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Hayashi M, Ueda M, Hayashi K, Kawahara E, Azuma SI, Suzuki A, Nakaya Y, Asano R, Sato M, Miura T, Hayashi H, Hayashi K, Kobayashi Y. Case report: Clinically mild encephalitis/encephalopathy with a reversible splenial lesion: an autopsy case. Front Neurol 2024; 14:1322302. [PMID: 38239318 PMCID: PMC10794512 DOI: 10.3389/fneur.2023.1322302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/28/2023] [Indexed: 01/22/2024] Open
Abstract
Clinically mild encephalitis/encephalopathy with a reversible splenial lesion is a clinicoradiological syndrome characterized by transient neuropsychiatric symptoms and hyperintensity of the splenium of the corpus callosum on diffusion-weighted MRI. Although intramyelinic edema and inflammatory cell infiltration can be predicted by MRI, the pathology of the splenium of the corpus callosum remains unknown. We encountered a case of clinically mild encephalitis/encephalopathy with a reversible splenial lesion and hypoglycemia in a patient who died of sepsis, and an autopsy was performed. The postmortem pathological findings included intramyelinic edema, myelin pallor, loss of fibrous astrocytes, microglial reactions, and minimal lymphocytic infiltration in the parenchyma. Based on these findings, transient demyelination following cytotoxic edema in the splenium of corpus callosum was strongly considered a pathogenesis of "clinically mild encephalitis/encephalopathy with a reversible splenial lesion" associated with hypoglycemia, and it could be generalized for the disease associated with the other causes. As cytotoxic edema could be the central pathology of the disease, the recently proposed term cytotoxic lesions of the corpus callosum may be applicable to this syndrome.
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Affiliation(s)
- Maho Hayashi
- Department of Diabetes and Endocrinology, Fukui General Hospital, Egami-cho, Fukui, Japan
| | - Midori Ueda
- Department of Rehabilitation Medicine, Fukui General Hospital, Egami-cho, Fukui, Japan
| | - Koji Hayashi
- Department of Rehabilitation Medicine, Fukui General Hospital, Egami-cho, Fukui, Japan
| | - Ei Kawahara
- Department of Pathology, Fukui General Hospital, Egami-cho, Fukui, Japan
| | - Shin-ichiro Azuma
- Department of Diabetes and Endocrinology, Fukui General Hospital, Egami-cho, Fukui, Japan
| | - Asuka Suzuki
- Department of Rehabilitation Medicine, Fukui General Hospital, Egami-cho, Fukui, Japan
| | - Yuka Nakaya
- Department of Rehabilitation Medicine, Fukui General Hospital, Egami-cho, Fukui, Japan
| | - Rei Asano
- Department of Rehabilitation Medicine, Fukui General Hospital, Egami-cho, Fukui, Japan
| | - Mamiko Sato
- Department of Rehabilitation Medicine, Fukui General Hospital, Egami-cho, Fukui, Japan
| | - Toyoaki Miura
- Department of Rehabilitation Medicine, Fukui General Hospital, Egami-cho, Fukui, Japan
| | - Hiromi Hayashi
- Department of Rehabilitation Medicine, Fukui General Hospital, Egami-cho, Fukui, Japan
| | - Kouji Hayashi
- Department of Rehabilitation, Faculty of Health Science, Fukui Health Science University, Egami-cho, Fukui, Japan
| | - Yasutaka Kobayashi
- Department of Rehabilitation, Faculty of Health Science, Fukui Health Science University, Egami-cho, Fukui, Japan
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Hamid M, Benmoh Y, Bourazza A. Hypoglycemic encephalopathy with extensive brain injuries: A case report. Radiol Case Rep 2023; 18:4495-4498. [PMID: 37868008 PMCID: PMC10589743 DOI: 10.1016/j.radcr.2023.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 10/24/2023] Open
Abstract
Hypoglycemia is known as a sudden diminution in blood glucose level <50 mg/dL. Hypoglycemic encephalopathy is a metabolic encephalopathy that is usually observed in patients treated for diabetes or chronic alcoholism. Neurological manifestations may range from transient deficits to prolonged coma, depending on the duration and severity of hypoglycemia. Neuroradiological features of hypoglycemia are variable involving the cerebral white and gray matter regions. Acquired metabolic or toxic conditions can cause hypoglycemia-like damage to the cerebral white matter and basal ganglia. Widespread lesions in the brain parenchyma or basal ganglia have a poor prognosis. In this report, we present a patient with widespread brain damage secondary to profound and prolonged hypoglycemia.
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Affiliation(s)
- Mohamed Hamid
- Department of Neurology, Mohammed V Military Instruction Hospital, Rabat, Morocco
| | - Youssouf Benmoh
- Department of Neurology, Mohammed V Military Instruction Hospital, Rabat, Morocco
| | - Ahmed Bourazza
- Department of Neurology, Mohammed V Military Instruction Hospital, Rabat, Morocco
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Onder H, Comoglu S. A Rare Case of Reversible Splenial Lesion Syndrome with Extracallosal Lesions in the Setting of Deep Anemia. Asian J Neurosurg 2023; 18:684-687. [PMID: 38152507 PMCID: PMC10749833 DOI: 10.1055/s-0043-1771320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Affiliation(s)
- Halil Onder
- Neurology Clinic, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Selcuk Comoglu
- Neurology Clinic, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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Pasini F, Karantzoulis A, Fanella G, Brovelli F, Iacobucci D, Aprea V, Storti B, Santangelo F, Canonico F, Remida P, Ferrarese C, Brighina L. Hypoglycemic Encephalopathy Manifesting with Cortical Hemichorea-Hemiballismus Syndrome: A Case Report. Case Rep Neurol 2023; 15:24-30. [PMID: 36762000 PMCID: PMC9906039 DOI: 10.1159/000528880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 12/20/2022] [Indexed: 02/10/2023] Open
Abstract
Hyper-/hypoglycemic states are rare but well-established causes of hyperkinetic movements, including chorea and ballismus, usually associated with brain lesions in the basal ganglia. We report a case of hemichorea-hemiballismus (HCHB) syndrome that developed after a severe hypoglycemic episode in a 71-year-old man with poorly controlled type 2 diabetes mellitus. Uncommonly, brain MRI showed contralateral cortical-subcortical T2 and T2-FLAIR-hyperintense frontoparietal lesions, with cingulate gyrus involved, while the basal ganglia were unaffected. In patients with hypoglycemic encephalopathy associated with cortical lesions, the long-term prognosis is usually poor. Nevertheless, in our patient, the dyskinesias and the cerebral lesions progressively regressed by achieving good glycemic control. After four and 12 months, the patient's neurological examination was normal. To our knowledge, this is the first evidence of hypoglycemic etiology of cortical HCHB syndrome, supporting recent theories that cortical circuitries may independently contribute to the pathogenesis of chorea and ballismus. This is also the first report of cingulate gyrus involvement in hypoglycemic encephalopathy. Finally, this case may indicate that a subset of patients with cortical lesions due to hypoglycemia could present a good clinical outcome, likely depending on the size of the lesions and the duration and severity of the hypoglycemic episode.
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Affiliation(s)
- Francesco Pasini
- Department of Neurology, School of Medicine and Surgery, San Gerardo Hospital, ASST Monza, University of Milano-Bicocca, Monza, Italy
| | - Aristotelis Karantzoulis
- Department of Neurology, School of Medicine and Surgery, San Gerardo Hospital, ASST Monza, University of Milano-Bicocca, Monza, Italy
| | - Gaia Fanella
- Department of Neurology, School of Medicine and Surgery, San Gerardo Hospital, ASST Monza, University of Milano-Bicocca, Monza, Italy
| | - Francesco Brovelli
- Department of Neurology, School of Medicine and Surgery, San Gerardo Hospital, ASST Monza, University of Milano-Bicocca, Monza, Italy
| | - Davide Iacobucci
- Department of Neurology, School of Medicine and Surgery, San Gerardo Hospital, ASST Monza, University of Milano-Bicocca, Monza, Italy
| | - Vittoria Aprea
- Department of Neurology, School of Medicine and Surgery, San Gerardo Hospital, ASST Monza, University of Milano-Bicocca, Monza, Italy
| | - Benedetta Storti
- Department of Neurology, School of Medicine and Surgery, San Gerardo Hospital, ASST Monza, University of Milano-Bicocca, Monza, Italy
| | - Francesco Santangelo
- Department of Neurology, School of Medicine and Surgery, San Gerardo Hospital, ASST Monza, University of Milano-Bicocca, Monza, Italy
| | - Francesco Canonico
- Department of Neuroradiology, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Paolo Remida
- Department of Neuroradiology, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Carlo Ferrarese
- Department of Neurology, School of Medicine and Surgery, San Gerardo Hospital, ASST Monza, University of Milano-Bicocca, Monza, Italy
| | - Laura Brighina
- Department of Neurology, School of Medicine and Surgery, San Gerardo Hospital, ASST Monza, University of Milano-Bicocca, Monza, Italy
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Romero SH, Torres DV, Rivera DM. Bilateral middle cerebellar peduncle compromise due to hypoglycemic encephalopathy: A case report and literature review. Radiol Case Rep 2022; 17:4599-4602. [PMID: 36193280 PMCID: PMC9525810 DOI: 10.1016/j.radcr.2022.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/07/2022] [Accepted: 08/10/2022] [Indexed: 11/29/2022] Open
Abstract
Hypoglycemic encephalopathy constitutes a critical presentation of severely diminished glucose levels. We present the case of a 53-year-old male patient with a history of diabetes mellitus with hypoglycemic encephalopathy and MRI findings of bilateral middle cerebellar peduncle lesions. Common findings of hypoglycemic encephalopathy described in the literature consist of bilateral compromise of the cerebral cortex, basal ganglia, hippocampus, and long tracts of white matter. The cerebellum and brainstem are usually not affected. This is the ninth report of cerebellar peduncle compromise with hypoglycemia. As increasing evidence regarding prognosis estimation of lesion distribution arises, we consider it important to report the different cases of rare patterns of compromise.
