A case report of reversible posterior encephalopathy syndrome with intracranial hemorrhage in a child

INTRODUCTION

The objective is to analyze the clinical diagnosis and treatment of children with rescindable posterior encephalopathy syndrome (PRES) and intracranial hemorrhage (ICH) to improve the pediatrician's understanding of PRES combined with ICH in children.

PATIENT CONCERNS AND DIAGNOSIS

After liver transplantation, the patient developed symptoms of epilepsy and coma. Meanwhile, massive necrosis of acute cerebral infarction and small hemorrhage was observed in the left cerebellar hemisphere and left occipital lobe, respectively. The above symptoms were initially diagnosed as PRES.

INTERVENTIONS AND OUTCOMES

After adjusting the anti-rejection drug regimen, it was found that the child's neurological symptoms were relieved, and the limb motor function gradually recovered during follow-up. Imaging examination showed significant improvement on abnormal signals in brain.

CONCLUSION

In general, children with PRES may further develop ICH and contribute to a poor prognosis. Early diagnosis, detection of risk factors and timely adjustment of medication regimen are the keys to prevent irreversible brain damage.

Quantitative susceptibility mapping of the rat brain after traumatic brain injury

The primary lesion arising from the initial insult after traumatic brain injury (TBI) triggers a cascade of secondary tissue damage, which may also progress to connected brain areas in the chronic phase. The aim of this study was, therefore, to investigate variations in the susceptibility distribution related to these secondary tissue changes in a rat model after severe lateral fluid percussion injury. We compared quantitative susceptibility mapping (QSM) and R₂ * measurements with histological analyses in white and grey matter areas outside the primary lesion but connected to the lesion site. We demonstrate that susceptibility variations in white and grey matter areas could be attributed to reduction in myelin, accumulation of iron and calcium, and gliosis. QSM showed quantitative changes attributed to secondary damage in areas located rostral to the lesion site that appeared normal in R₂ * maps. However, combination of QSM and R₂ * was informative in disentangling the underlying tissue changes such as iron accumulation, demyelination, or calcifications. Therefore, combining QSM with R₂ * measurement can provide a more detailed assessment of tissue changes and may pave the way for improved diagnosis of TBI, and several other complex neurodegenerative diseases.

Recent advances in our understanding of neurodevelopmental outcomes in congenital heart disease

PURPOSE OF REVIEW

Patients with congenital heart disease (CHD) suffer from a pattern of neurodevelopmental abnormalities including deficits in language and executive function. In this review, we summarize recent studies that examine these outcomes, their risk factors, possible biomarkers, and attempts to develop therapeutic interventions.

RECENT FINDINGS

The latest literature has highlighted the role of genetics in determining neurologic prognosis, as we have increased our understanding of potentially modifiable perioperative risk factors. The role of potentially neurotoxic medical therapies has become more salient. One recent focus has been how neurodevelopment affects quality of life and leads to a high prevalence of mental illness. Neuroimaging advances have provided new insights into the pathogenesis of deficits.

SUMMARY

Although many risk factors in CHD are not modifiable, there is promise for interventions to improve neurodevelopmental outcomes in patients with CHD. Biomarkers are needed to better understand the timing and prognosis of injury and to direct therapy. Research into psychosocial interventions is urgently needed to benefit the many survivors with CHD.

Cerebral Damage after Carbon Monoxide Poisoning: A Longitudinal Diffusional Kurtosis Imaging Study

BACKGROUND AND PURPOSE

Previous DTI cross-sectional studies have showed the cerebral damage feature was different in the three clinical stages after carbon monoxide poisoning. Diffusional kurtosis imaging (DKI) is an advanced diffusion imaging model and considered to better provide microstructural contrast in comparison with DTI parameters. The primary aim of this study was to assess microstructural changes in gray and white matter with diffusional kurtosis imaging in the acute, delayed neuropsychiatric, and chronic phases after acute carbon monoxide (CO) poisoning. The secondary aim was to relate diffusional kurtosis imaging measures to neuropsychiatric outcomes of acute carbon monoxide poisoning.

MATERIALS AND METHODS

In all, 17 patients with acute carbon monoxide poisoning and 30 sex- and age-matched healthy volunteers were enrolled in the study. Patients were scanned within 1 week, 3-8 weeks, and 6 months after acute carbon monoxide poisoning. Diffusional kurtosis imaging metrics including mean kurtosis, mean diffusivity, fractional anisotropy, and kurtosis fractional anisotropy were measured in 11 ROIs and then further correlated with neuropsychiatric scores.

