Presence Of Focal Neurological Deficits Research Articles

Cerebral venous sinus thrombosis complicated by seizures: a retrospective analysis of 69 cases

Cerebral venous sinus thrombosis (CVST) is a rare ischemic cerebrovascular disease. The aim of this retrospective observational study was to investigate the risk factors for complication of cerebral venous sinus thrombosis by seizures and to explore the impact of such seizures on clinical outcomes. Patients with cerebral venous sinus thrombosis with or without epileptic seizures were retrospectively analyzed and compared in terms of clinical variables, causative factors, clinical presentation, and imaging data. In all, 69 patients with cerebral venous sinus thrombosis were enrolled in this study, 32 (46.38%) of whom had experienced secondary seizures. Compared with those with no seizures, significantly more patients with secondary seizures had hemiplegia (37.50 vs. 15.63%; P = 0.020), bleeding (29.40 vs. 10.81%; P = 0.047), lesions involving the frontal (31.25 vs. 10.81%; P = 0.023) and temporal lobe (43.75 vs. 8.11%; P = 0.005), and thrombosis in the superior sagittal sinus (65.63 vs. 40.54%; P = 0.036). Multivariate logistic regression analysis showed focal neurological deficits (P = 0.004, odds ratio = 5.16, 95% CI 1.99–15.76) and thrombosis of the superior sagittal sinus (P = 0.039, odds ratio = 0.13, 95% CI 0.04–0.37) were independent risk factors for secondary seizures in patients with cerebral venous sinus thrombosis. In addition, mortality rate (9.38 vs. 5.41%; P = 0.469) and 90-day excellent prognosis rate (81.25 vs. 86.47%; P = 0.793) did not differ significantly between patients with and without epileptic seizures. The presence of focal neurological deficits and thrombosis of the superior sagittal sinus are independent risk factors for secondary seizures in patients with cerebral venous sinus thrombosis, whereas mortality and 90-day prognosis have no correlation with secondary seizures.

Multiple anti-epileptic drug use in children with epilepsy in Mulago hospital, Uganda: a cross sectional study.

BackgroundSeizures in up to one third of children with epilepsy may not be controlled by the first anti-epileptic drug (AED). In this study, we describe multiple AED usage in children attending a referral clinic in Uganda, the factors associated with multiple AED use and seizure control in affected patients.MethodsOne hundred thirty nine patients attending Mulago hospital paediatric neurology clinic with epilepsy and who had been on AEDs for ≥6 months were consecutively enrolled from July to December 2013 to reach the calculated sample size. With consent, the history and physical examination were repeated and the neurophysiologic and imaging features obtained from records. Venous blood was also drawn to determine AED drug levels. We determined the proportion of children on multiple AEDs and performed regression analyses to determine factors independently associated with multiple AED use.ResultsForty five out of 139 (32.4 %) children; 46.7 % female, median age 6 (IQR = 3–9) years were on multiple AEDs. The most common combination was sodium valproate and carbamazepine. We found that 59.7 % of children had sub-therapeutic drug levels including 42.2 % of those on multi-therapy. Sub-optimal seizure control (adjusted odds ratio [ORa] 3.93, 95 % CI 1.66–9.31, p = 0.002) and presence of focal neurological deficits (ORa 3.86, 95 % CI 1.31–11.48, p = 0.014) were independently associated with multiple AED use but not age of seizure onset, duration of epilepsy symptoms, seizure type or history of status epilepticus.ConclusionOne third of children with epilepsy in Mulago receive multiple AEDs. Multiple AED use is most frequent in symptomatic focal epilepsies but doses are frequently sub-optimal. There is urgent need to improve clinical monitoring in our patients.

Does distracting pain justify performing brain computed tomography in multiple traumas with mild head injury?