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Sangare A, Marois C, Perlbarg V, Pyatigorskaya N, Valente M, Zyss J, Borden A, Lambrecq V, Le Guennec L, Sitt J, Weiss N, Rohaut B, Demeret S, Puybasset L, Demoule A, Naccache L. Description and Outcome of Severe Hypoglycemic Encephalopathy in the Intensive Care Unit. Neurocrit Care 2022; 38:365-377. [PMID: 36109449 DOI: 10.1007/s12028-022-01594-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Disorders of consciousness due to severe hypoglycemia are rare but challenging to treat. The aim of this retrospective cohort study was to describe our multimodal neurological assessment of patients with hypoglycemic encephalopathy hospitalized in the intensive care unit and their neurological outcomes. METHODS Consecutive patients with disorders of consciousness related to hypoglycemia admitted for neuroprognostication from 2010 to 2020 were included. Multimodal neurological assessment included electroencephalography, somatosensory and cognitive event-related potentials, and morphological and quantitative magnetic resonance imaging (MRI) with quantification of fractional anisotropy. Neurological outcomes at 28 days, 3 months, 6 months, 1 year, and 2 years after hypoglycemia were retrieved. RESULTS Twenty patients were included. After 2 years, 75% of patients had died, 5% remained in a permanent vegetative state, 10% were in a minimally conscious state, and 10% were conscious but with severe disabilities (Glasgow Outcome Scale-Extended scores 3 and 4). All patients showed pathologic electroencephalography findings with heterogenous patterns. Morphological brain MRI revealed abnormalities in 95% of patients, with various localizations including cortical atrophy in 65% of patients. When performed, quantitative MRI showed decreased fractional anisotropy affecting widespread white matter tracts in all patients. CONCLUSIONS The overall prognosis of patients with severe hypoglycemic encephalopathy was poor, with only a small fraction of patients who slowly improved after intensive care unit discharge. Of note, patients who did not improve during the first 6 months did not recover consciousness. This study suggests that a multimodal approach capitalizing on advanced brain imaging and bedside electrophysiology techniques could improve diagnostic and prognostic performance in severe hypoglycemic encephalopathy.
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Affiliation(s)
- Aude Sangare
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France.
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France.
- Institut de Neurosciences Translationnelles, Paris, France.
- Brain Institute - ICM, Sorbonne Université, Inserm U1127, CNRS UMR 7225, 47 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Clémence Marois
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
- Groupe de Recherche Clinique en Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aigue Assistance Publique, Sorbonne Université, Paris, France
| | | | - Nadya Pyatigorskaya
- Département de Neuroradiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
| | - Mélanie Valente
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Julie Zyss
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Alaina Borden
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Virginie Lambrecq
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Loic Le Guennec
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Jacobo Sitt
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
| | - Nicolas Weiss
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
- Groupe de Recherche Clinique en Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aigue Assistance Publique, Sorbonne Université, Paris, France
- Brain Liver Pitié-Salpêtrière Study Group, Centre de Recherche Saint-Antoine, Maladies Métaboliques, Biliaires et Fibro-Inflammatoire du Foie & Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Benjamin Rohaut
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Sophie Demeret
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Louis Puybasset
- Laboratoire d'Imagerie Biomédicale, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Assistance Publique-Hôpitaux de Paris, Départements Médico-Universitaires Diagnostic, Radiologie, Explorations fonctionnelles, Anatomo-pathologie, Médecine nucléaire, Paris, France
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Alexandre Demoule
- Neurophysiologie Respiratoire Expérimentale et Clinique, Institut National de la Santé et de la Recherche Médicale, Sorbonne Université, Paris, France
- Service Médecine Intensive-Réanimation, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Lionel Naccache
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
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Park S, Yu IK, Kim H. MRI Findings of Acute Hippocampal Disorders: Pictorial Essay. J Korean Soc Radiol 2022; 83:1046-1058. [PMID: 36276220 PMCID: PMC9574276 DOI: 10.3348/jksr.2021.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/29/2021] [Accepted: 09/23/2021] [Indexed: 12/05/2022]
Abstract
The hippocampus is one of the most metabolically active regions of the brain; therefore, it may be affected by various acute disorders. This study aimed to introduce and categorize various acute conditions that can involve the hippocampus and explain the findings of MRI, especially diffusion-weighted imaging (DWI). Acute hippocampal disorders are divided into six categories: infection, inflammation, metabolic, ischemic, traumatic, and miscellaneous. In this study, patients were retrospectively reviewed based on clinical findings and MRI, especially DWI. All diseases had been confirmed clinically or pathologically. Many acute hippocampal disorders overlap with the clinical manifestations. Thus, it is necessary to categorize acute hippocampal lesions and understand their specific imaging findings for differential diagnosis.
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Sirbu CA, Stefani C, Mitrică M, Toma GS, Ranetti AE, Docu-axelerad A, Manole AM, Stefan I. MRI Evolution of a Patient with Viral Tick-Borne Encephalitis and Polymorphic Seizures. Diagnostics (Basel) 2022; 12:1888. [PMID: 36010239 PMCID: PMC9406907 DOI: 10.3390/diagnostics12081888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022] Open
Abstract
Some neurotropic viruses induce specific lesions in the deep structures, such as basal ganglia and thalamus. These anatomical structures play an important role in initiating and maintaining different types of epileptic seizures. We present the case of a 25-year-old male, transferred to our clinic one week after the onset of the symptomatology, with a recent history of traveling to Turkey and Egypt. At the moment of his hospital admission, his symptoms included altered consciousness, agitation, and seizures. Shortly after, his state worsened, requiring intubation. Viral tick-borne encephalitis diagnoses were favored by the CSF (cerebrospinal fluid) analysis, EEG (Electroencephalography), MRI (magnetic resonance imaging) images presenting symmetric hyper signal in the basal ganglia, and IgM antibodies for anti-tick-borne encephalitis. These lesions persisted for several weeks, and the patient’s seizures were polymorphic, originally generalized onset motor, generalized onset non-motor, and focal myoclonic. The patient achieved his independence, seizures decreasing both in intensity and frequency; the MRI images became almost normal. The reduction in antiepileptic doses was not followed by seizure recurrence.
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Bouyaknouden D, Peddada TN, Ravishankar N, Fatima S, Fong-Isariyawongse J, Gilmore EJ, Lee JW, Struck AF, Gaspard N. Neurological Prognostication After Hypoglycemic Coma: Role of Clinical and EEG Findings. Neurocrit Care 2022; 37:273-280. [PMID: 35437670 DOI: 10.1007/s12028-022-01495-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hypoglycemic coma (HC) is an uncommon but severe clinical condition associated with poor neurological outcome. There is a dearth of robust neurological prognostic factors after HC. On the other hand, there is an increasing body of literature on reliable prognostic markers in the postanoxic coma, a similar-albeit not identical-situation. The objective of this study was thus to investigate the use and predictive value of these markers in HC. METHODS We conducted a retrospective, multicenter, cohort study within five centers of the Critical Care EEG Monitoring Research Consortium. We queried our electroencephalography (EEG) databases to identify all patients undergoing continuous EEG monitoring after admission to an intensive care unit with HC (defined as Glasgow Coma Scale < 8 on admission and a first blood glucose level < 50 mg/dL or not documented but in an obvious clinical context) between 01/01/2010 and 12/31/2020. We studied the association of findings at neurological examination (Glasgow Coma Scale motor subscale, pupillary light and corneal reflexes) and at continuous EEG monitoring(highly malignant patterns, reactivity, periodic discharges, seizures) with best neurological outcome within 3 months after hospital discharge, defined by the Cerebral Performance Category as favorable (1-3: recovery of consciousness) versus unfavorable (4-5: lack of recovery of consciousness). RESULTS We identified 60 patients (30 [50%] women; age 62 [51-72] years). Thirty-one and 29 patients had a favorable and unfavorable outcome, respectively. The presence of pupillary reflexes (24 [100%] vs. 17 [81%]; p value 0.04) and a motor subscore > 2 (22 [92%] vs. 12 [63%]; p value 0.03) at 48-72 h were associated with a favorable outcome. A highly malignant EEG pattern was observed in 7 of 29 (24%) patients with unfavorable outcome versus 0 of 31 (0%) with favorable outcome, whereas the presence of EEG reactivity was observed in 28 of 31 (90%) patients with favorable outcome versus 13 of 29 (45%) with unfavorable outcome (p < 0.001 for comparison of all background categories). CONCLUSIONS This preliminary study suggests that highly malignant EEG patterns might be reliable prognostic markers of unfavorable outcome after HC. Other EEG findings, including lack of EEG reactivity and seizures and clinical findings appear less accurate. These findings should be replicated in a larger multicenter prospective study.
