Unresponsive Pupil Research Articles

Predictive power of the eTBI score for 30 day outcome in elderly patients with traumatic brain Injury

Traumatic brain injury (TBI) is a common problem in elderly individuals, with significant morbidity and mortality. The elderly Traumatic Brain Injury (eTBI) score, a novel tool for predicting outcomes in elderly patients with TBI, has shown promising results in previous studies. This study aimed to validate the eTBI score in a larger cohort of elderly patients with TBI in the Middle East. We conducted a retrospective study on 337 TBI patients with a mean age of 73.04 ± 8.73, admitted to a tertiary care hospital between March 2021 and November 2022. Within 30 days of admission, the patients’ conditions, including mortality and entering a vegetative state, were evaluated. The study population was split into three groups based on eTBI score: low, medium, and high risk; then patients were divided into two subgroups based on their Glasgow Outcome Scale (GOS ≤ 2, GOS > 2) in 30 days from hospital admission. Poor outcomes (mortality and entering a vegetative state) occurred in 24.3% of the study population. Within 30 days of hospital admission, 88% of low-risk patients experienced some degree of improvement, while 100% of high-risk patients died or fell into a vegetative state. In the medium-risk group, there was a significant correlation between unresponsive pupil (P = 0.006), initial GCS score (P = 0.003), need for a ventilator device (P = 0.015), need for surgical treatment (P = 0.031) and poor outcomes. Despite having a low sensitivity (21% vs. 57%), the eTBI score performed well in terms of accuracy (81% vs. 88%), specificity (100 vs. 98%), positive predictive value (100% vs. 90%), and negative predictive value (80% vs. 88%) for both eTBI ≤ 0 and eTBI ≤ 3 thresholds. The eTBI score is a reliable tool for predicting outcomes in elderly patients with TBI. This scoring system has a positive predictive value of 100% in the eTBI ≤ 0 group, which shows that 100% of the patients who are predicted by the eTBI score to have a poor outcome will indeed have a poor outcome. Patients in the high-risk group should be closely monitored and provided with intensive care, while those in the low-risk group can be reassured about their prognosis. The eTBI score can also be used in conjunction with other clinical factors to inform treatment decisions for patients in the medium-risk group.

Bilateral mydriasis as the first manifestation of Miller Fisher syndrome

Miller Fisher Syndrome (MFS) is a rare variant of Guillain-Barré Syndrome (GBS), characterised by a unique clinical triad of ophthalmoplegia, ataxia, and areflexia. MFS, which was first described in 1956 by Charles Miller Fisher , is frequently preceded by an infection, usually respiratory or gastrointestinal, and is believed to be triggered by an autoimmune reaction targeting peripheral nervous system components. However the MFS is further categorised into incomplete forms which can be present without the classical triad, such as acute ophthalmoparesis, acute ataxic neuropathy, acute ptosis and acute mydriasis. We report a case of a 50-year-old man presenting with dilated and unresponsive pupils, which progressed rapidly to ophthalmoplegia, ataxia, and areflexia. Given the clinical history supported by the cyto-protein dissociation in cerebrospinal fluid, the patient was diagnosed to have MFS and successfully treated with intravenous immunoglobulin. This case underscores the importance of recognising atypical features of MFS, such as primary mydriasis, and highlights the variable clinical spectrum within the syndrome. Clinicians should maintain a high index of suspicion for MFS, particularly when faced with unusual neurological presentations, to ensure timely intervention and optimal patient outcomes.

The Richmond Acute Subdural Hematoma Score: A Validated Grading Scale to Predict Postoperative Mortality.