RESULTS

In WM, mean kurtosis tended to increase from the acute-to-delayed neuropsychiatric phases and then decrease in the chronic phase, while in GM mean kurtosis showed a constant decline. Contrary to mean kurtosis, mean diffusivity first decreased then tended to increase in WM, while in GM, from the acute to chronic phases, mean diffusivity showed a constant increase. In both WM and GM, the fractional anisotropy and kurtosis fractional anisotropy values progressively declined with time. Kurtosis fractional anisotropy showed the best diagnostic efficiency with an area under the curve of 0.812 (P = .000). Along with neuropsychiatric scores, kurtosis fractional anisotropy of the centrum semiovale and Digit Span Backward were most relevant (r = 0.476, P = .000).

CONCLUSIONS

Longitudinally, microstructural changes were inconsistent in WM and GM with time after acute carbon monoxide poisoning. Diffusional kurtosis imaging metrics provided important complementary information to quantify the damage to cognitive impairment.

Impact of Spot Sign Etiology in Supratentorial Intracerebral Hemorrhage on Outcomes of Endoscopic Surgery

BACKGROUND

The spot sign (SS) in spontaneous intracerebral hemorrhage has been reported to be a predictive factor of poor outcome; however, how SS is related with the clinical outcome remains unclear. We aimed to investigate how etiology associated with SS affects the clinical outcome of endoscopic surgery.

METHODS

We retrospectively analyzed data from 104 patients (43 women and 61 men, mean age: 64.2 ± 11.0 years) who underwent endoscopic surgery for supratentorial intracerebral hemorrhage. The outcome variables analyzed were in-hospital mortality and modified Rankin scale score at 90 days from onset.

RESULTS

The prevalence of intraventricular hemorrhage and the mean initial modified Graeb score were greater in SS-positive than in SS-negative patients (100% vs. 47.7%, P < 0.001, and 14.4 ± 5.4 vs. 10.6 ± 6.0, P = 0.03, respectively). Postoperative rebleeding occurred more frequently in SS-positive than -negative patients (25.0% vs. 6.8%, P = 0.045). The in-hospital mortality rate was 7.7% and was not significantly different between the groups (18.8% vs. 5.7%, P = 0.09). There was a significant unfavorable shift in modified Rankin scale scores at 90 days among SS-positive patients compared with SS-negative patients in an analysis with ordinal logistic regression (adjusted common odds ratio, 4.38; 95% confidence interval 0.06-0.79, P = 0.02).

CONCLUSIONS

Intraventricular hemorrhage and postoperative rebleeding were considered to be associated with the poor outcome in patients with SS. The SS on computed tomography angiography may be valuable in predicting rebleeding and clinical outcome after surgery.

Bridging the Gap Between Diabetes and Stroke in Search of High Clinical Relevance Therapeutic Targets

Diabetes affects more than 425 million people worldwide, a scale approaching pandemic proportion. Diabetes represents a major risk factor for stroke, and therefore is actively addressed for stroke prevention. However, how diabetes affects stroke severity has not yet been extensively considered, which is surprising given the evident but understudied common mechanistic features of both pathologies. The increase in number of diabetic people, incidence of stroke in the presence of this specific risk factor, and the exacerbation of ischemic brain damage in diabetic conditions (at least in animal models) warrants the need to integrate this comorbidity in preclinical studies of brain ischemia to develop novel therapeutic approaches. Therefore, a better understanding of the commonalties involved in the course of both diseases would offer the promise of discovering novel neuroprotective pathways that would be more appropriated to clinical scenarios. In this article, we will review the relevant mechanisms that have been identified as common traits of both pathologies and that could be, to our knowledge, potential targets in both pathologies.

The Impatient Patient and the Unreceptive Receptionist: Darnley v Croydon Health Services NHS Trust [2018] UKSC 50

In Darnley v Croydon Health Services NHS Trust [2018] UKSC 50, the Supreme Court held that a hospital receptionist's misleading statement about A&E waiting times constituted a breach of duty and that the claimant's decision, based on this misinformation, to leave the hospital did not break the chain of causation when he was left paralysed as a result of a head injury. In this commentary, I argue that while the Supreme Court's treatment of duty of care and breach is, for the most part, a model of doctrinal clarity, its treatment of the causation issue is problematic as it elides the test of whether there has been a break in the chain of causation with that for remoteness. I then comment on the Supreme Court's construction of the patient in medical negligence cases.