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Affiliation(s)
- Douaae Bouyaknouden
- Department of Neurology, Hôpital Erasme - Cliniques Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Teja N Peddada
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Safoora Fatima
- Department of Neurology, University of Wisconsin, Madison, WI, USA
| | | | - Emily J Gilmore
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Aaron F Struck
- Department of Neurology, University of Wisconsin, Madison, WI, USA.,William S. Middleton Veterans Hospital, Madison, WI, USA
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Erasme - Cliniques Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium. .,Department of Neurology, Yale University, New Haven, CT, USA.
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Harrar D, Mondok L, Adams S, Farias-Moeller R. Zebras Seize the Day. Crit Care Clin 2022; 38:349-373. [DOI: 10.1016/j.ccc.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shah NR, Tavana S, Opoku A, Martin D. Toxic and metabolic leukoencephalopathies in emergency department patients: a primer for the radiologist. Emerg Radiol 2022; 29:545-555. [PMID: 35201508 DOI: 10.1007/s10140-022-02032-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
Abstract
One of the most common chief complaints in the emergency department (ED) is altered mental status (AMS). Imaging plays a critical role in triaging patients and identifying the etiology of AMS. Toxic and metabolic etiologies are one of the primary differential categories for AMS, leading to toxic leukoencephalopathies. Toxic leukoencephalopathies are white matter disorders that result from either exogenous or endogenous sources. Common exogeneous causes of toxic leukoencephalopathy include drugs of abuse (heroin and cocaine), alcohol, inhaled gases (carbon monoxide), industrial agents (pesticides, toluene, ethylene glycol), and neurotoxic medications (methotrexate, metronidazole, vigabatrine, etc.); endogenous causes include hyper- and hypoglycemia, hyperammonemia, hyponatremia, and uremia. The imaging findings of toxic leukoencephalopathies manifest through a combination of vasogenic and cytotoxic edema, resulting in white matter patterns. These white matter patterns have been found to be pathognomonic. In the ED setting, it is imperative to develop a diagnosis based off of the imaging due to the lack of history and context that is typically provided with a chief complaint of altered mental status (AMS). To offer expeditious and accurate diagnosis, we present the classic imaging features of toxic leukoencephalopathies and correlate these imaging findings with pathophysiology.
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Affiliation(s)
- Neal R Shah
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA.
| | - Shahrzad Tavana
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Akwasi Opoku
- Department of Radiology, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232, USA
| | - Douglas Martin
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA
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Lee YE, Lee EJ, Lee SE, Park J. Predictors of consciousness improvement in patients with hypoglycemic encephalopathy. Front Endocrinol (Lausanne) 2022; 13:956367. [PMID: 36051391 PMCID: PMC9424633 DOI: 10.3389/fendo.2022.956367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/28/2022] [Indexed: 11/17/2022] Open
Abstract
AIMS Hypoglycemic encephalopathy (HE) can cause long-lasting mental changes, disability, and even death. We aimed to investigate prognostic factors for HE and to determine when the treatment of HE becomes futile. METHODS We retrospectively evaluated the data of patients admitted for prolonged HE at Dongguk University Ilsan Hospital between December 2005 and July 2021. We assessed the Glasgow Outcome Scale (GOS) to assess functional outcome. RESULTS Forty-four patients were enrolled in the study. Thirty-two of these showed the improvement on GOS after treatment. Patients with improved consciousness had a shorter duration of hypoglycemia (1.6±1.4 vs. 7.8±15.0 hours, p = 0.04) and a lower incidence of brain lesions than those without improvements in consciousness (76.0% vs. 25.0%, p < 0.01). Patients whose lesions were detected in initial MRIs were 1.3 times less likely to recover consciousness after HE (odds ratios, 1.28; 95% CI, 1.09-1.52; p < 0.01). None of the patients recovered consciousness after 320 h. Maximum time spent to recover was 194 in patients without brain lesions and 319 in those with lesions. CONCLUSIONS Hypoglycemic brain injury detected in initial MRIs predicted poorer HE prognosis. Nevertheless, treatment should be provided for at least for 14 days after admission.
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Affiliation(s)
- Yu Eun Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Eun Ja Lee
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Seung Eun Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
- *Correspondence: Jinkyeong Park, ; Seung Eun Lee,
| | - Jinkyeong Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, South Korea
- *Correspondence: Jinkyeong Park, ; Seung Eun Lee,
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Garg D, Tomer S, Motiani R. A Sweet Imbalance: Reversible Middle Cerebellar Peduncle Signal Change in Hypoglycaemic Encephalopathy. Ann Indian Acad Neurol 2022; 25:952-954. [PMID: 36560989 PMCID: PMC9764921 DOI: 10.4103/aian.aian_292_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 12/25/2022] Open
Affiliation(s)
- Divyani Garg
- Department of Neurology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India,Address for correspondence: Dr. Divyani Garg, Assistant Professor, Department of Neurology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India. E-mail:
| | - Sagar Tomer
- Department of Radiodiagnosis, Neo Hospital, Noida, Uttar Pradesh, India
| | - Rajiv Motiani
- Department of Neurology, Neo Hospital, Noida, Uttar Pradesh, India
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Suzuki R, Sato M, Ogura M, Murofushi Y, Abe Y, Kamei K. Unilateral motor weakness with kidney failure: Answers. Pediatr Nephrol 2021; 36:4131-4134. [PMID: 34499255 DOI: 10.1007/s00467-021-05187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Ryutaro Suzuki
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Yuka Murofushi
- Division of Neurology, National Center for Child Health and Development, Tokyo, Japan
| | - Yuichi Abe
- Division of Neurology, National Center for Child Health and Development, Tokyo, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
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15
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Gaddamanugu S, Shafaat O, Sotoudeh H, Sarrami AH, Rezaei A, Saadatpour Z, Singhal A. Clinical applications of diffusion-weighted sequence in brain imaging: beyond stroke. Neuroradiology 2022; 64:15-30. [PMID: 34596716 DOI: 10.1007/s00234-021-02819-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/10/2021] [Indexed: 11/20/2022]
Abstract
Diffusion-weighted imaging (DWI) is a well-established MRI sequence for diagnosing early stroke and provides therapeutic implications. However, DWI yields pertinent information in various other brain pathologies and helps establish a specific diagnosis and management of other central nervous system disorders. Some of these conditions can present with acute changes in neurological status and mimic stroke. This review will focus briefly on diffusion imaging techniques, followed by a more comprehensive description of the utility of DWI in common neurological entities beyond stroke.
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Jeon SJ, Choi SS, Kim HY, Yu IK. Acute Acquired Metabolic Encephalopathy Based on Diffusion MRI. Korean J Radiol 2021; 22:2034-2051. [PMID: 34564957 PMCID: PMC8628163 DOI: 10.3348/kjr.2019.0303] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 11/02/2020] [Accepted: 11/20/2020] [Indexed: 11/22/2022] Open
Abstract
Metabolic encephalopathy is a critical condition that can be challenging to diagnose. Imaging provides early clues to confirm clinical suspicions and plays an important role in the diagnosis, assessment of the response to therapy, and prognosis prediction. Diffusion-weighted imaging is a sensitive technique used to evaluate metabolic encephalopathy at an early stage. Metabolic encephalopathies often involve the deep regions of the gray matter because they have high energy requirements and are susceptible to metabolic disturbances. Understanding the imaging patterns of various metabolic encephalopathies can help narrow the differential diagnosis and improve the prognosis of patients by initiating proper treatment regimen early.
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Affiliation(s)
- Se Jeong Jeon
- Department of Radiology, Wonkwang University Hospital, Iksan, Korea
| | - See Sung Choi
- Department of Radiology, Wonkwang University Hospital, Iksan, Korea
| | - Ha Yon Kim
- Department of Radiology, Eulji University Hospital, Deajeon, Korea
| | - In Kyu Yu
- Department of Radiology, Eulji University Hospital, Deajeon, Korea.