Traumatic acute subdural hematomas (aSDHs) are common, life-threatening injuries often requiring emergency surgery. To develop and validate the Richmond acute subdural hematoma (RASH) score to stratify patients by risk of mortality after aSDH evacuation. The 2016 National Trauma Data Bank (NTDB) was queried to identify adult patients with traumatic aSDHs who underwent craniectomy or craniotomy within 4 h of arrival to an emergency department. Multivariate logistic regression modeling identified risk factors independently associated with mortality. The RASH score was developed based on a factor's strength and level of association with mortality. The model was validated using the 2017 NTDB and the area under the receiver operating characteristic curve (AUC). A total of 2516 cases met study criteria. The patients were 69.3% male with a mean age of 55.7 yr and overall mortality rate of 36.4%. Factors associated with mortality included age between 61 and 79 yr (odds ratio [OR] = 2.3, P < .001), age ≥80 yr (OR = 6.3, P < .001), loss of consciousness (OR = 2.3, P < .001), Glasgow Coma Scale score of ≤8 (OR = 2.6, P < .001), unilateral (OR = 2.8, P < .001) or bilateral (OR = 3.9, P < .001) unresponsive pupils, and midline shift >5 mm (OR = 1.7, P < .001). Using these risk factors, the RASH score predicted progressively increasing mortality ranging from 0% to 94% for scores of 0 to 8, respectively (AUC = 0.72). Application of the RASH score to 3091 cases from 2017 resulted in similar accuracy (AUC = 0.74). The RASH score is a simple and validated grading scale that uses easily accessible preoperative factors to predict estimated mortality rates in patients with traumatic aSDHs who undergo surgical evacuation.

Effects of Primary Decompressive Craniectomy on the Outcomes of Serious Traumatic Brain Injury with Mass Lesions, and Independent Predictors of Operation Decision

Although operative indications for traumatic brain injury (TBI) are known, neurosurgeons are unsure whether to remove the bone flap after mass lesion extraction, and an efficient scoring system for predicting which patients should undergo decompressive craniectomy (DC) does not exist. Nine parameters were assessed. In total, 245 patients with severe TBI were retrospectively assessed from June 2015 to May 2019, who underwent DC or craniotomy to remove mass lesions. The 6-month mortality and Extended Glasgow Outcome Scale scores were compared between the DC and craniotomy groups. Using univariable and multivariable logistic regression equations, receiver operating characteristic curves were obtained for predicting the decision for DC. The overall 6-month mortality in the entire cohort was 11.43% (28/245). Patients undergoing DC had lower mean preoperative Glasgow Coma Scale scores (P= 0.01), and higher amounts of individuals with a Glasgow Coma Scale score of 6 (P= 0.007), unresponsive pupillary light reflex (P < 0.001), closed basal cisterns (P < 0.001), and diffuse injury (P= 0.025), compared with the craniotomy group. Because of high disease severity, individuals administered primary DC showed increased 6-month mortality compared with the craniotomy group. However, in surviving patients, favorable Extended Glasgow Outcome Scale rates were similar in both groups. Pupillary light reflex and basal cisterns were independent predictors of the DC decision. Based on receiver operating characteristic curves, the model had sensitivity and specificity of 81.6% and 84.9%, respectively, in predicting the probability of DC. These preliminary data showed that primary DC may benefit some patients with severe TBI with mass lesions. In addition, unresponsive preoperative pupil reaction and closed basal cistern could predict the DC decision.

Surgical treatment of spontaneous intracranial hemorrhage in patients with cancer: Analysis of prognostic factors

BackgroundIntracranial hemorrhage (ICH) is the most common cerebrovascular event in patients with cancer. We sought to evaluate the outcomes of surgical treatment for ICH and to determine possible pre-operative outcome predictors. MethodsWe retrospectively reviewed surgical procedures for the treatment of ICH in patients with cancer. Analysis included clinical and radiological findings of the patients. Primary endpoints were survival and mortality in index hospitalization. ResultsNinety-four emergency neurosurgeries were performed for ICH in 88 different patients with cancer over ten years. 51 patients had chronic subdural hematomas (CSDH: 54.3%), 35 with intraparenchymal hemorrhage (37.2%), 6 with acute subdural hematoma (ASDH: 6.4%), and only 2 with epidural hemorrhages (2.1%). Median patient follow-up was 63 days (IQR = 482.2). 71 patients (75.5%) died at follow-up, with a median survival of 33 days. Overall 30-day mortality was 38.3%; 27.5% for patients with CSDH. Lower survival was associated to higher absolute leucocyte count (HR 1.06; 95%CI 1.04–1.09), higher aPTT ratio (HR 3.02; 95% CI 1.01–9.08), higher serum CRP (HR 1.01; 95%CI 1.01–1.01), and unresponsive pupils (each unresponsive pupil - HR 2.65; 95%CI 1.50–4.68). ConclusionOutcomes following surgical treatment of ICH in patients with cancer impose significant morbidity and mortality. Type of hematoma, altered pupillary reflexes, coagulopathies, and increased inflammatory response were predictors of mortality for any type of ICH.

