. She is transferred to a hospital that has a neonatal intensive care unit (NICU) for close monitoring. On transfer, the oxygen saturation dips into the upper 80s/lower 90s, and nasal cannula administration of oxygen is initiated. Furthermore, during transfer (8 to 9 hours after birth), the blood glucose value is 44 mg/dL (2.4 mmol/l), so the D10 infusion rate is increased back to 100 mL/kg per day. On arrival at the second hospital, her oxygen saturation is about 85% and glucose is 50 mg/dL (2.8 mmol/L). In the NICU, she receives noninvasive respiratory support as well as 15% dextrose (D15) at a rate of 70 mL/kg per day. Twin A remains stable and continues to receive routine newborn care in the newborn nursery of the first hospital. Two days after birth, twin B continues to have glucose …

Idiopathic Intracranial Hypertension With Dan and Beyond: The 2010 Jacobson Lecture

Neuro-ophthalmologists frequently care for patients with idiopathic intracranial hypertension (IIH), although many questions remain unanswered regarding its diagnosis, pathogenesis, and treatment. The Friedman-Jacobson criteria for the diagnosis of IIH specify lumbar puncture (LP) opening pressure values that are largely based on experience with little supporting normative data. Until recently, there were sparse data to define normal values of the LP opening pressure in children. Papilledema, the sine qua non of IIH, may not always be present, but the frequency of true IIH without papilledema is controversial and the threshold for diagnosing it varies among clinicians. Concepts regarding the pathogenesis of IIH continue to evolve; venous hypertension is certainly implicated even though it is uncertain whether venous sinus stenosis is the cause or effect of increased intracranial pressure. The 2010 Jacobson Lecture discusses the evidence for some of the prevailing assumptions about normal lumbar puncture opening pressure, venous sinus stenosis, and the phenotypic continuum between chronic daily headaches and IIH.

677 Hypervitaminosis a - is it Stilla Cause of Idiopathic Intracranial Hypertension in Childhood?

Idiopathic intracranial hypertension (IIH) in prepubertal children is rare and different in presentation from the adult, occurring with no apparent preference for sex or weight Clinically, strabismus with VI nerve palsy and stiff neck are more frequent, and secondary causes more common. Vitamin A toxicity has been described mainly in adolescents treated with topic retinoids for acne, rather than oral intake as dietary supplement. We present the case of a previously healthy 9-yearold male, with strabismus, ptosis of the left eye and diplopia about a month after a cold with occipital headache and vomiting (medications included supplements containing vitamin A) Fundoscopy revealed bilateral papilledema with enlargement of blind spot and endotropium of the left eye Brain CT was normal Lumbar puncture (LP) at admission revealed opening pressure of 500 mmH2O, with normal CSF results Admitting IIH, he was started on acetazolamide, with good clinical results Regular eye exams revealed visual acuity 8/10 bilaterally and stabilization of papilledema Elevated serum levels of vitamin A were the only positive findings. He was discharged after two weeks, asymptomatic; completed two months of acetazolamide, then repeated LP with opening pressure of 200mm H2O. Hypervitaminosis A has been associated with IIH in children, although its causative role is yet to be determined A limiting factor is that IIH does not correlate directly with increased vitamin A serum levels, but with CSF levels, which are not tested routinely Nevertheless, vitamin intake in children should be started only in cases with formal indication and monitored carefully.

POC28 A rare reversal in neurology

A 51-year-old woman presented with a 10 day history of left shoulder pain which was managed with paracetamol and codeine. On straining the next day she developed a severe headache...