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Abstract
This article reviews diseases for which persistent signal abnormalities on diffusion-weighted imaging are the key to their diagnosis. Specifically, updated knowledge regarding the neuroimaging patterns of the following diseases is summarized: sporadic Creutzfeldt-Jakob disease, neuronal intranuclear inclusion disease, and hereditary diffuse leukoencephalopathy with axonal spheroids-colony-stimulating factor receptors/adult-onset leukoencephalopathy with axonal spheroids and pigmented glia. In addition, their differential diagnoses; clinical manifestations; and pathologic, genetic, and imaging correlates are discussed.
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Affiliation(s)
- Aya Midori Tokumaru
- Department of Diagnostic Radiology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan.
| | - Yuko Saito
- Brain Bank for Aging Research, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan
| | - Shigeo Murayma
- Brain Bank for Aging Research, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan; Brain Bank for Neurodevelopmental, Neurological and Psychiatric Disorders, United Graduate School of Child Development, Osaka University, 2-2, Yamadaoka, Suita-shi, Osaka-fu 565-0871, Japan
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Chouksey D, Rathi P, Goyal N, Sodani A. A reversible lentiform nucleus T1 hyperintensity in hypoglycemic chorea. Ann Mov Disord 2021. [DOI: 10.4103/aomd.aomd_40_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Rodríguez-Vázquez A, Vicente-Pascual M, Mayà-Casalprim G, Valldeoriola F. Neuroimaging in hypoglycaemic encephalopathy diagnosis and prognosis: a case report. Neurología (English Edition) 2020. [DOI: 10.1016/j.nrleng.2017.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Rodríguez-Vázquez A, Vicente-Pascual M, Mayà-Casalprim G, Valldeoriola F. Neuroimagen en el diagnóstico y pronóstico de la encefalopatía hipoglucémica: a propósito de un caso. Neurologia 2020; 35:131-132. [DOI: 10.1016/j.nrl.2017.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 09/20/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022] Open
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Abstract
Gyriform restricted diffusion (GRD) refers to hyperintense signal involving the cerebral cortex on diffusion-weighted images (DWI) with corresponding hypointensity on apparent diffusion coefficient (ADC) images. These changes are commonly seen following a vascular occlusion, reflecting the limitation of water molecule movement across cell membranes (restricted diffusion) due to the failure of Na+/K+-ATPase pumps (cytotoxic oedema). However, GRD can occur in several other neurological conditions as well. A thorough understanding of these conditions and their anatomic predilection plays a critical role in identifying and differentiating them from vascular thrombo-occlusion, with impact towards appropriate clinical management. This review highlights the less commonly encountered, non-stroke causes of GRD in adults with case-based examples. A tabulated chart of the patterns of cortical and subcortical involvement associated with these aetiologies is provided for a quick, pattern-based reference for daily radiological reporting.
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Affiliation(s)
- Vivek Pai
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yih Yian Sitoh
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Bela Purohit
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
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Tanitame K. A schizophrenic man with severe disorders of consciousness. Eur J Intern Med 2020; 71:85-86. [PMID: 31685350 DOI: 10.1016/j.ejim.2019.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/07/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Keizo Tanitame
- Department of Diagnostic Radiology ,Hiroshima Prefectural Hospital, 1-5-54 Ujinakanda, Minami-ku, Hiroshima, 734-8530, Japan.
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Abstract
Neuroimaging is an invaluable diagnostic tool for sorting through the vast array of etiologies that underlie altered mental status (AMS). Head computed tomography (CT) without contrast is the primary modality for evaluation of AMS and should be complemented by MR imaging in cases of negative CT but high clinical concern. Studies to maximize brain imaging efficiency and improve the yield of positive scans through the utilization of clinical and laboratory pre-scan diagnostics are ongoing. However, imaging remains the gold standard due to its rapidity with which certain diagnoses can be made or excluded.
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Affiliation(s)
- Alina Uzelac
- Neuroradiology, Department of Radiology, Zuckerberg San Francisco General Hospital, University of California, 1001 Potrero Avenue, Room 1X56, San Francisco, CA 94110, USA.
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Gugger JJ, Geocadin RG, Kaplan PW. A multimodal approach using somatosensory evoked potentials for prognostication in hypoglycemic encephalopathy. Clin Neurophysiol Pract 2019; 4:194-197. [PMID: 31886445 PMCID: PMC6921239 DOI: 10.1016/j.cnp.2019.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 12/12/2022] Open
Abstract
Hypoglycemic encephalopathy may be associated with poor neurological prognosis. Little data exists to guide prognostication in hypoglycemic encephalopathy. We describe a multimodal approach to prognostication in hypoglycemia. MRI, EEG, and SSEPs estimate severity of brain injury in hypoglycemic coma.
Objectives We present a case of a patient with hypoglycemic encephalopathy with loss of median nerve N20 somatosensory evoked potentials (SSEPs) and describe our multimodal approach to prognostication in hypoglycemic encephalopathy. Case The patient was a 67-year-old woman with type 2 diabetes and stage 5 chronic kidney disease hospitalized for hypoglycemic encephalopathy. SSEPs showed bilateral absence of the median nerve N20 response. She ultimately suffered a poor outcome. Discussion There are no high-quality evidence-based clinical, neurophysiologic, or imaging studies available to aid in neurologic outcome prediction in hypoglycemic encephalopathy. In our practice we use a multimodal approach to neurologic prognostication, similar to that used in coma after cardiac arrest that includes SSEPs, EEG, and brain MRI, which enables an estimate of the severity of brain injury. As the literature is largely based on small studies or case reports, and is extrapolated from the cardiac arrest literature, we caution against early prognostication and disposition including the withdrawal of care, to avoid a self-fulfilling prophecy.
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Affiliation(s)
- James J Gugger
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Romergryko G Geocadin
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter W Kaplan
- Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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de Oliveira AM, Paulino MV, Vieira APF, McKinney AM, da Rocha AJ, dos Santos GT, Leite CDC, Godoy LFDS, Lucato LT. Imaging Patterns of Toxic and Metabolic Brain Disorders. Radiographics 2019; 39:1672-1695. [DOI: 10.1148/rg.2019190016] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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28
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Moghaddam SM, Birbeck GL, Taylor TE, Seydel KB, Kampondeni SD, Potchen MJ. Diffusion-Weighted MR Imaging in a Prospective Cohort of Children with Cerebral Malaria Offers Insights into Pathophysiology and Prognosis. AJNR Am J Neuroradiol 2019; 40:1575-1580. [PMID: 31439630 PMCID: PMC7048462 DOI: 10.3174/ajnr.a6159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/28/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Validation of diffusion-weighted images obtained on 0.35T MR imaging in Malawi has facilitated meaningful review of previously unreported findings in cerebral malaria. Malawian children with acute cerebral malaria demonstrated restricted diffusion on brain MR imaging, including an unusual pattern of restriction isolated to the subcortical white matter. We describe the patterns of diffusion restriction in cerebral malaria and further evaluate risk factors for and outcomes associated with an isolated subcortical white matter diffusion restriction. MATERIALS AND METHODS Between 2009 and 2014, comatose Malawian children admitted to the hospital with cerebral malaria underwent admission brain MR imaging. Imaging data were compiled via NeuroInterp, a RedCap data base. Clinical information obtained included coma score, serum studies, and coma duration. Electroencephalograms were obtained between 2009 and 2011. Outcomes captured included death, neurologic sequelae, or full recovery. RESULTS One hundred ninety-four/269 (72.1%) children with cerebral malaria demonstrated at least 1 area of diffusion restriction. The most common pattern was bilateral subcortical white matter involvement (41.6%), followed by corpus callosum (37.5%), deep gray matter (36.8%), cortical gray matter (17.8%), and posterior fossa (8.9%) involvement. Sixty-one (22.7%) demonstrated isolated subcortical white matter diffusion restriction. These children had lower whole-blood lactate levels (OR, 0.9; 95% CI, 0.85-0.98), were less likely to require anticonvulsants (OR, 0.6; 95% CI, 0.30-0.98), had higher average electroencephalogram voltage (OR, 1.01; 95% CI, 1.00-1.02), were less likely to die (OR, 0.09; 95% CI, 0.01-0.67), and were more likely to recover without neurologic sequelae (OR, 3.7; 95% CI, 1.5-9.1). CONCLUSIONS Restricted diffusion is common in pediatric cerebral malaria. Isolated subcortical white matter diffusion restriction is a unique imaging pattern associated with less severe disease and a good prognosis for full recovery. The underlying pathophysiology may be related to selective white matter vulnerability.