Surgical treatment of spontaneous intracranial hemorrhage in patients with cancer

Introduction: Intracranial hemorrhage (ICH) is the most common cerebrovascular event in patients with cancer. We sought to evaluate the outcomes of surgical treatment for ICH and to determine possible pre-operative outcome predictors.&#x0D; Methods: We retrospectively reviewed surgical procedures for the treatment of ICH in patients with cancer. Analyses included clinical, laboratory, and radiological characteristics. Primary endpoints were survival and mortality in index hospitalization.&#x0D; Results: Ninety-four emergency neurosurgeries were performed for ICH in 88 different patients with cancer over ten years. 51 patients had chronic subdural hematomas (CSDH: 54.3%), 35 with intraparenchymal hemorrhage (37.2%), 6 with acute subdural hematoma (ASDH: 6.4%), and only 2 with epidural hemorrhages (2.1%). Median patient follow-up was 63 days (IQR=482.2). 71 patients (75.5%) died at follow-up, with a median survival of 33 days. Overall 30-day mortality was 38.3% and reached 27.5% in patients with CSDH. Lower survival was associated to higher absolute leucocyte count (HR 1.06; 95%CI 1.04-1.09), higher aPTT ratio (HR 3.02; 95% CI 1.01-9.08), higher serum CRP (HR 1.01; 95%CI 1.01-1.01), and unresponsive pupils (each unresponsive pupil - HR 2.65; 95%CI 1.50-4.68). Lower absolute platelet count was associated with a modest increase in survival rates (every 1000 platelets - HR 0.99; 95%CI 0.97-0.99).&#x0D; Conclusion: Outcomes following surgical treatment of ICH in patients with cancer impose significant morbidity and mortality. Altered pupillary reflexes, coagulopathies, and increased inflammatory response were predictors of mortality for any type of ICH. CSDH was the most common type of ICH and had higher mortality rates than non-oncologic patients.

The synthetic cannabinoid 5F-MDMB-PICA: A case series

5F-MDMB-PICA has been detected in products sold on the internet as well as in biological samples since 2016. It is associated with serious adverse health and behavioral effects and even death.Herein we report on twelve cases with proven 5F-MDMB-PICA consumption, including three fatalities, four cases of driving under the influence of drugs and five other criminal acts. In these cases, 5F-MDMB-PICA was detected in postmortem blood or serum. Concentrations ranged from 0.1–16ng/mL. In some blood (serum) and urine samples, the hydrolysis metabolite of 5F-MDMB-PICA (M12) could also be detected.In this case series, co-consumption with other drugs occurred in 9 of 12 cases, most commonly alcohol, cannabis and other contemporary SCs. In five cases, 4F-MDMB-BINACA was also detected.The described cases demonstrate various adverse effects that might be associated with 5F-MDMB-PICA. Observed physical adverse effects were mainly balance deficiencies and ocular effects such as reddened conjunctivae, glassy eyes and delayed or unresponsive pupil light reactions. Observed mental and behavioral effects were mainly changing moods, aggression, confusion, erratic behavior, mental leaps, disorientation, slowed reaction, logorrhea and slurred speech.Due to the fast changing market of synthetic cannabinoids, data on such new appearing substances are basically scarce. Because of the limited number of studies on pharmacological properties of synthetic cannabinoids, reports of findings in human samples along with corresponding case history descriptions can be valuable for the interpretation of upcoming routine cases.