Traumatic brain injury (TBI) is a significant health concern classified as mild, moderate, and severe. Although the indications to perform brain computed tomography (CT) are clear in moderate and severe cases, there still exists controversy in mild TBI (mTBI). We designed the study to evaluate the significance of distracting pain in patients with mTBI. The study population included patients with mild traumatic brain injury (GCS ≥13). Moderate and high risk factors including age <18months or ≥60years, moderate to severe or progressive headache, ≥2 episodes of vomiting, loss of consciousness (LOC), post-traumatic amnesia, seizure or prior antiepileptic use, alcohol intoxication, previous neurosurgical procedures, uncontrolled hypertension, anticoagulant use, presence of focal neurologic deficits, deformities in craniofacial region, and penetrating injuries were excluded. The patients were then grouped based on presence (DP+) or absence (DP-) of another organ fracture with severe pain (based on VAS). The primary outcome was any abnormal findings on brain CT scans; 330 patients were enrolled (184 DP+ and 146 DP-). Overall, two DP+ and one DP- patients had mild cerebral edema in brain CT (p > 0.99). No patients had any neurologic symptoms or signs in follow-up. Our results show that in the absence of any other risk factors, distracting pain from other organs (limbs, pelvis, and non-cervical spine) cannot be regarded as a brain CT indication in patients with mild TBI, as it is never associated with significant intracranial lesions.

Evaluation of Short-Term Neurological Outcomes in Children with Brain Abscesses.

To evaluate the neurological outcomes of children diagnosed with brain abscesses in the early post-treatment period. < b > MATERIAL and METHODS: This study was a retrospective analysis of pediatric brain abscess patients between January 2000 and December 2015, during a 16-years period. Patients were divided into two groups according to their outcome at the end of the treatment. The patients with "good outcome" were the ones without any neurological sequelae [Glasgow Outcome Scale (GOS) score 5]. "Unfavorable outcome" was defined as having any kind of neurological deficit (GOS score 1-4). A total number of 31 patients (22 male, 71%) with the median age at diagnosis of 84 months (range, 1-202 months) were enrolled in this study. The most common presenting symptom was fever being encountered in 71% of the patients (n=22), followed by focal neurological deficit (FND)(n=17, 54.8%), vomiting (n=14, 45.2%), headache (n=13, 41.9%), seizure (n=13, 41.9%), change in mental status (n=12, 38.7%) and visual disturbance (n=2, 6.5%). Twenty-four patients (77.4%) had predisposing factors. The most common pathogens were gram-positive cocci (n=9, 29%). Seventeen patients (54.8%) had unfavorable outcome; 2 patients (6.4%) died. All patients were treated with parenteral antibiotherapy with median duration of 73 days (range, 28-540 days). Surgical procedures were performed in 83.9% (n=26) of patients [isolated aspiration (n=19, 61.3%), only resection (n=5, 16.1%), aspiration and resection (n=2, 6.5%)]. Glasgow coma scale score below 12 and the presence of FND on admission were found to be independent risk factors for unfavourable neurological outcome in children with brain abscesses.

Periprocedural Risk of Stroke Is Elevated in Patients with End-Stage Renal Disease on Hemodialysis