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Affiliation(s)
- S M Moghaddam
- From the Department of Imaging Sciences (S.M.M., M.J.P.)
| | - G L Birbeck
- Department of Neurology, Department of Public Health, Center for Experimental Therapeutics (G.L.B.), University of Rochester, Rochester, New York
| | - T E Taylor
- Department of Osteopathic Medical Specialties (T.E.T., K.B.S.), Michigan State University, East Lansing, Michigan
| | - K B Seydel
- Department of Osteopathic Medical Specialties (T.E.T., K.B.S.), Michigan State University, East Lansing, Michigan
| | - S D Kampondeni
- Queen Elizabeth Central Hospital (S.D.K.), University of Malawi College of Medicine, Blantyre, Malawi
| | - M J Potchen
- From the Department of Imaging Sciences (S.M.M., M.J.P.)
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Aiba Y, Sakakibara R, Katsumata M, Watanabe Y. Diffuse Cortical Injury by Hypoglycemia. Intern Med 2019; 58:2415. [PMID: 31118389 PMCID: PMC6746653 DOI: 10.2169/internalmedicine.2623-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Yosuke Aiba
- Neurology, Internal Medicine, Sakura Medical Center, Toho University, Japan
| | - Ryuji Sakakibara
- Neurology, Internal Medicine, Sakura Medical Center, Toho University, Japan
| | - Masao Katsumata
- Gastroenterology, Internal Medicine, Sakura Medical Center, Toho University, Japan
| | - Yasuhiro Watanabe
- Metabolism, Internal Medicine, Sakura Medical Center, Toho University, Japan
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Arrabyru PR, Qureshi IA, Skalomenos L, Rodriguez GJ. Magnetic resonance imaging changes in a 69-year old man with hypoglycemia induced brain injury: case report and literature review. Pan Afr Med J 2019; 32:131. [PMID: 31223419 PMCID: PMC6561004 DOI: 10.11604/pamj.2019.32.131.17967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/09/2019] [Indexed: 11/29/2022] Open
Abstract
We present the case of a 69-year old man who was brought to the hospital after being found unconscious; last seen at baseline 9 hours prior. On admission he was found to be severely hypoglycemic and received prompt glucose administration, with no immediate neurological improvement. Stroke was suspected. A brain MRI revealed abnormal hyperintense signal involving the head and tail of the left hippocampus. After close neurological monitoring and supportive care in the ICU, his condition improved over time, leaving no residual focal deficits. This case highlights the presence of MRI changes in patients with severe hypoglycemia as it happens in hypoglycemic coma.
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Affiliation(s)
- Pranitha Reddy Arrabyru
- Neurology Department, Texas Tech University Health Sciences Center, El Paso, Texas, United States
| | - Ihtesham Aatif Qureshi
- Neurology Department, Texas Tech University Health Sciences Center, El Paso, Texas, United States
| | - Lauren Skalomenos
- Neurology Department, Texas Tech University Health Sciences Center, El Paso, Texas, United States
| | - Gustavo Jose Rodriguez
- Neurology Department, Texas Tech University Health Sciences Center, El Paso, Texas, United States
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Tong F, Zou Y, Liang Y, Lei H, Lopsong T, Liu Y, Le Grange JM, He G, Zhou Y. The Water Diffusion of Brain Following Hypoglycemia in Rats – A Study with Diffusion Weighted Imaging and Neuropathologic Analysis. Neuroscience 2019; 409:58-68. [DOI: 10.1016/j.neuroscience.2019.04.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/15/2019] [Accepted: 04/16/2019] [Indexed: 01/26/2023]
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Chuang KI, Hsieh KLC, Chen CY. Hypoglycemic encephalopathy mimicking acute ischemic stroke in clinical presentation and magnetic resonance imaging: a case report. BMC Med Imaging 2019; 19:11. [PMID: 30678650 PMCID: PMC6344988 DOI: 10.1186/s12880-019-0310-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 01/11/2019] [Indexed: 12/03/2022] Open
Abstract
Background The imaging findings of hypoglycemic encephalopathy can be considerably similar to those of ischemic infarction or toxic leukoencephalopathy. We demonstrated unusual magnetic resonance (MR) imaging features of hypoglycemic encephalopathy which can be confused with other pathology both on imaging and acute clinical presentation. The diffusion-weighted imaging (DWI) and apparent diffusion coefficients (ADC) map findings in our case further supports the hypothesis of hypoglycemia-induced “excitotoxic injury” of glial cells and myelin sheath that might protect neuron axons from intracellular edema and irreversible damage. Case presentation A 72-year-old woman presented with poor appetite and was initially drowsy at home; the symptoms progressed to loss of consciousness accompanied by mild incontinence. The initial glucose level was 44 mg/dL, but no nausea, vomiting, fever, or cold sweating was reported. Physical examination after intravenous glucose supplementation revealed the absence of focal neurological signs, facial palsy, and tongue or eye deviations. The images obtained 24 h after symptoms onset revealed symmetrical hyperintensities on DWI (b-value: 1000) associated with hypointensities on ADC map along the corticospinal tract, from the levels of the cerebral peduncle and the posterior limbs of the internal capsule to the level of the corona radiata, which may mimic the imaging findings of acute ischemic infarction or amyotrophic lateral sclerosis. The patient received sliding-scale insulin therapy and rehabilitation, and she recovered consciousness without motor function deficits after 1 month. Moreover, repeat DWI and ADC map showed the complete disappearance of the lesions. Conclusions In the phenomenon of excitotoxic injury, axons could be protected from intracellular edema and irreversible damage, which may explain the reversible clinical symptoms and imaging abnormality after controlling for blood glucose because of the preserved motor axon. The diagnosis of acute symptomatic hypoglycemic encephalopathy through clinical and imaging features can be challenging. It is crucial to differentiate it from ischemic encephalopathy since the management and clinical outcome are different. Electronic supplementary material The online version of this article (10.1186/s12880-019-0310-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kai-I Chuang
- Department of Medical Imaging, Taipei Medical University Hospital, 252 Wu Hsing Street, Taipei, 110, Taiwan
| | - Kevin Li-Chun Hsieh
- Department of Medical Imaging, Taipei Medical University Hospital, 252 Wu Hsing Street, Taipei, 110, Taiwan.,Research Center of Translational Imaging, College of Medicine, Taipei Medical University, 250 Wu Hsing Street, Taipei, 110, Taiwan.,Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, 250 Wu Hsing Street, Taipei, 110, Taiwan
| | - Cheng-Yu Chen
- Department of Medical Imaging, Taipei Medical University Hospital, 252 Wu Hsing Street, Taipei, 110, Taiwan. .,Research Center of Translational Imaging, College of Medicine, Taipei Medical University, 250 Wu Hsing Street, Taipei, 110, Taiwan. .,Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, 250 Wu Hsing Street, Taipei, 110, Taiwan.
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Kawashita T, Nakajima M, H Kaszynski R, Shirokawa M, Nakano T, Ochiai K, Inoue Y, Goto H. Persistent Vegetative State after Diabetic Ketoacidosis Triggered by an Overdose of Psychotropic Agents. Intern Med 2019; 58:247-250. [PMID: 30210110 PMCID: PMC6378160 DOI: 10.2169/internalmedicine.1041-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
A 28-year-old man with type 1 diabetes mellitus was admitted for shock and coma due to diabetic ketoacidosis. Despite aggressive treatment and management of the patient's underlying clinical issues, the patient remained in a comatose state. Further investigations revealed an excess consumption of psychotropic agents; however, there was no evidence of an insulin overdose. Physicians should be aware that, in patients who are highly dependent upon insulin, an overdose of psychotropic agents can lead to hypoxic-ischemic brain injury.