COCAINE-INDUCED AORTIC DISSECTION AND LEFT HEMOTHORAX

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Aortic dissection is a rare and potentially lethal complication of cocaine use. Cocaine has been reported as a precipitating factor in 0.5% to 37% of aortic dissections depending on the patient population. Aortic dissection is seen at a frequency of 2.6-3.5 per 100,000 patient admitted for chest pain. Cocaine use is also associated with alveolar hemorrhage and hemothorax. We report a case of aortic dissection causing unilateral hemothorax and alveolar hemorrhage in a patient who was found to have smoked crack – cocaine while in the hospital for chest pain. CASE PRESENTATION: A 64 year old female with a past medical history of HTN and CAD presented to ED complaining of atypical chest pain with dyspnea following use of crack-cocaine. Her physical exam and vital signs were normal. She was admitted to cardiac telemetry unit for further work up. ACS and PE were ruled out by negative cardiac enzymes and normal V/Q scan. Forty-eight hours after admission, the patient was found unresponsive by nursing staff with a warm glass pipe at her bedside. The patient was noted to have agonal breathing with dilated and unresponsive pupils. Left sided breath sounds were absent on physical exam. She was intubated and a portable chest x-ray revealed complete white out of the L lung with mediastinal shift to the Right. Subsequent CT revealed an acute intramural hematoma of the aortic arch measuring up to 16 mm and an ascending aortic aneurysm measuring 4cm. Patient was admitted to ICU where she was found to have aortic and coronary arteries dissection with high troponin and bradycardia. On point of care US study she was found to have abdominal aortic dissection and and a large L pleural effusion. Her urine toxicology was positive for cocaine. Within 48 hours the patient expired. DISCUSSION: The exact mechanism of cocaine induced aortic dissection and hemothorax is not well known. Presumably, the sudden and profound hypertension that accompany cocaine usage causes a stressful force on the aorta intima leading to aortic dissection (5). Aortic dissection diagnosis is usually suspected clinically by obtaining detailed medical history and finding a difference of blood pressure between the patient’s arms. Widened mediastinum on chest x-ray is also suggestive of aortic dissection. Diagnosis is confirmed by TEE or CT angiography. Our case underlines the importance of maintaining a high index of suspicion for aortic dissection in patients presenting with chest pain especially in the setting of cocaine use. CONCLUSIONS: Although it is a rare cause of acute pathology, aortic dissection due to cocaine usage should be suspected in every patient admitted to the hospital for chest pain. Thorough medical history, physical exam, and imaging review are essential components for diagnosis Reference #1: Eagle, KA et al. Cocaine-related Aortic Dissection in Perspective. Circulation. 2002;105(13):1529-1530. Reference #2: Hsue, PY et al. Acute Aortic Dissection Related to Crack Cocaine. Circulation. 2002;105(13):1592-1595. Reference #3: Singh, S et al. Cocaine-related Acute Aortic Dissection: Patient Demographics and Clinical Outcomes. Canadian Journal of Cardiology. 2007;23(14):1131-1134. DISCLOSURES: No relevant relationships by Obed Adarkwah, source=Web Response No relevant relationships by Araz Baboujian, source=Web Response No relevant relationships by Sivacharan Buddhavarapu, source=Web Response No relevant relationships by Louis Gerolemou, source=Web Response No relevant relationships by Kunal Nangrani, source=Web Response No relevant relationships by Matthew Peachey, source=Web Response No relevant relationships by jad sargi, source=Web Response No relevant relationships by John Zeibeq, source=Web Response

Are unresponsive dilated pupils an indicator for brain death? An evaluation of Edinger Westphal nucleus in rabbits with brain death

Aim: To investigate a relationship between unresponsive pupils and severity of neurodegeneration in Edinger Westphal nucleus (EWN) of animals diagnosed with brain death.Material and Methods: A total of 24 New Zealand white rabbits were used. The animals were divided into three groups, as control group (n=5), sham (n=5) and subarachnoid hemorrhage (SAH) group (n=14). Pupil diameters were measured after giving 2 mL of physiological saline for sham and 2 ml non‑heparinized autologous arterial blood for the study group into the cisterna magna. Brain death was diagnosed in 10 rabbits in the SAH group. Then all animals were sacrificed. The brains, oculomotor nerves of all animals were extracted and stored in 10% formalin solutions for histopathological examination.Results:TThe mean neuron numbers of Edinger Westphal nucleus was 253±43/mm3 in the control group; 244±12/mm3 in the sham group and 236±12/mm3 in dead unresponsive animals. Pupil diameters and degenerated neuron density of EWN in control, sham and SAH groups were found as follows, respectively: 8960±990µm-3±1/mm3; 10543±1.123µm-13±4/mm3 and 13540±1.356µm-63±11/mm3 (P0.005). There was a positive relationship between degenerated neuron density of the EWN and pupil diameters (P0.001). The mean nondegenerated neuron numbers were 170±32/mm3 in unresponsive pupils of examined animals.Conclusion: In the absence of electrocardiographic/electroencephalographic functions, unresponsive pupils could not indicate real brain death.