[Emergency treatment for traumatic cardiac arrest: prognostic factors and hospital outcome]

OBJECTIVES

To identify prehospital and on-arrival factors associated with hospital outcome in patients with traumatic cardiac arrest (TCA) discharged with recovered spontaneous circulation from the emergency department.

MATERIAL AND METHODS

Multipurpose prospective cohort study of patients with TCA who recovered after treatment at a tertiary care hospital emergency department between 2003 and 2016. We gathered data on epidemiologic variables, type and cause of injuries, and prehospital and hospital emergency care. The outcome was overall hospital mortality.

RESULTS

A total of 130 TCA cases were included; 123 patients (94.6%) had received blunt trauma injuries and 65 (50%) had been in traffic accidents. The mean (SD) age was 39 (16) years, and 96 (73.8%) were male. Fifty patients (65%) were in asystole and 42 (32.3%) had pulseless electrical activity. Sixteen (12.3%) survived to be discharged; 13 of the survivors (81.3%) had recovered neurological activity. Factors that were independently associated with hospital mortality were asystole on arrival of first responders (odds ratio [OR], 25; 95% CI, 2.5-247; P=.006), nonreactive pupils on arrival at the hospital (OR, 13; 95% CI, 2.0-79; P=.006), and an Injury Severity Score over 25 (OR, 13; 95% CI, 1.8-94; P=.011).

CONCLUSION

Twelve percent of patients in this cohort survived to discharge after TCA and 8 out of 10 of the surviving patients recovered neurologically. Asystole at start of prehospital care, nonreactive pupils on hospital arrival, and a severity score over 25 may indicate poor prognosis after TCA.

Feasibility of a home-based computerized cognitive training for pediatric patients with congenital or acquired brain damage: An explorative study

Objectives

Pediatric brain damage is associated with various cognitive deficits. Cognitive rehabilitation may prevent and reduce cognitive impairment. In recent years, home-based computerized cognitive training (CCT) has been introduced in clinical practice to increase treatment opportunities for patients (telerehabilitation). However, limited research has been conducted thus far on investigating the effects of remote CCT for the juvenile population in contexts other than English-speaking countries. The aim of the present study was to investigate the feasibility of a home-based CCT in a group of Italian adolescents with brain damage. A commercially available CCT (Lumosity) developed in the English language was used due to the lack of telerehabilitation programs in the Italian language that allow stimulation of multiple cognitive domains and, at the same time, remote automatic collection of data. Thus, this investigation provides information on the possibility of introducing CCT programs available in foreign languages in countries with limited investment in the telerehabilitation field.

Methods

32 adolescents aged 11–16 with a diagnosis of congenital or acquired (either traumatic or non-traumatic) brain damage participated in the study. They received 40 training sessions (5 days/week for 8 weeks). Before starting the training program, they received face-to-face demonstration of training exercises and written instructions in their mother tongue. The feasibility of both training and study design and procedures was assessed through 9 criteria taken from extant literature.

Results

All 9 feasibility criteria were met. 31 out of the 32 participants demonstrated adherence to the training program. 94.2% of training sessions were completed in the recommended timeframe. No significant technical issue was found.

Conclusions

Telerehabilitation seems to be a feasible practice for adolescents with brain damage. A training program developed in a foreign language can be used to counter the unavailability of programs in patients’ mother tongue.

Trial registration

The trial is registered with the ISRCTN registry with study ID ISRCTN59250807

[Psychomotor development in patients with severe congenital heart disease]

AIM

Retrospective analysis of the neurodevelopment in the first two years of life in patients with severe congenital heart disease.

PATIENTS AND METHODS

Out of 89 patients with severe congenital heart disease 19 were excluded due to a history of prematurity and/or chromosomopathy, four due to a history of ischemic stroke and two due to lack of medical history. Denver Test (DT) results at 2, 6, 12, 15 and 18 months, and results in motor, language and social interaction fields were achieved.