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Affiliation(s)
- Takeshi Kawashita
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Japan
| | - Richard H Kaszynski
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Japan
| | - Masamitsu Shirokawa
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Japan
| | - Tomotsugu Nakano
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Japan
| | - Koji Ochiai
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Japan
| | - Yoshitaka Inoue
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Japan
| | - Hideaki Goto
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Japan
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Koksel Y, Benson J, Huang H, Gencturk M, McKinney AM. Review of diffuse cortical injury on diffusion-weighted imaging in acutely encephalopathic patients with an acronym: "CRUMPLED". Eur J Radiol Open 2018; 5:194-201. [PMID: 30456218 PMCID: PMC6231053 DOI: 10.1016/j.ejro.2018.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 10/21/2018] [Indexed: 02/07/2023] Open
Abstract
Purpose Acute encephalopathic syndromes can present a diagnostic challenge due to the wide range of possible etiologies, which also can have vastly different outcomes. The presence of diffuse cortical injury (DCI) on diffusion-weighted imaging (DWI) can help narrow the differential diagnosis. The aim of this review is to categorize the range of possible etiologies of DCI into a useful acronym, "CRUMPLED". Methods A review of the PACS system was completed to find a characteristic example of patients with DCI on DWI from different etiologies. The diagnosis was confirmed for each example via a subsequent review of the electronic medical record used to assess for data such as biopsy results, laboratory values, and clinical correlation. The electronic exhibit intends to demonstrate several sample cases of each letter within the acronym, and to demonstrate which types of DCI are potentially reversible or irreversible. Findings/Discussion The possible etiologies of DCI on DWI can be organized using the acronym "CRUMPLED": 'C' = Creutzfeldt-jakob disease, 'R' = reversible cerebral vasoconstriction syndrome; 'U' = urea cycle disorders (hyperammonemia) and Uremia; 'M' = mitochondrial (cytopathy/encephalopathy); 'P' = prolonged seizure and posterior reversible encephalopathy (PRES); 'L' = laminar necrosis (hypoxic-ischemic encephalopathy) and liver disease (acute hepatic encephalopathy); 'E' = encephalitis (infectious meningoencephalitis); 'D' = diabetes mellitus (hypoglycemia). Other secondary imaging findings (outside of DWI) can be used to help differentiate between the aforementioned etiologies, such as the use of ADC maps, FLAIR imaging, intravenous contrast. Conclusion "CRUMPLED" is proposed as a convenient acronym for the categorization of a diverse range of acute etiologies associated with DCI on DWI, arising from varying degrees of cytotoxic edema. These etiologies can range from being potentially reversible (e.g. hyperammonemia or prolonged seizures) to irreversible (e.g. hypoxic-ischemic injury).
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Key Words
- AHE, Acute Hepatic/Hyperammonemic Encephalopathy
- Acute encephalopathy
- CJD, Creutzfeldt-Jakob disease
- DCI, Diffuse cortical injury
- DWI
- Diffuse cortical injury
- MELAS, mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes
- PRES, Posterior reversible encephalopathy syndrome
- RCVS, Reversible cerebral vasoconstriction syndrome
- UCD, Urea cycle disorders
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Affiliation(s)
- Yasemin Koksel
- Corresponding author at: Dept. of Radiology, Mayo Building, Univ. of MN, 420 Delaware St. SE, 55418, USA.
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Godinho MV, Pires CE, Hygino da Cruz LC. Hypoxic, Toxic, and Acquired Metabolic Encephalopathies at the Emergency Room: The Role of Magnetic Resonance Imaging. Semin Ultrasound CT MR 2018; 39:481-494. [DOI: 10.1053/j.sult.2018.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lee AK, Rawlings AM, Lee CJ, Gross AL, Huang ES, Sharrett AR, Coresh J, Selvin E. Severe hypoglycaemia, mild cognitive impairment, dementia and brain volumes in older adults with type 2 diabetes: the Atherosclerosis Risk in Communities (ARIC) cohort study. Diabetologia 2018; 61:1956-1965. [PMID: 29961106 PMCID: PMC6152822 DOI: 10.1007/s00125-018-4668-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/21/2018] [Indexed: 12/18/2022]
Abstract
AIMS/HYPOTHESIS We aimed to evaluate the link between severe hypoglycaemia and domain-specific cognitive decline, smaller brain volumes and dementia in adults with type 2 diabetes, which so far has been relatively poorly characterised. METHODS We included participants with diagnosed diabetes from the community-based Atherosclerosis Risk in Communities (ARIC) study. At the participants' fifth study visit (2011-2013), we examined the cross-sectional associations of severe hypoglycaemia with cognitive status, brain volumes and prior 15 year cognitive decline. We also conducted a prospective survival analysis of incident dementia from baseline, visit 4 (1996-1998), to 31 December 2013. Severe hypoglycaemia was identified, using ICD-9 codes, from hospitalisations, emergency department visits and ambulance records. Prior cognitive decline was defined as change in neuropsychological test scores from visit 4 (1996-1998) to visit 5 (2011-2013). At visit 5, a subset of participants underwent brain MRIs. Analyses were adjusted for demographics, APOE genotype, use of diabetes medication, duration of diabetes and glycaemic control. RESULTS Among 2001 participants with diabetes at visit 5 (mean age 76 years), a history of severe hypoglycaemia (3.1% of participants) was associated with dementia (vs normal cognitive status): OR 2.34 (95% CI 1.04, 5.27). In the subset of participants who had undergone brain MRI (n = 580), hypoglycaemia was associated with smaller total brain volume (-0.308 SD, 95% CI -0.612, -0.004). Hypoglycaemia was nominally associated with a 15 year cognitive change (-0.14 SD, 95% CI -0.34, 0.06). In prospective analysis (n = 1263), hypoglycaemia was strongly associated with incident dementia (HR 2.54, 95% CI 1.78, 3.63). CONCLUSIONS/INTERPRETATION Our results demonstrate a strong link between severe hypoglycaemia and poor cognitive outcomes, suggesting a need for discussion of appropriate diabetes treatments for high-risk older adults.
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Affiliation(s)
- Alexandra K Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, 2024 East Monument Street, Suite 2-600, Baltimore, MD, 21205, USA
| | - Andreea M Rawlings
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, 2024 East Monument Street, Suite 2-600, Baltimore, MD, 21205, USA
| | - Clare J Lee
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Alden L Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, 2024 East Monument Street, Suite 2-600, Baltimore, MD, 21205, USA
- Center on Aging and Health, Johns Hopkins University, Baltimore, MD, USA
| | - Elbert S Huang
- Section of Internal Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - A Richey Sharrett
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, 2024 East Monument Street, Suite 2-600, Baltimore, MD, 21205, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, 2024 East Monument Street, Suite 2-600, Baltimore, MD, 21205, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, 2024 East Monument Street, Suite 2-600, Baltimore, MD, 21205, USA.
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Morgan RK, Cortes Y, Murphy L. Pathophysiology and aetiology of hypoglycaemic crises. J Small Anim Pract 2018; 59:659-669. [PMID: 30102417 PMCID: PMC7166581 DOI: 10.1111/jsap.12911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 04/24/2018] [Accepted: 06/15/2018] [Indexed: 01/09/2023]
Abstract
Hypoglycaemia is a common, life-threatening complication that occurs as a component of a wide variety of disease processes. Despite its frequent occurrence, information concerning the aetiology, characteristics and outcomes of hypoglycaemic crises in veterinary medicine is limited. This review summarises the current understanding of the pathophysiology of hypoglycaemia, the body's counter-regulatory response, underlying aetiologies, diagnosis and treatment. Disease mechanisms are discussed and published evidence in veterinary literature regarding prognostic indicators, prevalence, diagnosis and treatment is examined for hypoglycaemia-related disease processes including insulinoma, glucose-lowering toxins and medications.
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Affiliation(s)
- R K Morgan
- Metropolitan Veterinary Associates, Norristown, Pennsylvania, USA
| | - Y Cortes
- Emergency Department, Oradell Animal Hospital, Paramus, New Jersey, USA
| | - L Murphy
- Veterinary Specialty Center of Delaware, New Castle, Delaware, USA
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Holstein A, Zimmer M, Rohde M, Frier BM. Permanent brain damage following parasuicide with severe insulin-induced hypoglycaemia. Acta Diabetol 2018; 55:873-875. [PMID: 29732467 DOI: 10.1007/s00592-018-1148-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Andreas Holstein
- First Department of Medicine, Lippe-Detmold Hospital, Röntgenstr. 18, 32756, Detmold, Germany.
| | - Markus Zimmer
- Department of Radiology, Lippe-Detmold Hospital, Detmold, Germany
| | - Mathias Rohde
- Department of Neurology, Lippe-Detmold Hospital, Detmold, Germany
| | - Brian M Frier
- The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, Scotland, UK
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Torres C, Zakhari N, Symons S, Nguyen TB. Imaging the Unconscious “Found Down” Patient in the Emergency Department. Neuroimaging Clin N Am 2018; 28:435-51. [DOI: 10.1016/j.nic.2018.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Adam G, Ferrier M, Patsoura S, Gramada R, Meluchova Z, Cazzola V, Darcourt J, Cognard C, Viguier A, Bonneville F. Magnetic resonance imaging of arterial stroke mimics: a pictorial review. Insights Imaging 2018; 9:815-31. [PMID: 29934921 DOI: 10.1007/s13244-018-0637-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/23/2018] [Accepted: 05/14/2018] [Indexed: 12/18/2022] Open
Abstract
Acute ischaemic stroke represents the most common cause of new sudden neurological deficit, but other diseases mimicking stroke happen in about one-third of the cases. Magnetic resonance imaging (MRI) is the best technique to identify those 'stroke mimics'. In this article, we propose a diagnostic approach of those stroke mimics on MRI according to an algorithm based on diffusion-weighted imaging (DWI), which can be abnormal or normal, followed by the results of other common additional MRI sequences, such as T2 with gradient recalled echo weighted imaging (T2-GRE) and fluid-attenuated inversion recovery (FLAIR). Analysis of the signal intensity of the parenchyma, the intracranial arteries and, overall, of the veins, is crucial on T2-GRE, while anatomic distribution of the parenchymal lesions is essential on FLAIR. Among stroke mimics with abnormal DWI, T2-GRE demonstrates obvious abnormalities in case of intracerebral haemorrhage or cerebral amyloid angiopathy, but this sequence also allows to propose alternative diagnoses when DWI is negative, such as in migraine aura or headaches with associated neurological deficits and lymphocytosis (HaNDL), in which cortical venous prominence is observed at the acute phase on T2-GRE. FLAIR is also of major interest when DWI is positive by better showing evocative distribution of cerebral lesions in case of seizure (involving the hippocampus, pulvinar and cortex), hypoglycaemia (bilateral lesions in the posterior limb of the internal capsules, corona radiata, striata or splenium of the corpus callosum) or in posterior reversible encephalopathy syndrome (PRES). Other real stroke mimics such as mitochondrial myopathy, encephalopathy, lactic acidosis, stroke-like episodes (MELAS), Susac's syndrome, brain tumour, demyelinating diseases and herpes simplex encephalitis are also included in our detailed and practical algorithm. KEY POINTS: • About 30% of sudden neurological deficits are due to non-ischaemic causes. • MRI is the best technique to identify stroke mimics. • Our practical illustrated algorithm based on DWI helps to recognise stroke mimics.