Reversal of Severe Methanol Induced Visual Impairment Due to Prompt Hemodialysis

We report a case series of recovery from severe visual impairment due to methanol intoxication following treatment with fomepizol and prompt hemodialysis. Three adult males presented to our hospital few hours after unintended methanol intoxication. All patients reported weakness and dizziness, two of them suffered visual impairment with visual acuity loss and one of them presented complete blindness and unresponsive dilated pupils. Fundoscopy examination revealed edema of the disk margin. Their laboratory findings included severe high anion gap metabolic acidosis with elevated osmolar gap and methanol levels. All three patients were treated with fomepizole, folic acid IV, and 2-3 sessions of hemodialysis four hours each. The first session of dialysis was performed about 16 h after the methanol ingestion. They all exhibited a full recovery including the patient with the blindness who reported normal vision 20/20 with normal fundoscopic examination on discharge at the fifth day of hospitalization. This case report confirms the effectiveness of the combined treatment based on early dialysis with fomepizol in reversing the retinal impairment in methanol intoxication. The reversibility of retinal end organ damage demonstrated here raises doubts about the common thought regarding the poor outcome of methanol induced retinal end organ damage.

Predictors for outcome after surgery for traumatic acute subdural hematoma

Abstract Introduction: Acute traumatic subdural hematoma (ASDH) is one of the most frequent conditions in neurosurgery demanding emergency surgery. The aim of the study was to identify factors influencing outcome in patients who had surgery for evacuation of ASDH. Methods: From 2005 to 2012 eighty-five patients at age above 18 years had surgery for evacuation of ASDH. Outcome was measured according GOS at discharge and was dichotomized as “favorable outcome” (GOS 4 to 5) and “unfavorable outcome” (GOS 1 to 3). These factors were evaluated with univariate and logistic regression analysis for significance with outcome. Results: The mean age of the 85 patients was 62.7 years (SD±18.5). 45.9% patients were with favorable outcome and 54.1% had unfavorable outcome. Patients with GCS score 3-8 (54.1%) had 80.4% unfavorable outcome whereas 78.6% of patients with GCS score 13-15 (32.9%) had favorable outcome. All patients with nonreactive pupils (bilaterally or unilaterally - 31.8%) had unfavorable outcome whereas patients (36.5%) with both reactive pupils (36.5%) had in 80.6% favorable outcome. All patients (40%) with Rotterdam CT scores 5 and 6 had unfavorable outcome. The factors determining outcome were admission GSC score, Rotterdam CT scores, and prothrombin time. Conclusion: Patients who have GSC score of 3, unresponsive pupil(s) or have Rotterdam CT scores 5 and 6 have little chance of survival. Patients with coagulopathy have two times more unfavorable outcome. The patients with ASDH should have surgery as soon as possible after correction of vital parameters in order to avoid deterioration which can be very rapid and irreversible.

Novel Clinical Scale for Evaluating Pre-Operative Risk of Cerebral Herniation from Traumatic Epidural Hematoma.

Secondary massive cerebral infarction (MCI) is the predominant prognostic factor for cerebral herniation from epidural hematoma (EDH) and determines the need for decompressive craniectomy. In this study, we tested the clinical feasibility and reliability of a novel pre-operative risk scoring system, the EDH-MCI scale, to guide surgical decision making. It is comprised of six risk factors, including hematoma location and volume, duration and extent of cerebral herniation, Glasgow Coma Scale score, and presence of preoperative shock, with a total score ranging from 0 to 18 points. Application of the EDH-MCI scale to guide surgical modalities for initial hematoma evacuation surgery for 65 patients (prospective cohort, 2012.02-2014.01) showed a significant improvement in the accuracy of the selected modality (95.38% vs. 77.95%; p = 0.002) relative to the results for an independent set of 126 patients (retrospective cohort, 2007.01-2012.01) for whom surgical modalities were decided empirically. Results suggested that simple hematoma evacuation craniotomy was sufficient for patients with low risk scores (≤9 points), whereas decompressive craniectomy in combination with duraplasty were necessary only for those with high risk scores (≥13 points). In patients with borderline risk scores (10-12 points), those having unstable vital signs, coexistence of severe secondary brainstem injury, and unresponsive dilated pupils after emergent burr hole hematoma drainage had a significantly increased incidence of post-traumatic MCI and necessity of radical surgical treatments. In conclusion, the novel pre-operative risk EDH-MCI evaluation scale has a satisfactory predictive and discriminative performance for patients who are at risk for the development of secondary MCI and therefore require decompressive craniectomy.