Objective: To describe the most common clinical factors and stroke etiologies in a case series of patients with end-stage renal disease on hemodialysis (ESRD/HD) with transient ischemic attack (TIA) or ischemic stroke (IS). Background: Prior studies have shown that patients on HD are at an elevated risk of stroke, but these studies have focused on the overall stroke risk. This case series sought to determine the percentage of acute ischemic events that occur during or immediately after HD. Methods: ICD-9 codes were used to identify IS and TIA patients with ESRD/HD admitted to the stroke service from August 22, 2011, to June 21, 2014. Charts were reviewed to determine the age, sex, and race/ethnicity of the cohort. TIA/IS diagnosis was confirmed by a vascular neurologist. Clinical factors were assessed, including: onset during or shortly after HD, defined as occurring within 12 h of HD; the presence of a lesion on diffusion-weighted MRI; hypotension, hyponatremia, or hypoglycemia at symptom onset; the stroke etiology; the presence of focal neurologic deficits; whether the patient was in the window period for intravenous tissue plasminogen activator (IVtPA) upon presentation, and whether the patient received IVtPA. Results: We identified 34 ESRD/HD patients with a diagnosis of TIA/stroke in the specified time period. A majority of patients (70.6%) were African American. Patient age ranged from 32 to 84 years, with a median age of 67 years. Twenty-seven patients (79.4%) had confirmed ischemic infarcts on diffusion-weighted MRI. Seven patients (20.6%) were diagnosed with TIA. In 13 patients (38.2%), symptom onset occurred during or shortly after HD. Of these 13 patients, 8 (61.5%) had symptom onset during HD. Three patients (8.8%) had documented hypotension near the time of symptom onset, and 2 (5.9%) were hyponatremic on presentation to the emergency department. The distribution of stroke etiologies was as follows: 4 (11.8%) watershed distribution, 1 (2.9%) large artery atherosclerosis, 2 (20.6%) small vessel disease, 10 (29.4%) cardioembolic, and 9 (26.5%) cryptogenic. In 28 patients (82.4%), focal neurologic deficits were observed on presentation. Nine patients (26.5%) arrived within the window period for IVtPA, and 4 (11.8%) were eligible and received IVtPA. Conclusions: Of all patients with ESRD on HD admitted to the stroke service over the study period, over one third (38.3%) had the onset of their ischemic event during or shortly after HD, and nearly one quarter (23.5%) had the onset during HD. While clinicians may be tempted to attribute neurologic changes after HD to metabolic etiologies, they should also be aware that HD represents a period of elevated risk for acute ischemia.

Postencephalitic epilepsy: clinical characteristics and predictors.

To describe the etiologies, clinical presentations, outcomes, and predictors of postencephalitic epilepsy (PE) in a large series of adult patients with acute encephalitis. We conducted a retrospective review of patients diagnosed with acute encephalitis at Mayo Clinic, Rochester, between January 2000 and December 2012. The patients were categorized into two groups based on the presence or absence of PE at last follow-up. Multivariate logistic regression analysis was used to analyze factors associated with PE. We identified 198 consecutive patients (100 [50.5%] male and 98 [49.5%] female) with a median age of 58 years (range 41.8-69). Etiologies included viral infection (n=95, 48%), autoimmune (n=44, 22%), and unknown/others (n=59, 30%). During hospitalization, seizures were seen in patients with autoimmune encephalitis (n=24, 54.5%), unknown/others (n=20, 33.9%), and viral encephalitis (n=23, 24.2%). Interictal epileptiform discharges on electroencephalography (EEG) were present in 34 (54%), whereas periodic lateralized epileptiform discharges (PLEDs) and generalized periodic discharges (GPDs) were seen in 14 (41.2%) and 2 (5.9%) patients. Forty-six patients with seizures (70.8%) had fluid-attenuated inversion recovery (FLAIR)/T2 abnormalities, 20 (31.3%) diffusion abnormalities, and 43 (66.2%) cortical involvement. Good outcome at discharge among patients with seizures was seen in 8/23 patients with viral etiology (34.8%), 10/24 patients with autoimmune encephalitis (45.5%), and 12/20 patients with unknown cause (60%). PE was present in 43 patients (29.9%). On multivariate regression analysis, the factors associated with PE were generalized seizures during hospitalization (p=0.03), focal seizures (p≤0.001), and the presence of FLAIR/T2 abnormalities on brain magnetic resonance imaging (MRI) (p=0.003). The presence of seizures during hospitalization and an abnormal brain MRI are the strongest predictors of the development of PE. The etiology of encephalitis, presence of focal neurologic deficits, and interictal EEG abnormalities did not influence the development of PE.

