The hyperdense basilar artery sign: a case of locked-in syndrome

Background

Locked-in syndrome, although a notoriously famous clinical entity, the rarity of the condition coupled with the variability of clinical features on acute presentation represents a potential diagnostic pitfall for the emergency physician.

Case

A previously healthy 25-year-old female was brought to our Emergency Department after being found unresponsive. On examination, she was conscious and alert with a Glasgow Coma Score of 9; on neurological examination, the patient was quadriplegic and unable to speak but was able to move her eyes and blink. Non-contrast brain computed tomography (CT) revealed a hyperdense basilar artery, and CT cerebral angiography confirmed basilar artery thrombosis.

Conclusion

This case highlights the need for a high index of suspicion to make a diagnosis of locked-in syndrome in the Emergency Department, especially in young patients with no apparent risk factors for an ischemic stroke. The hyperdense basilar artery sign is one of the earliest signs on non-contrast CT imaging and may be the only clue to guide further management in a patient with basilar artery occlusion.

Streptococcus pluranimalium: A novel human pathogen?

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Subdural empyema is difficult to differentiate from meningitis on clinical examination alone.

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CT or MRI imaging must be performed for definitive diagnosis.

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Prompt diagnosis, IV antibiotics and neurosurgical evacuation improve morbidity and mortality.

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Use of prophylactic anticonvulsants and wide-exposure craniotomy are recommended.

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Streptococcus pluranimalium needs to be further studied to assess for zoonotic potential.

INTRODUCTION

We present the first case of a subdural empyema caused by Streptococcus pluranimalium, in a healthy adolescent male as a possible complication of subclinical frontal sinusitis. Clinical features, diagnostic approach and management of subdural empyema are discussed.

PRESENTATION OF CASE

A 17-year-old male with a 2 day history of headache and nausea was referred to our Emergency Department (ED) as a case of possible meningitis. He was afebrile, lethargic and drowsy with significant neck stiffness on examination. Computerized tomography (CT) revealed a large frontotemporoparietal subdural fluid collection with significant midline shift. Subsequent contrast-enhanced CT established the presence of intracranial empyema; the patient underwent immediate burr-hole evacuation of the pus and received 7 weeks of intravenous antibiotics, recovering with no residual neurological deficit.

DISCUSSION

The diagnosis of subdural empyema as a complication of asymptomatic sinusitis in an immunocompetent patient with no history of fever or upper respiratory symptoms was unanticipated. Furthermore, the organism Streptococcus pluranimalium that was cultured from the pus has only been documented twice previously in medical literature to cause infection in humans, as it is primarily a pathogen responsible for infection in bovine and avian species.

CONCLUSION

Subdural empyema represents a neurosurgical emergency and if left untreated is invariably fatal. Rapid diagnosis, surgical intervention and intensive antibiotic therapy improve both morbidity and mortality.

Congenital Anomalies at Birth: A Hospital Based Study in UAE

Introduction: It is widely acknowledged that congenital anomalies heavily contribute to infant morbidity and mortality worldwide, with an estimated 9 million infants (7% of all births) born annually having a serious congenital anomaly that result in death or lifelong disability. The objective of our study was to estimate the frequency of congenital anomalies at the Gulf Medical College Hospital and Research Center, Ajman and to estimate the proportion of births with congenital anomalies per 1,000 live births. Materials and Methods: It was a Hospital-Record based descriptive study of the 1,222 consecutive live births from December 2007 to June 2008. Results: There were 84 cases of congenital anomalies among the 1,222 live births; the rate of anomalous births was 68.7 per 1,000 live births or 6.9%. Anomalies of the genitourinary system (40.5%) were the most common, followed by musculoskeletal (28.6%) and cardiovascular (10.7%). Gastrointestinal, chromosomal and multiple system anomalies accounted for 3.6% each and miscellaneous anomalies were seen in 7.1%. Central Nervous system (2.4%) anomalies were the least. Congenital hydrocele (19.0%) was seen to have the highest frequency amongst all recorded anomalies, followed by Talipes or Clubfoot (14.3%). 9.3% of the male and 4.3% of the female population of live births had a congenital anomaly. Birth Weight (p=0.005) and Gender (p=0.001) were found to have significant association with the frequency of birth defects. Maternal Age, gravidity, parity, previous abortions, VDRL and Hepatitis B status, Gestational Diabetes, Pregnancy Induced Hypertension, gestational age, maternal and infant blood group, nationality and consanguinity showed no statistically significant association with congenital anomalies. Conclusion: The proportion of congenital anomalies found in our study is alarmingly high and emphasizes the need for more accessible nationwide screening, counseling and surveillance systems. J. Nepal Paediatr. Soc. 32(2) 2012 105-112 doi: http://dx.doi.org/10.3126/jnps.v32i2.5995

Abdominal apoplexy: A rare case of spontaneous rupture of the superior mesenteric artery in a hypertensive patient

INTRODUCTION

Spontaneous rupture of an intra-abdominal visceral artery is an exceptionally rare and potentially fatal cause of abdominal apoplexy.

PRESENTATION OF CASE

We present a case of a 54-year-old hypertensive male who developed hypovolemic shock in our Emergency Department after presenting with abrupt onset of abdominal pain and diarrhea. Intra-operative findings revealed rupture of the superior mesenteric artery with massive hemoperitoneum. The bleeding vessel was ligated and the patient made a full recovery after 3 weeks in the Intensive Care Unit.

DISCUSSION

High index of suspicion is necessary for early preoperative diagnosis and must be considered in any patient with a history of hypertension presenting with abrupt abdominal pain, signs of peritoneal irritation and unexplained hypovolemic shock. Immediate resuscitation and prompt surgical control of bleeding is paramount in patient prognosis.

CONCLUSION

The seemingly unpredictable nature of abdominal apoplexy must be noted, a precipitating cause in most cases is untraceable and early diagnosis relies solely on awareness of the condition.