Childhood drowning in South Africa: local data should inform prevention strategies.

Drowning is an important cause of childhood injury, however, little is known about drowning in Africa. The aim of this study is to investigate submersion incidents in Cape Town, South Africa and provide specific prognostic factors as well as to develop age-appropriate prevention strategies. A retrospective chart review performed at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa. Patients admitted because of 'drowning' or 'near-drowning' between January 2007 and April 2013 were included. 75 children were included. 63 (84%) survived without complications, 8 (10.7%) died and 4 (5.3%) had permanent neurological sequelae. The median age was 2.2years (range 0.1-12.4). 46 (60.5%) incidents happened in or around the home, only 14 (18.7%) were witnessed. 42 (56%) took place in a pool (29 private, 13 public). Significant predictors of the outcome were: estimated submersion time, duration of apnea, unresponsive and dilated pupils, intubation and use of inotropes. On arrival at the ER we found these significant predictors of the outcome: CPR, a GCS <5, hypothermia, bradycardia, asystole, as well as the PIM2-calculated mortality risk for patients admitted to the ICU. The majority of incidents were unwitnessed and occurred in or around the home. Prevention programs should be focused on adult supervision for younger children and creating awareness on the dangers of drowning in the home environment. While bathing in baths or buckets, children should never be left alone and parents should be made aware of the dangers. In our study, the majority of incidents occurred in swimming pools and limiting access to these could prevent many incidents of drowning among older children. Although children of all language groups are at risk for drowning, English- or Afrikaans-speaking children were particularly at risk for drowning in private pools while Xhosa-speaking children mostly drowned in baths or buckets. We also report multiple prognostic factors for the outcome, but none of them were absolute predictive of the outcome, indicating that each victim of submersion deserves full resuscitative treatment.

Cerebral edema and a transtentorial brain herniation syndrome associated with pandemic swine influenza A (H1N1) virus infection

Acute encephalitis, encephalopathy, and seizures are known rare neurologic sequelae of respiratory tract infection with seasonal influenza A and B virus, but the neurological complications of the pandemic 2009 swine influenza A (H1N1) virus, particularly in adults, are ill-defined. We document two young adults suffering from H1N1-associated acute respiratory distress syndrome and renal failure who developed cerebral edema. The patients acutely developed a transtentorial brain herniation syndrome including a unilateral third nerve palsy (dilated and unresponsive pupils), elevated intracranial pressure, coma, and radiological evidence of diffuse cerebral edema. In both patients, neurological deterioration occurred in the context of hyponatremia and a systemic inflammatory state. These patients illustrate that severe neurologic complications, including malignant cerebral edema, can occur in adults infected with H1N1 virus, and illustrate the need for close neurological monitoring of potential neurological morbidities in future pandemics.

Hypercapnic cerebral edema presenting in a woman with asthma: a case report

IntroductionCommon causes of non-traumatic acute cerebral edema include malignant hypertension, hyponatremia, anoxia, and cerebral vascular accident. The computed tomographic images and data obtained during care of the patient described in this case report provide evidence that hypercarbia can cause increased intracranial pressure and coma without permanent brain injury. Partial pressure of carbon dioxide evaluation for coma is essential to provide faster diagnosis and therapeutic correction in certain common critical disease states. We present the case of a patient in a coma associated with cerebral edema during a typical asthma exacerbation with hypercapnic respiratory failure.Case presentationAn obese 63-year-old African American woman with asthma presented to our hospital with facial swelling and shortness of breath. Immediately following intubation for hypercapnic respiratory failure, she was noted to have a dilated, unresponsive right pupil. An emergent computed tomographic head scan revealed that she had increased intracranial pressure. A neurosurgeon agreed with the computed tomography interpretation and recommended no surgical intervention. The patient's respiratory acidosis was corrected with ventilatory management over several hours in the intensive care unit. Nine and one-half hours later a follow-up head computed tomographic scan was read as normal without cerebral edema. At 12 hours, the patient's right pupil was 5 mm in diameter and reactive. By 24 hours, her pupils were symmetrically equal and reactive. Her symptoms had improved, and she was extubated. A brain magnetic resonance imaging scan revealed no abnormalities.ConclusionAlteration of consciousness related to hypercapnia during respiratory failure is not generally thought to be related to cerebral edema. Respiratory acidosis resulting from hypercarbia is known to produce carbon dioxide narcosis and coma, but no current treatment algorithm suggests that rapid hypercapnia correction can be critical to neurologic outcome. To the best of our knowledge, our case is a unique example of the physiological changes that may occur in relation to arterial carbon dioxide concentration in the normal brain in the setting of typical hypercapnic respiratory failure. Correction of respiratory acidosis reversed the neurologic symptoms and physiology causing cerebral edema and coma in our patient. Rare similar cases have been sporadically reported in the medical literature, typically in children. Our case is also unusual in that rapid deterioration and clinical status were directly observed on simultaneous computed tomographic scans. Had this patient been found unresponsive, or had she had brief respiratory or cardiac arrest, the scan could have been interpreted as global anoxic injury leading to a different therapeutic course.