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Morales H, Kong M. Stroke Mimics: The Quest for Leptomeningeal Anastomoses and Isolated Diffusion-Weigthed MR Signal. Semin Ultrasound CT MR 2018; 39:425-440. [PMID: 30244758 DOI: 10.1053/j.sult.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Stroke is caused by occlusion of a medium- or large-sized vessel in the brain. The treatment with either intravenous or intra-arterial thrombolysis is based on an accurate and time-sensitive diagnosis. On clinical and imaging grounds a number of entities-seizures, toxic-metabolic, infectious, or demyelinating diseases-can mimic stroke. Identifying them is paramount as the treatment differs significantly. Prior imaging reviews have focused on the nonterritorial distribution of these mimics. However, some important questions arise here. Are the vascular territories and their boundaries invariable in the human brain? Where should we draw the lines separating arterial territories? van der Zwan and colleagues addressed these questions decades ago. For him and others, the leptomeningeal anastomoses-a contentious concept for some but increasingly linked to collateral flow in stroke-is an important anatomic structure with significant variations in their distribution and pathophysiology. Variations in blood supply appear larger that traditionally taught. We revisit this concept and entertained their implications in cases of stroke mimics. For instance, the distribution of abnormalities in some toxic-metabolic processes appear to correlate with areas where rich leptomeningeal anastomoses are expected. We will also explore the concept of hyperintense signal on diffusion weighted-imaging with no correlated changes on apparent diffusion coefficient maps. We name this finding as "isolated DWI signal" and lay-out its importance in the recognition of many entities mimicking stroke. Taking together, the discussed anatomic and imaging concepts will help radiologists and clinicians to recognize not only the common but the unusual entities imitating stroke in the emergency room.
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Affiliation(s)
- Humberto Morales
- Section of Neuroradiology, University of Cincinnati Medical Center.
| | - Marshall Kong
- Section of Neuroradiology, University of Cincinnati Medical Center
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Matsuda M, Takesako S, Nakazaki M, Nandate T, Umehara F. [Portal-systemic encephalopathy with bilateral thalamic and internal capsule lesions using diffusion-weighted MRI in a super-aged patient]. Rinsho Shinkeigaku 2017; 57:759-763. [PMID: 29187686 DOI: 10.5692/clinicalneurol.cn-001068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We describe the case of a 90-year-old woman who was hospitalized in July 2016 and subsequently experienced a sudden decline in consciousness level resulting in a state of deep coma. Involuntary movements were not observed, and bilateral Babinski signs were inconclusive. Diffusion-weighted MRI (DWI) of the brain showed bilateral hyperintensity in the thalamus and internal capsule, laboratory testing detected high levels of plasma ammonia, and an electroencephalogram showed delta waves and triphasic waves predominantly in the frontal lobe. Based on these results, treatment for hepatic encephalopathy was administered, which led to an improvement in consciousness level, a decrease in plasma ammonia levels, and a normalization in the DWI scan. Abdominal computed tomography scan showed no abnormality in the liver, but revealed an abnormal blood vessel leading from the ileocolic vein to the inferior vena cava; the patient was diagnosed with portal-systemic encephalopathy. In deep coma patients, acute encephalopathy with hyperammonemia is important for differential diagnosis when DWI shows high-density legions in the thalamus and internal capsule.
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Yedavalli V, Nyberg EM, Chow DS, Thaker AA. Beyond the embolus: "do not miss" diffusion abnormalities of ischaemic and non-ischaemic neurological disease. Insights Imaging 2017; 8:573-580. [PMID: 28986862 PMCID: PMC5707221 DOI: 10.1007/s13244-017-0574-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/21/2017] [Accepted: 09/04/2017] [Indexed: 11/23/2022] Open
Abstract
Abstract Given the rapid evolution and technological advances in the diagnosis and treatment of acute ischaemic stroke (AIS), including the proliferation of comprehensive stroke centres and increasing emphasis on interventional stroke therapies, the need for prompt recognition of stroke due to acute large vessel occlusion has received significant attention in the recent literature. Diffusion-weighted imaging (DWI) is the gold standard for the diagnosis of acute ischaemic stroke, as images appear positive within minutes of ischaemic injury, and a high signal-to-noise ratio enables even punctate infarcts to be readily detected. DWI lesions resulting from a single arterial embolic occlusion or steno-occlusive lesion classically lateralise and conform to a specific arterial territory. When there is a central embolic source (e.g. left atrial thrombus), embolic infarcts are often found in multiple vascular territories. However, ischaemic disease arising from aetiologies other than arterial occlusion will often not conform to an arterial territory. Furthermore, there are several important entities unrelated to ischaemic disease that can present with abnormal DWI and which should not be confused with infarct. This pictorial review explores the scope and typical DWI findings of select neurologic conditions beyond acute arterial occlusion, which should not be missed or misinterpreted. Teaching points • DWI abnormalities due to acute arterial occlusion must be promptly identified. • DWI abnormalities not due to arterial occlusion will often not conform to an arterial territory. • Several important non-ischaemic entities can present on DWI and should not be confused with infarct.
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Affiliation(s)
- Vivek Yedavalli
- Department of Diagnostic Radiology, Advocate Illinois Masonic Medical Center, Chicago, IL, 60657, USA
| | - Eric M Nyberg
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Daniel S Chow
- Department of Radiological Sciences, UC Irvine Health School of Medicine, Orange, CA, 92868, USA
| | - Ashesh A Thaker
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, 80045, USA.
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Talamanca LF, Pasquini L, Napolitano A, Longo D. MRI in medium-chain acyl-coenzyme a dehydrogenase deficiency: neuroimaging during the first month. J Pediatr Endocrinol Metab 2017; 30:905-908. [PMID: 28753542 DOI: 10.1515/jpem-2017-0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 07/03/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Medium-chain acyl-coenzyme A dehydrogenase (MCAD) is the most common genetic disorder of fatty acid oxidation, which presents before the age of 2 with the onset of acute hypoketotic hypoglycemia, and is typically precipitated by stress. CASE PRESENTATION We report serial brain magnetic resonance imaging (MRI) changes, including MR spectroscopy (MRS) and diffusion weighted imaging (DWI), in a patient with a classical MCAD presentation, compared with five healthy controls. CONCLUSIONS Through this unique case we analyze the evolution of radiological findings during the first month of illness and we highlight the pivotal role of MRI, especially DWI, in the early diagnosis of the decompensated state of the disease.