A prospective study of risk factors for neurological complications in childhood bacterial meningitis

ObjectiveTo prospectively analyze the prognostic factors for neurological complications of childhood bacterial meningitis. MethodsThis prospective study enrolled 77 children from 1 month until 16 years of age, treated for bacterial meningitis during the period of January 1, 2009 through December 31, 2010. 16 relevant predictors were chosen to analyze their association with the incidence of neurological complications. p-values < 0.05 were considered statistically significant. ResultsOf the 77 children treated for bacterial meningitis, 33 patients developed neurological complications (43%), and two children died (2.6%). The etiology of bacterial meningitis cases was proven in 57/77 (74%) cases: 32 meningococci, eight pneumococci, six Gram-negative bacilli, five H. influenzae, five staphylococci, and one S. viridans isolates were found. Factors found to be associated with increased risk of development of neurological complications were age < 12 months, altered mental status, seizures prior to admission, initial therapy with two antibiotics, dexamethasone use, presence of focal neurological deficit on admission and increased proteins in cerebrospinal fluid (CSF) (p < 0.05). Initial pleocytosis > 5,000 cells/mm3, pleocytosis > 5,000 cells/mm3 after 48hours, CSF/blood glucose ratio < 0.20, female gender, previous treatment with antibiotics, community-acquired infection, duration of illness > 48hours, presence of comorbidity, and primary focus of infection were not associated with increased risk for the development of neurological complications. ConclusionAge < 12 months and severity of clinical presentation at admission were identified as the strongest predictors of neurological complications and may be of value in selecting patients for more intensive care and treatment.

A prospective study of risk factors for neurological complications in childhood bacterial meningitis

ObjectiveTo prospectively analyze the prognostic factors for neurological complications of childhood bacterial meningitis. MethodsThis prospective study enrolled 77 children from 1 month until 16 years of age, treated for bacterial meningitis during the period of January 1, 2009 through December 31, 2010. 16 relevant predictors were chosen to analyze their association with the incidence of neurological complications. p-values < 0.05 were considered statistically significant. ResultsOf the 77 children treated for bacterial meningitis, 33 patients developed neurological complications (43%), and two children died (2.6%). The etiology of bacterial meningitis cases was proven in 57/77 (74%) cases: 32 meningococci, eight pneumococci, six Gram-negative bacilli, five H. influenzae, five staphylococci, and one S. viridans isolates were found. Factors found to be associated with increased risk of development of neurological complications were age < 12 months, altered mental status, seizures prior to admission, initial therapy with two antibiotics, dexamethasone use, presence of focal neurological deficit on admission and increased proteins in cerebrospinal fluid (CSF) (p < 0.05). Initial pleocytosis > 5,000 cells/mm3, pleocytosis > 5,000 cells/mm3 after 48hours, CSF/blood glucose ratio < 0.20, female gender, previous treatment with antibiotics, community-acquired infection, duration of illness > 48hours, presence of comorbidity, and primary focus of infection were not associated with increased risk for the development of neurological complications. ConclusionAge < 12 months and severity of clinical presentation at admission were identified as the strongest predictors of neurological complications and may be of value in selecting patients for more intensive care and treatment.

Clinicoepidemiological Profile and Poor Prognostic Factors in Neurotuberculosis: Study of Indian Children

Background: Neurotuberculosis is associated with high mortality and morbidity and is difficult to diagnose, has variable presentation and difficult to treat.Aims: To study the clinical, demographic and diagnostic parameters and independent poor prognostic factors in children with neurotuberculosis.Methods: We prospectively reviewed all cases of neurotuberculosis diagnosed over a period of 19 months. Data were collected with regard to the clinical, laboratory and demographic characteristics of patients, as well as the results of radiological investigations and data on clinical outcome.Results: 50 patients of neurotuberculosis were enrolled in the present study. 40 cases of tuberculous meningitis, 4 cases of tuberculous meningitis with tuberculoma and 6 cases of tuberculoma. The age of presentation varied from 1 month to 11years. Out of 44 patients of tuberculous meningitis 4 (9.09%) presented in Stage 1 of TBM, 25 (56.82%) in stage 2 and 15 (34.09%) in stage 3. Patients with absence of BCG scar presented in higher stage of TBM (p value = 0.048). In this study 11 patients died (22%). Presence of focal neurological deficits (p value = 0.031), stage of TBM (p value = 0.002 ) and HIV positive status (p value = 0.031) were found to significantly affect mortality.Conclusion: Neurotuberculosis continues to be a condition which carries significant morbidity and mortality. Focal neurological deficits, HIV positive status, stage of TBM and BCG unimmunised status are independent predictors of poor prognosis in patients of neurotuberculosis.