Prognostic Predictors of Outcome in an Operative Series in Traumatic Brain Injury Patients

Although several prognostic factors for traumatic brain injury (TBI) have been evaluated, a useful predictive scoring model for outcome has yet to be developed for TBI patients. The aim of this study was to determine independent predictors and develop a multivariate logistic regression equation to determine prognosis in TBI patients. A total of 13 different variables were evaluated. All 84 patients in this study were retrospectively evaluated between October 2003 and January 2008 and all underwent craniectomy or craniotomy for hematoma removal and were fitted with intracranial pressure (ICP) microsensor monitors. By using univariate, multiple logistic regression and prognostic regression scoring equations it was possible to draw Receiver-Operating Characteristic curves (ROC) to predict Glasgow Outcome Scale (GOS) 6 months after TBI. We found that patients over 40 years of age (p < 0.001), unresponsive pre-op pupil reaction (p =0.001), pre-op midline shift (p =0.008), higher injury severity score (ISS; p=0.007), and craniectomy (p < 0.05) were associated with poor outcome in patients with TBI. Using ROC curve to predict the probability of unfavorable outcome, the sensitivity was 97.5% and the specificity was 90.7%. In our preliminary findings, five variables to predict poor outcomes 6 months after TBI were useful. These sensitive variables can be used as a referential guideline in our daily practice to decide whether or not to perform advanced management or avoid decompressive craniectomy.

Therapeutic Hypothermia: Treatment for Hypoxic-Ischemic Encephalopathy in the NICU

Baby M was born limp, blue, and without respiratory effort at 38 weeks gestation to a 38-year-old, gravida 5, para 1, woman. Delivery was vaginal after a rapid progression of labor leaving no opportunity for a cesarean section. No other complications were noted during labor but a large surge at delivery, later diagnosed as uterine rupture, initially raised concerns about placental abruption. Apgar scores were 1, 2, and 4 at one, five, and ten minutes, respectively. She was resuscitated in the delivery room, intubated, and transferred in critical condition to the neonatal intensive care unit (NICU) at the birth hospital. Her initial cord pH was 6.7 and was slightly improved at 7.17 on arterial blood gas after resuscitation. Our NICU team was consulted because of her severe neurologic depression. The birth hospital was within walking distance of our tertiary care center and our neurologists went to evaluate her for the hypothermia protocol. Her neurologic exam was notable for dilated and unresponsive pupils, no spontaneous movements, and diminished reflexes and tone, consistent with moderate-to-severe encephalopathy. Seizure activity began at one hour of age and consisted of lip smacking, which was later confirmed by electroencephalogram (EEG). Enrollment criteria were met based on respiratory depression at birth requiring intubation and continued need for ventilation, concern for placental abruption, cord pH less than 7, and encephalopathy on exam and EEG. After stabilizing her airway and achieving central access to treat acidosis and seizures, the team prepared her for transfer to our NICU. At this point, the primary concern became her neurologic status.

Is the Increase in DCD Organ Donors in the United Kingdom Contributing to a Decline in DBD Donors?