RESULTS

59.4% were male and 40.6% female. The mean age of patients undergoing extracorporeal membrane oxygenation with pathological DT at 18 months was 3 months, compared to 11.88 months in those with normal DT. DT at 2 months was normal in 98.4% of patients, 87.5% at 6 and 12 months, 81.3% at 15 months and 85% at 18 months. Two patients with abnormal neurodevelopment normalized the DT before 24 months. The field of neurodevelopment most affected was language (15.6%), followed by motor (10.9%) and social interaction (8%).

CONCLUSIONS

Psychomotor development delay, especially in the area of language, is more frequent in patients with severe congenital heart disease. The presence of cyanosis and the need for extracorporeal membrane oxygenation were the variables that are most associated with this type of pathology.

[Non-aneurysmal subarachnoid haemorrhage secondary to panarteritis nodosa at paediatric age: a case report]

INTRODUCTION

Polyarteritis nodosa is a necrotizing vasculitis that mainly affects small and medium-sized arteries in skin and internal organs. Neurological involvement is reported in around 25% of cases: ischemic stroke is relatively common, but haemorrhagic lesions are extremely rare. Subarachnoid haemorrhage in polyarteritis nodosa is an uncommon expression of this disease, mostly associated with aneurism rupture. To the best of the authors' knowledge, there is just one published case in pediatric age with polyarteritis nodosa and subarachnoid haemorrhage with no underlying aneurismal disease.

CASE REPORT

A 7-year-old girl, who presented a non-aneurismal subarachnoid haemorrhage with intraparenchymal extension in the left basal ganglia. She was previously diagnosed with polyarteritis nodosa and prothrombotic condition, being under immunosuppressive and anti-platelet treatment at that moment.

CONCLUSIONS

The clinical features of polyarteritis nodosa together with continued anti-platelet therapy to prevent thromboembolic disease in this patient could have predisposed to the haemorrhagic event in the process of cerebral vasculitis. Standard subarachnoid haemorrhage management is initially required in such cases as cerebral aneurysms are the most common cause of haemorrhage in the context of polyarteritis nodosa disease.

[A systematic review of the characteristics and prognosis of subjects who suffer an embolic stroke of undetermined source]

INTRODUCTION

The concept of embolic stroke of undetermined source (ESUS) has recently appeared to better characterise patients with cryptogenic stroke.

PATIENTS AND METHODS

A systematic review of studies published since 2014 was performed to evaluate the epidemiology, clinical features and prognosis of patients with ESUS and their proportion among patients with cryptogenic stroke.

RESULTS

Ten studies were identified with a total of 14,810 patients. The frequency of ESUS varied between 6% and 42%. We observed a high percentage of patients with cryptogenic stroke who met ESUS criteria (37-82%). The mean age of these patients was 65-68 years. The mean severity of the stroke, as measured using the National Institutes of Health Stroke Scale, was found to be 3-7 points. A high degree of variability was seen in the proportion of atrial fibrillation (detected during follow-up) related to the electrocardiogram monitoring technique. In five studies, some minor source of cardioembolism was observed in one out of every two patients, the most frequent being the persistence of patent foramen ovale. The risk of recurrence was 5-14.5%.

CONCLUSION

The application of the new ESUS criteria provides a better definition of patients with cryptogenic stroke. Applying the concept of ESUS requires not only adequate electrocardiogram monitoring, but also routine complementary examinations to rule out the presence of minor sources of cardioembolism and other sources of embolism other than atrial fibrillation.

[Childhood ischemic cerebrovascular disease in a paediatric emergency service: a descriptive study]

AIM

To describe the clinical presentation, risk factors and complementary tests in patients of our paediatric emergency service with a final diagnosis of ischemic stroke.

PATIENTS AND METHODS

Retrospective, analytical and observational study, performed in a Paediatric Emergency Service of a tertiary-level hospital. We included patients aged 1 month to 14 years during a 12-years period with a final diagnosis of ischemic cerebrovascular disease (CVD). We analyzed personal history, symptomatology and initial complementary tests.

RESULTS

Twelve patients were included, 66% males, with a median age of 77 months. 42% had remarkable history. The most frequent clinical manifestation was motor disorder (75%). 42% were diagnosed in the first 24 hours, noticing an earlier diagnosis after the introduction of a multidisciplinary protocol about CVD. CT was performed in all patients, except in two cases in whom MRI was performed. 50% of the CTs were initially normal. In the etiological study developed lately, only 42% of the patients had risk factors. 91% had some kind of sequel.