Seltene Differentialdiagnose linksbrachialer Schmerzen – Fall 6/2010

An 83-year old woman was admitted with pain in the left arm and on the left hemithorax. Subsequently, herpes zoster developed on the left arm. The next day, the patient got confused and was agitated. Furthermore, paresis of both legs and the left arm occurred. Cranial computed tomography was negative for intracerebral haemorrhage or ischaemia. Examination of cerebrospinal fluid revealed lymphocytic pleocytosis and increased albumin and lactate concentrations. Polymerase chain reaction (PCR) confirmed presence of varicella zoster virus DNA in the cerebrospinal fluid. After diagnosis of varicella zoster encephalitis, complicating herpes zoster on the left arm, intravenous treatment with aciclovir was initiated. Consequently, the patient's clinical status improved and the neurological signs declined. Herpes zoster is a rare differential diagnosis of pain on the left hemithorax and may manifest without skin rashes in the initial stadium. In older patients suffering from herpes zoster, disorientation is common. However, in the presence of focal neurological deficits, varicella zoster encephalitis should definitively be ruled out by spinal tap, even if cranial imaging studies are negative.

HHH Regime for Arteritis Secondary to TB Meningitis: A Prospective Randomized Study

Tuberculous meningitis (TBM) is a fairly common, debilitating disease and is often complicated by arteritis resulting in brain infarction. Few treatment regimes specifically address this condition. Hypervolemia-hypertension-hemodilution (HHH) regime is known to be effective for treatment of vasospasm complicating subarachnoid hemorrhage. We studied the efficacy of HHH regime in patients with TBM with arteritis using a prospective, randomized study design. Patients diagnosed to have TB meningitis by clinical, CSF, and imaging findings were evaluated for arteritis, which was recognized by presence of focal neurologic deficits with or without corresponding focal hypodensities on brain CT scan. Patients with deficits of < 96 h were randomized to HHH or conservative treatment. All patents received four-first-line anti-TB drugs and Inj.dexamethasone. HHH therapy was administered over 3-9 days. Neurologic status and modified Rankin score were noted serially and at discharge. Seven patients received HHH and 5, conservative treatment. All had hemiparesis with power 0-3/5. Median GCS was worse in HHH group (11 vs. 13). In the HHH group, 6/7 improved in motor power, and 5/7 in sensorium. In the control group, 3/5 improved in motor power and 3/5 in sensorium. Four patients died in each group. HHH therapy is safe and may be beneficial in the management of patients with infective arteritis secondary to TBM. Further study in a larger group with improved monitoring of cerebral circulation is indicated.

Cystic lesion of the ventriculus terminalis: proposal for a new clinical classification