Organ donation after brain death (DBD) has declined in the United Kingdom, whereas donation after cardiac death (DCD) has increased markedly. We sought to understand the reasons for the decline in DBD and determine whether the increase in DCD was a major factor. The UK Transplant Registry was analyzed to determine trends in organ donation. Data from the "Potential Donor Audit," an audit of all patients younger than 76 years who died in noncardiothoracic UK intensive care units, was analyzed to identify trends in clinical demographics and management and to determine whether potential donors (DBD and DCD) were identified and appropriate steps were taken to enable organ donation. There were 7589 (12.8 per million of population [pmp]) deceased organ donors in the United Kingdom from 1999 to 2009. The total number of deceased donors increased by 16% (to 14.9 pmp), but DBD donors decreased from 744 to 612, and the overall increase in donors was due to an 8-fold increase in DCD donors (33 in 1999 to 2000, 288 in 2008 to 2009). Analysis of the Potential Donor Audit over the 5-year period 2004 to 2005 to 2008 to 2009 showed that the number of patients dying in intensive care units who were possibly brain stem dead (comatose, apparently apnoeic with unresponsive pupils) decreased from 1929 in 2004 to 2005 to 1495 in 2008 to 2009 (22.5% reduction). The proportion of potential DBD donors who became donors increased from 45% to 51%. There is no evidence that the increase in DCD donors has contributed directly to the decline in DBD, which reflects a decrease in the number of patients with brain death.

CASE REPORT: Bilateral vision loss in a captive cheetah (Acinonyx jubatus)

AbstractThe following case report describes a 1‐year‐old female cheetah (Acinonyx jubatus) with bilateral blindness and unresponsive pupils. For comparison, a second healthy 2.5‐year‐old male cheetah without visual deficits was also examined. Clinical examination of both animals included biomicroscopy, indirect ophthalmoscopy, tonometry, and electroretinography. The young female cheetah showed no menace response, no direct or indirect pupillary light reflex, and no dazzle reflex in either eye. Fundus lesions, as detected by indirect ophthalmoscopy, are described for the female animal. In both eyes, the fundus color was green/turquoise/yellow with multiple hyperpigmented linear lesions in the tapetal area around the optic nerve. The optic nerve head was dark gray and about half the normal size suggesting bilateral optic nerve hypoplasia and retinal dysplasia or differentially optic nerve atrophy and chorioretinal scarring. The ERG had low amplitudes in the right eye but appeared normal in the left eye compared with the male cheetah. Blood levels did not suggest current taurine deficiency. This is addressed to some degree in the discussion. Bilateral optic nerve hypoplasia or optic nerve atrophy is a rare anomaly in cats and has not yet been described in a cheetah.

Poster 9: An Intermittent “Blown Pupil” in a Severe Traumatic Brain-Injured Patient Undergoing Rehabilitation: A Case Report

Setting: Inpatient rehabilitation unit. Patient: A 16-year-old male undergoing rehabilitation after severe traumatic brain injury. Case Description: The patient was transferred to the rehabilitation unit 4 months after a motor vehicle accident in which he sustained a splenic rupture, bilateral femoral, tibial, and multiple cranial fractures with a right cranial nerve VII injury. His previous hospital course was complicated by intracranial and subdural hematoma, multiple infections, bilateral pneumothoraces, hydrocephalus, and several ventriculoperitoneal (VP) shunt revisions and shunt-related complications. On admission to the rehabilitation unit the patient was unable to communicate or follow directions due to the severity of his brain injury. On the third day of rehabilitation the on-call resident was called to investigate the concerns of the nurse and parents about a new right “blown pupil.” Examination confirmed an extremely dilated and unresponsive right pupil. A stat computerized tomography (CT) of the head showed no significant changes when compared with previous CTs. No other mental status or neurologic changes were noted on exam, although he was severely cognitively impaired from his accident. Neurosurgery suggested close monitoring. 6 hours later his pupils were again symmetric. The next morning the rehabilitation residents were called again to the bedside for a right “blown pupil;” it was at this time that the cause of the intermittent mydriasis was identified. Assessment/Results: The patient's intermittent unilateral mydriasis, or “blown pupil,” was induced by the ipratropium contained in his nebulizer administered by a loose-fitting face mask. Due to a right sided seventh cranial nerve injury the patient was unable to blink his right eye (lagophthalmos), which then led to the this unilateral exposure to the nebulized anticholinergic. The nebulizers were discontinued and his pupils remained symmetric during the remainder of his rehabilitation. Conclusions: Once serious complications, such as VP shunt complication, are excluded, it is important to consider medications and other iatrogenic causes of new symptoms. To our knowledge, this is the first reported case of mydriasis from nebulized ipratropium.