CONCLUSIONS

CVD is uncommon in pediatrics, but with a high morbimortality, so it is important to make an early diagnosis. Clinical and personal history are fundamental, nevertheless, we mainly deal with a previously healthy child without known risk factors at the time of the first evaluation. In case of clinical suspicion of stroke, a normal initial CT does not rule out a CVD, so other additional tests, such as MRI, are necessary.

Comparison of neuroprotective efficacy of poly-arginine R18 and R18D (D-enantiomer) peptides following permanent middle cerebral artery occlusion in the Wistar rat and in vitro toxicity studies

We have previously demonstrated that arginine-rich and poly-arginine peptides possess potent neuroprotective properties, with poly-arginine peptide R18 identified as being highly effective at reducing infarct volume following middle cerebral artery occlusion (MCAO) in the Sprague Dawley rat. Since peptides synthesised using D-isoform amino acids have greater stability than L-isoform peptides due to increased resistance to proteolytic degradation, they represent potentially more effective peptide therapeutics. Therefore we compared the neuroprotective efficacy of R18 and its D-enantiomer R18D following permanent MCAO in the Wistar rat. Furthermore, as increased peptide stability may also increase peptide toxicity, we examined the effects of R18 and R18D on cultured cortical neurons, astrocytes, brain endothelial cells (bEND.3), and embryonic kidney cells (HEK293) following a 10-minute or 24-hour peptide exposure duration. The in vivo studies demonstrated that R18D resulted in a greater reduction in mean infarct volume compared to R18 (33%, p = 0.004 vs 12%, p = 0.27) after intravenous administration at 300 nmol/kg 30 minutes after MCAO. Both R18D and R18 reduced cerebral hemisphere swelling to a comparable degree (27%, p = 0.03 and 30%, p = 0.02), and improved neurological assessment scores (1.5, p = 0.02 and 2, p = 0.058 vs 3 for vehicle). No abnormal histological findings specific to peptide treatments were observed in hematoxylin and eosin stained sections of kidney, liver, spleen, lung and heart. In vitro studies demonstrated that R18 and R18D were most toxic to neurons, followed by astrocytes, HEK293 and bEND.3 cells, but only at high concentrations and/or following 24-hour exposure. These findings further highlight the neuroprotective properties of poly-arginine peptides, and indicate that R18D at the dose examined is more potent than R18 in Wistar rats, and justify continued investigation of the R18 peptide as a novel neuroprotective agent for stroke.

Life After the Neurosurgical Ward in Sub-Saharan Africa: Neurosurgical Treatment and Outpatient Outcomes in Uganda

BACKGROUND

In the past decade, neurosurgery in Uganda experienced increasing surgical volume and a new residency training program. Although research has examined surgical capacity, minimal data exist on the patient population treated by neurosurgery and their eventual outcomes in sub-Saharan Africa.

METHODS

Patients admitted to Mulago National Referral Hospital neurosurgical ward over 2 years (2014 and 2015) were documented in a prospective database. In total, 1167 were discharged with documented phone numbers and thus eligible for follow-up. Phone surveys were developed and conducted in the participant's language to assess mortality, neurologic outcomes, and follow-up health care.

RESULTS

During the study period, 2032 patients were admitted to the neurosurgical ward, 80% for traumatic brain injury. A total of 7.8% received surgical intervention. The in-hospital mortality rate was 18%. A total of 870 patients were reached for phone follow-up, a 75% response rate, and 30-day and 1-year mortality were 4% and 8%, respectively. Almost one-half of patients had not had subsequent health care after the initial encounter. Most patients had Glasgow Outcome Scale-Extended scores consistent with good recovery and mild disability, with patients experiencing trauma faring best and patients with tumor faring worst. A total of 85% felt they returned to baseline work performance, and 76% of guardians felt that children returned to baseline school performance.

CONCLUSIONS

The neurosurgical service provided health care to a large proportion of nonoperative patients. Phone surveys captured data on patients in whom nearly one-half would be lost to subsequent health care. Although mortality during initial hospitalization was high, more than 90% of those discharged survived at 1-year follow up, and the vast majority returned to work and school.

Association Between Neurological Outcomes Related to Aneurysmal Subarachnoid Hemorrhage and Onsite Access to Neurointerventional Radiology

OBJECTIVE

An onsite access to neurointerventional radiology (NIR) may be useful for managing patients with aneurysmal subarachnoid hemorrhage (aSAH) after the aneurysm-securing procedure. We aimed to assess the association between neurological outcomes related to aSAH and onsite access to NIR service.