The ventriculus terminalis is a small cavity inside the conus medullaris that is formed during the embryonic development. Previous reports regarding cystic lesion of the ventriculus terminalis (CLVT) in adults have detailed a broad and diversified distribution in terms of clinical symptoms, clinical evolution, neurological findings, and treatment. Therefore, nonstandardized management has led to unsatisfactory outcomes. Thus, the authors propose a new classification system in which the clinical presentation is taken into account to standardize the cases and facilitate the proper management of these lesions. Two more cases are described. The literature was reviewed, dividing the patients into 3 groups by clinical presentation as follows: CLVT Type I, patients with nonspecific neurological symptoms or nonspecific complaints; CLVT Type II, presence of focal neurological deficit; and CLVT Type III, presence of sphincter disturbances (bowel or bladder dysfunction). Two patients were classified as CLVT Type I, 3 as CLVT Type II, and 12 as CLVT Type III. In Type I, no improvement was observed in clinical evaluation after surgery, and stable symptoms were achieved with clinical management. In Type II, 2 patients had total improvement and 1 had subtotal improvement after surgery. Finally, in Type III, 92% of the patients improved postoperatively; among these 33% presented with total improvement. Only 1 case in this group was handled conservatively and no improvement was documented. This new classification is useful to group the patients into 3 clinical types to provide guidance as to the best management options. Treatment for the Type I lesion seems to be best conducted conservatively, whereas Types II and III seem to be best handled surgically.

Clinico-laboratory profile and outcome of Japanese encephalitis in Nepali children

Japanese encephalitis (JE) is associated with high mortality and neurological sequelae. The unpredictable course and lack of specific treatment pose major challenges in management. The tropical climate and paddy ecosystem in Nepal provide a suitable setting. To determine the aetiology of febrile encephalopathy and describe the clinico-laboratory profile and outcome of JE in Nepali children. A hospital-based prospective and observational study was conducted over a 1-year period (2000-2001). Children aged from >1 month to 14 years with fever >38 degrees C for <2 weeks and altered sensorium were recruited. JE was confirmed by anti-JE IgM in cerebrospinal fluid and/or serum. Of 117 consecutively enrolled patients, 58 had JE. Ten patients had concomitant infections, four with malaria and six with bacterial meningitis, and were excluded from analysis. Clinical findings were as follows: boys, 69%; age 4-14 years, 71%; presentation during summer and autumn, 83%; fever >3 days, 69%; altered sensorium <2 days, 50%; Glasgow coma score 8-12, 63%; seizures, 58%. Four (8.3%) died. At discharge, neurological sequelae were detected in 24 (50%) and hemiparesis was the most common form. Longer duration of vomiting, altered sensorium and focal neurological deficit on admission were independently associated with sequelae at discharge. Sequelae persisted in nine (18.8%) at 6 weeks follow-up. Long duration of altered sensorium (beta co-efficient 0.35, odds ratio 1.4, p=0.042) and presence of focal neurological deficit on admission (beta co-efficient 1.6, odds ratio 5.2, p=0.049) were independent predictors of sequelae at 6 weeks. JE was the commonest cause of febrile encephalopathy. Neurological sequelae were common but resolved in two-thirds of cases.

Clinical Yield of Computed Tomography Brain Scans in Older General Medical Patients

To evaluate the clinical yield of computed tomography (CT) brain scans in a prospective cohort of older patients admitted to the general medicine service. Nested cohort study of 117 subjects enrolled in previous prospective cohort study of 919 subjects. University-affiliated teaching hospital. Hospitalized general medical patients aged 70 and older who received one or more brain CT scans during their hospital stay. Review of medical records and interpretation of the first brain CT scan in these 117 patients for indications for ordering scans and clinically significant brain abnormalities. Medical records of patients with brain CT scans with abnormalities were reviewed for 2 weeks after the scan for changes in medical management resulting from scan findings. Three independent reviewers adjudicated the presence of abnormalities and resulting treatment changes. Of the 117 brain CT scans, 32 (27%) were ordered to exclude intracranial hemorrhage, 30 (26%) to exclude cerebrovascular accident (CVA), 16 (14%) for falls, 15 (13%) for syncope, seven (6%) to exclude subdural hemorrhage, five (4%) for mental status change, and 12 (10%) for other reasons. Of the 117 brain CT scans, 29 (25%) had abnormalities, including acute CVA or hemorrhage, old CVA, meningioma, and other abnormalities. Only 10 (9% of all scans, 34% of abnormal scans) resulted in treatment changes (including consultations, further imaging, stroke evaluation, and drug changes). The presence of focal neurological deficits was significantly associated with treatment changes after CT scans (odds ratio=13.2, 95% confidence interval=1.7-161.5). These results suggest that the overall clinical yield of brain CT scans in unselected older hospitalized patients is low. Targeting scans toward patients with new focal neurological deficits will help to improve clinical yield.