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Barbara G, Mégarbane B, Argaud L, Louis G, Lerolle N, Schneider F, Gaudry S, Barbarot N, Jamet A, Outin H, Gibot S, Bollaert PE. Functional outcome of patients with prolonged hypoglycemic encephalopathy. Ann Intensive Care 2017; 7:54. [PMID: 28534234 DOI: 10.1186/s13613-017-0277-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 05/08/2017] [Indexed: 11/22/2022] Open
Abstract
Background Little is known about the causes, clinical course and long-term outcome of comatose patients with prolonged hypoglycemic encephalopathy. Methods In a multicenter retrospective study conducted in patients hospitalized from July 1, 2004, to July 1, 2014, we investigated functional long-term prognosis and identified prognosis factors of patients admitted in an intensive care unit (ICU) with prolonged neurological manifestations related to hypoglycemia. Eligible patients were adults admitted to the ICU with a Glasgow Coma Score <8 due to hypoglycemia and persistent consciousness disorders after normalizing blood glucose levels. Patients with possible other causes of consciousness disorders, previous cognitive disorders, hypothermia <35 °C or circulatory arrest within 24 h after ICU admission, were excluded. Follow-up phone call was used to determine patients’ functional outcome using modified Rankin Scale (mRS) at a minimum of 1-year follow-up with mRS 0–3 defining good and mRS 4–6 poor outcomes. Results Forty-nine patients were included. Causes of hypoglycemia were various, mainly including insulin or oral antidiabetic drugs abuse (65%) and neuroendocrine carcinoma (16%). Twenty (41%) patients died in the ICU, two (4%) patients further died and nine (18%) patients had a poor outcome at long-term follow-up. Five patients discharged from the ICU with mRS > 3 improved enough to be in the good outcome group 1 year later. Twenty-two (45%) patients underwent therapeutic limitation, mainly related to no expected hope for improvement. On multivariate analysis, only low mRS prior to ICU admission (OR 2.6; 95% CI 1.1–6.3; P = 0.03) and normal brain imaging (OR 7.1; 95% CI 1.1–44; P = 0.03) were significantly predictive of a good outcome. All patients (n = 15) who remained hypoglycemic >480 min had a poor outcome. Conclusion Poor outcome was observed in about 60% of this population of hypoglycemic encephalopathy. However, some patients can recover satisfactorily over time.
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Park SE, Choi DS, Shin HS, Baek HJ, Choi HC, Kim JE, Choi HY, Park MJ. Splenial Lesions of the Corpus Callosum: Disease Spectrum and MRI Findings. Korean J Radiol 2017; 18:710-721. [PMID: 28670166 PMCID: PMC5447647 DOI: 10.3348/kjr.2017.18.4.710] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 12/18/2016] [Indexed: 11/17/2022] Open
Abstract
The corpus callosum (CC) is the largest white matter structure in the brain, consisting of more than 200–250 million axons that provide a large connection mainly between homologous cerebral cortical areas in mirror image sites. The posterior end of the CC is the thickest part, which is called the splenium. Various diseases including congenital to acquired lesions including congenital anomalies, traumatic lesions, ischemic diseases, tumors, metabolic, toxic, degenerative, and demyelinating diseases, can involve the splenium of the CC and their clinical symptoms and signs are also variable. Therefore, knowledge of the disease entities and the imaging findings of lesions involving the splenium is valuable in clinical practice. MR imaging is useful for the detection and differential diagnosis of splenial lesions of the CC. In this study, we classify the disease entities and describe imaging findings of lesions involving the splenium of the CC based on our experiences and a review of the literature.
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Affiliation(s)
- Sung Eun Park
- Department of Radiology, Gyeongsang National University School of Medicine, Jinju 52727, Korea
| | - Dae Seob Choi
- Department of Radiology, Gyeongsang National University School of Medicine, Jinju 52727, Korea.,Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju 52727, Korea
| | - Hwa Seon Shin
- Department of Radiology, Gyeongsang National University School of Medicine, Jinju 52727, Korea
| | - Hye Jin Baek
- Department of Radiology, Gyeongsang National University School of Medicine, Jinju 52727, Korea
| | - Ho Cheol Choi
- Department of Radiology, Gyeongsang National University School of Medicine, Jinju 52727, Korea
| | - Ji Eun Kim
- Department of Radiology, Gyeongsang National University School of Medicine, Jinju 52727, Korea
| | - Hye Young Choi
- Department of Radiology, Gyeongsang National University School of Medicine, Jinju 52727, Korea
| | - Mi Jung Park
- Department of Radiology, Gyeongsang National University School of Medicine, Jinju 52727, Korea
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Helleskov A, Melikyan M, Globa E, Shcherderkina I, Poertner F, Larsen AM, Filipsen K, Brusgaard K, Christiansen CD, Hansen LK, Christesen HT. Both Low Blood Glucose and Insufficient Treatment Confer Risk of Neurodevelopmental Impairment in Congenital Hyperinsulinism: A Multinational Cohort Study. Front Endocrinol (Lausanne) 2017; 8:156. [PMID: 28740482 PMCID: PMC5502348 DOI: 10.3389/fendo.2017.00156] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 06/21/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND/AIMS Congenital hyperinsulinism (CHI) is a heterogeneous disease most frequently caused by KATP-channel (ABCC8 and KCNJ11) mutations, with neonatal or later onset, variable severity, and with focal or diffuse pancreatic involvement as the two major histological types. CHI confers a high risk of neurological impairment; however, sparsely studied in larger patient series. We assessed the neurodevelopmental outcome in children with CHI at follow-up in a mixed international cohort. METHODS In two hyperinsulinism expert centers, 75 CHI patients were included (Russian, n = 33, referred non-Scandinavian, treated in Denmark n = 27, Scandinavian, n = 15). Hospital files were reviewed. At follow-up, neurodevelopmental impairment and neurodevelopmental, cognitive and motor function scores were assessed. RESULTS Median (range) age at follow-up was 3.7 years (3.3 months-18.2 years). Neurodevelopmental impairment was seen in 35 (47%). Impairment was associated with abnormal brain magnetic resonance imaging (MRI); odds ratio (OR) (95% CI) 15.0 (3.0-74.3), p = 0.001; lowest recorded blood glucose ≤1 mmol/L; OR 3.8 (1.3-11.3), p = 0.015, being non-Scandinavian patient, OR 3.8 (1.2-11.9), p = 0.023; and treatment delay from first symptom to expert center >5 days; OR 4.0 (1.0-16.6), trend p = 0.05. In multivariate analysis (n = 31) for early predictors with exclusion of brain MRI, treatment delay from first symptom to expert center >5 days conferred a significantly increased risk of neurodevelopment impairment, adjusted OR (aOR) 15.6 (1.6-146.7), p = 0.016, while lowest blood glucose ≤1 mmol/L had a trend toward increased risk, aOR 3.5 (1.1-14.3), p = 0.058. No associations for early vs. late disease onset, KATP-channel mutations, disease severity, focal vs. diffuse disease, or age at follow-up were seen in uni- or multivariate analysis. CONCLUSION Not only very low blood glucose, but also insufficient treatment as expressed by delay until expert center hospitalization, increased the risk of neurodevelopmental impairment. This novel finding calls for improvements in spread of knowledge about CHI among health-care personnel and rapid contact with an expert CHI center on suspicion of CHI.
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Affiliation(s)
| | - Maria Melikyan
- Pediatric, Endocrinology Scientific Centre, Russian Academy of Science, Moscow, Russia
| | - Evgenia Globa
- Pediatric Endocrinology, Ukrainian Centre of Endocrine Surgery, Kyiv, Ukraine
| | | | - Fani Poertner
- Hans Christian Andersen Children’s Hospital, Odense, Denmark
| | | | - Karen Filipsen
- Hans Christian Andersen Children’s Hospital, Odense, Denmark
| | - Klaus Brusgaard
- Clinical Genetic Department, Odense University Hospital, Odense, Denmark
| | | | | | - Henrik T. Christesen
- Hans Christian Andersen Children’s Hospital, Odense, Denmark
- *Correspondence: Henrik T. Christesen,
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Onder H. Reversible diffusion restriction in the splenium of the corpus callosum due to severe hypoglycemia: A case report and literature review. J Neuroradiol 2016; 43:419-421. [DOI: 10.1016/j.neurad.2016.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 05/20/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022]
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Codron P, Verny C. Encefalopatie metaboliche e tossiche non farmacologiche. Neurologia 2016; 16:1-12. [DOI: 10.1016/s1634-7072(16)78793-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Abnormal movements are frequently encountered in patients with brain injury hospitalized in intensive care units (ICUs), yet characterization of these movements and their underlying pathophysiology is difficult due to the comatose or uncooperative state of the patient. In addition, the available diagnostic approaches are largely derived from outpatients with neurodegenerative or developmental disorders frequently encountered in the outpatient setting, thereby limiting the applicability to inpatients with acute brain injuries. Thus, we reviewed the available literature regarding abnormal movements encountered in acutely ill patients with brain injuries. We classified the brain injury into the following categories: anoxic, vascular, infectious, inflammatory, traumatic, toxic-metabolic, tumor-related and seizures. Then, we identified the abnormal movements seen in each category as well as their epidemiologic, semiologic and clinicopathologic correlates. We propose a practical paradigm that can be applied at the bedside for diagnosing abnormal movements in the ICU. This model seeks to classify observed abnormal movements in light of various patient-specific factors. It begins with classifying the patient’s level of consciousness. Then, it integrates the frequency and type of each movement with the availability of ancillary diagnostic tests and the specific etiology of brain injury.
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Affiliation(s)
- Yousef Hannawi
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins University, Baltimore, MD, USA. .,Present address: Division of Cerebrovascular Diseases and Neurocritical Care, Department of Neurology, The Ohio State University, Columbus, OH, USA.
| | - Michael S Abers
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Romergryko G Geocadin
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Marek A Mirski
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
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