METHODS

This was a sequential period study of 47 patients with aSAH admitted consecutively during the pre-NIR period (January 2010 to June 2012) compared with 81 patients with aSAH admitted consecutively during the post-NIR period (January 2013 to June 2015) at an academic tertiary referral intensive care unit (ICU). The primary end point was the incidence of poor neurological outcome, defined as modified Rankin scale of ≥3 at 6 months from ictus. Secondary outcomes included incidence of symptomatic vasospasm (SV) and length of stay in ICU/hospital.

RESULTS

The primary end point was observed in 18 of 47 (38%) patients during the pre-NIR period versus 25 of 81 (31%) patients during the post-NIR period (P = 0.39). The post-NIR period did not have an independent impact on neurological outcomes (adjusted odds ratio = 0.8, 95% confidence interval 0.3-2.1; P = 0.66). Of the patients who developed SV, 10 of 47 (21%) were during the pre-NIR period versus 33 of 81 (41%) during the post-NIR period (P = 0.02). The post-NIR period and higher Fisher grade were independent predictors of SV. Patients with SV had similar outcomes, but with longer stay in ICU during the post-NIR period compared with the pre-NIR period.

CONCLUSIONS

Among patients with aSAH, the post-NIR period was associated with more frequent detection of SV, more endovascular procedures, longer hospital stay, but with no appreciable improvement in neurological outcomes either overall or in the subset of patients with SV.

STUDY REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616000201471.

Pharmacological targeting of secondary brain damage following ischemic or hemorrhagic stroke, traumatic brain injury, and bacterial meningitis - a systematic review and meta-analysis

BACKGROUND

The effectiveness of pharmacological strategies exclusively targeting secondary brain damage (SBD) following ischemic stroke, aneurysmal subarachnoid hemorrhage, aSAH, intracerebral hemorrhage (ICH), traumatic brain injury (TBI) and bacterial meningitis is unclear. This meta-analysis studied the effect of SBD targeted treatment on clinical outcome across the pathological entities.

METHODS

Randomized, controlled, double-blinded trials on aforementioned entities with 'death' as endpoint were identified. Effect sizes were analyzed and expressed as pooled risk ratio (RR) estimates with 95% confidence intervals (CI). 123 studies fulfilled the criteria, with data on 66,561 patients.

RESULTS

In the pooled analysis, there was a minor reduction of mortality for aSAH [RR 0.93 (95% CI:0.85-1.02)], ICH [RR 0.92 (95% CI:0.82-1.03)] and bacterial meningitis [RR 0.86 (95% CI:0.68-1.09)]. No reduction of mortality was found for ischemic stroke [RR 1.05 (95% CI:1.00-1.11)] and TBI [RR 1.03 (95% CI:0.93-1.15)]. Additional analysis of "poor outcome" as endpoint gave similar results. Subgroup analysis with respect to effector mechanisms showed a tendency towards a reduced mortality for the effector mechanism category "oxidative metabolism/stress" for aSAH with a risk ratio of 0.86 [95% CI: 0.73-1.00]. Regarding specific medications, a statistically significant reduction of mortality and poor outcome was confirmed only for nimodipine for aSAH and dexamethasone for bacterial meningitis.

CONCLUSIONS

Our results show that only a few selected SBD directed medications are likely to reduce the rate of death and poor outcome following aSAH, and bacterial meningitis, while no convincing evidence could be found for the usefulness of SBD directed medications in ischemic stroke, ICH and TBI. However, a subtle effect on good or excellent outcome might remain undetected. These results should lead to a new perspective of secondary reactions following cerebral injury. These processes should not be seen as suicide mechanisms that need to be fought. They should be rather seen as well orchestrated clean-up mechanisms, which may today be somewhat too active in a few very specific constellations, such as meningitis under antibiotic treatment and aSAH after surgical or endovascular exclusion of the aneurysm.