Clinical predictors of abnormal computed tomography scans in paediatric head injury.

To evaluate whether clinical features associated with head injury in children can be correlated with an abnormal computed tomography (CT) scan. Three hundred and eleven children aged 14 years or younger admitted with a diagnosis of acute head injury were studied retrospectively. A Glasgow Coma Scale (GCS) score of 12 or lower and the presence of focal neurological deficits were significant predictors of an abnormal CT scan. Ninety-five per cent of those with abnormal CT scans and 100% of those with intracranial injury could be identified by the presence of one or more of the nine clinical findings, particularly by a GCS score of 12 or lower, and the presence of focal neurological deficits. Identification was also possible to a lesser degree by loss of consciousness, ataxia, amnesia, drowsiness, headache, seizure or vomiting. Use of CT scans can be limited to children with ongoing specific symptoms and/or focal neurological signs. The implementation of guidelines in the management of head injuries in children could have a substantial effect on clinical practice and health-care costs.

Low-risk criteria for cervical-spine radiography in blunt trauma: A prospective study

Cervical-spine radiography does not need to be performed on selected blunt trauma patients who are awake, alert, nonintoxicated, do not complain of midline neck pain, and have no tenderness over the bony cervical spine. One thousand consecutive patients seen in the UCLA Emergency Medicine Center with a chief complaint of blunt trauma, for whom cervical-spine films were ordered and for whom prospective data questionnaires were completed. Clinicians completed data forms for each patient before radiograph results were known. Data items included mechanism of injury, evidence of intoxication, presence of cervical-spine pain and/or tenderness, level of alertness, presence of focal neurologic deficits, and presence of other severely painful injuries unrelated to the cervical spine. Physicians were also asked to estimate likelihood of significant cervical-spine injury. Twenty-seven patients with cervical-spine fracture were among the 974 patients for whom data forms were completed. A number of findings were statistically more common in the group of patients with fracture than without, but no single or paired findings identified all patients with fracture. All 27 patients with fracture had at least one of the following four characteristics: midline neck tenderness, evidence of intoxication, altered level of alertness, or a severely painful injury elsewhere. Three hundred fifty-three of 947 (37.3%) patients without cervical-spine fracture had none of these findings. Cervical-spine radiology may not be necessary in patients without spinous tenderness in the neck, intoxication, altered level of alertness, or other severely painful injury. A policy to limit films in such patients would have decreased film ordering by more than one third in this series, while identifying all patients with fracture.

Subarachnoid hemorrhage of unknown etiology: early prognostic factors for long-term functional capacity

Forty-one patients suffering subarachnoid hemorrhage (SAH) of unknown etiology were re-investigated at an average of 91 months after the bleed to determine functional capacity. Nineteen patients were performing at their previous level of work, five were employed part-time, and four could not work due to the SAH. Five patients showed a moderate disability in activities of daily living but were not dependent on help, one patient was severely disabled, and two had died. There was one rebleed. Early prognosis of an unfavorable outcome was possible on the basis of three clinical variables on admission: a history of hypertension, a Hunt and Hess grade of greater than II, and the presence of focal neurological deficits. In addition, the presence of an organic mental syndrome at discharge was identified as a predictive factor for reduced functional capacity later on. Other clinical variables in the acute stage, including sex, age, history of headache, interval between SAH and admission, impaired consciousness, and cognitive deficits, were not related to a limited functional level. Residual neurological deficits and the Glasgow Outcome Scale score on discharge were also not predictive of restrictions in global functions evaluated by means of the Karnofsky Performance Scale status at follow-up review.