Clinical Characteristics and Outcome in Elderly Patients with Traumatic Brain Injury: For Establishment of Management Strategy

In recent years, instances of neurotrauma in the elderly have been increasing. This article addresses the clinical characteristics, management strategy, and outcome in elderly patients with traumatic brain injury (TBI). Falls to the ground either from standing or from heights are the most common causes of TBI in the elderly, since both motor and physiological functions are degraded in the elderly. Subdural, contusional and intracerebral hematomas are more common in the elderly than the young as the acute traumatic intracranial lesion. High frequency of those lesions has been proposed to be associated with increased volume of the subdural space resulting from the atrophy of the brain in the elderly. The delayed aggravation of intracranial hematomas has been also explained by such anatomical and physiological changes present in the elderly. Delayed hyperemia/hyperperfusion may also be a characteristic of the elderly TBI, although its mechanisms are not fully understood. In addition, widely used pre-injury anticoagulant and antiplatelet therapies may be associated with delayed aggravation, making the management difficult for elderly TBI. It is an urgent issue to establish preventions and treatments for elderly TBI, since its outcome has been remained poor for more than 40 years.

[Infantile acquired brain injury, a personal experience. Demands from the socio-familial point of view]

We report on the experience of a family in which the youngest child has acquired brain injury and the struggle undertaken by the family to improve the neurorehabilitation resources in the public health service. The article outlines the main demands, from the socio-familial point of view, as regards the improvement of neurological rehabilitation and the resources needed to deliver it.

[Update on congenital and neonatal herpes infections: infection due to cytomegalovirus and herpes simplex]

Newborn infants are a population which is especially susceptible to viral infections that frequently affect the central nervous system. Herpes infections can be transmitted to the foetus and to the newborn infant, and give rise to severe clinical conditions with long-term sensory and cognitive deficits. Two thirds of newborn infants with encephalitis due to herpes simplex virus and half of the children with symptomatic congenital infection by cytomegalovirus develop sequelae, which results in high community health costs in the long term. Fortunately, the better knowledge about these infections gained in recent years together with the development of effective antiviral treatments have improved the patients' prognosis. Valganciclovir (32 mg/kg/day in two doses for six months) prevents the development of hypoacusis and improves the neurological prognosis in symptomatic congenital infection due to cytomegalovirus. Acyclovir (60 mg/kg/day in three doses for 2-3 weeks) prevents the development of severe forms in skin-eyes-mouth herpes disease, and lowers the rate of mortality and sequelae when the disease has disseminated and is located in the central nervous system.

[Rehabilitation treatment in child and youth patients with acquired brain injury]

Brain injury is one of the most frequent causes of death and disability in the child and adolescent. The improvement in patient care in the acute moment and the evolution of health care has meant and increase in the survival of these patients and also of the sequelae. Physical, cognitive-behavioral or organic symptoms are usually. The second is being one of the most frequent and most limiting in these patients. The brain injury affects the patient but involves the whole family because of the disability and the dependence it entails. The team is multidisciplinary and the rehabilitation physician performs the coordination functions. The family should receive assistance from the first day and are an important part in the proper evolution of patients. The treatment must be individualized and adapted for each patient and usually last between 6 and 18 months.

[Disability after stroke: a longitudinal study in moderate and severe stroke patients included in a multidisciplinary rehabilitation program]

INTRODUCTION

Stroke is a recognized cause of disability among adults. However the impact that the deficits that occur after a moderate/severe stroke have on long-term disability, as well as the response of the resultant deficits to rehabilitation, are not completely understood.

PATIENTS AND METHODS

A total of 396 patients with a modified Rankin score >= 3 after an ischemic (n = 221) or hemorrhagic (n = 175) stroke were included in this study. All patients were assessed with cognitive, behavior, emotional, motor and functional domains. All patients were assessed at baseline and six months after inclusion in a multidisciplinary rehabilitation program.

RESULTS

Risk of falling (Berg Balance Scale < 45 in 83.1% of the sample at baseline and 49.5% at follow-up) and functional problems (82.8% with a Barthel Index < 75 at baseline and 53% at follow-up) were the most prevalent deficits. Emotional disturbances were those that most improved while behavioral problems were those that did less. Although global disability improved during treatment among most patients, only 11% of our patients, especially those with preserved cognitive function at baseline, could be classified as patients with mild disability at follow-up.

CONCLUSIONS

Stroke consequences are multidimensional. The symptoms that the stroke can cause in multiple domains, as well as the pattern of recovery are widely diverse, with prevalence of behavioral long-term disturbances.

[Long-term effect of policosanol on the functional recovery of non-cardioembolic ischemic stroke patients: a one year study]

INTRODUCTION

Stroke is a leading cause of mortality and disability. Policosanol has been effective in brain ischemia models. The aim of this study is to investigate whether policosanol, added to aspirin therapy within 30 days of stroke onset, is better than placebo + aspirine for the long-term recovery of non-cardioembolic ischemic stroke subjects.

PATIENTS AND METHODS

Randomized, double-blind, placebo-controlled study. Eighty patients (mean age: 69 years) within 30 days of onset, with a modified Rankin Scale score (mRS) 2 to 4, were included. They were randomized in two groups (policosanol + aspirine or placebo + aspirine) for 12 months.

RESULTS

Policosanol + aspirine decreased significantly mean mRS from the first interim check-up (1.5 months). The treatment even improved after long-term therapy. More policosanol + aspirin (87.5%) than placebo + aspirine (0%) patients achieved mRSs <= 1. Policosanol + aspirine increased significantly Barthel Index, lowered LDL-cholesterol and increased HDL-cholesterol versus placebo + aspirin.

CONCLUSIONS

Long-term (12 months) administration of policosanol + aspirin given after suffering non-cardioembolic ischemic stroke was shown to be better than placebo + aspirin in improving functional outcomes when used among patients with non-cardioembolic ischemic stroke of moderate severity.

Alcohol Teratogenesis: Mechanisms of Damage and Strategies for Intervention

There are multiple mechanisms by which alcohol can damage the developing brain, but the type of damage induced will depend on the amount and developmental timing of exposure, along with other maternal and genetic factors. This article reviews current perspectives on how ethanol can produce neuroteratogenic effects by its interactions with molecular regulators of brain development. The current evidence suggests that alcohol produces many of its damaging effects by exerting specific actions on molecules that regulate key developmental processes (e.g., L1 cell adhesion molecule, alcohol dehydrogenase, catalase), interfering with the early development of midline serotonergic neurons and disrupting their regulatory-signaling function for other target brain structures, interfering with trophic factors that regulate neurogenesis and cell survival, or inducing excessive cell death via oxidative stress or activation of caspase-3 proteases. The current understanding of pathogenesis mechanisms suggests several strategic approaches to develop rational molecular prevention. However, the development of behavioral and biologic treatments for alcohol-affected children is crucial because it is unlikely that effective delivery of preventative interventions can realistically be achieved in ways to prevent prenatal damage in at-risk pregnancies. Toward that end, behavioral training that promotes experience-dependent neuroplasticity has been effective in a rat model of cerebellar damage induced by alcohol exposure during the period of brain development that is comparable to that of the human third trimester.

Clinical effect of mechanical fragmentation combined with recombinant tissue plasminogen activator artery thrombolysis on acute cerebral infarction

This study aims to explore the clinical effect of mechanical fragmentation combined with recombinant tissue plasminogen activator (rt-PA) artery thrombolysis on acute cerebral infarction (ACI). One hundred and thirty-two cases of ACI patients were randomly divided into an experimental group (66 patients) and a control group (66 patients). The experimental group was treated with mechanical fragmentation combined with rt-PA artery thrombolysis method, while the control group was treated with only the rt- PA artery thrombolysis method. All the patients had their basic information recorded. A computational analysis on National Institutes of Health Stroke Scale (NIHSS) scores, curative effect and bleeding data was carried out. The results showed that in the experimental group the curative effects were better and there were fewer complications. Accordingly, we conclude that mechanical fragmentation combined with rt-PA artery thrombolytic method is a safe and reliable therapy with significant curative effects. It improves the NIHSS scores of the patients markedly and reduces the incidence of subsequent pneumonia.

Endovascular Treatment with Stent-Retriever Devices for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

IMPORTANCE

Acute ischemic stroke is a leading cause of death and disability worldwide. Several recent clinical trials have shown that endovascular treatment improves clinical outcomes among patients with acute ischemic stroke.

OBJECTIVE

To provide an overall and precise estimate of the efficacy of endovascular treatment predominantly using second-generation mechanical thrombectomy devices (stent-retriever devices) compared to medical management on clinical and functional outcomes among patients with acute ischemic stroke.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Collaboration Central Register of Controlled Clinical Trials, Web of Science, and NIH ClinicalTrials.gov were searched through November 2015.

STUDY SELECTION

Searches returned 3,045 articles. After removal of duplicates, two authors independently screened titles and abstracts to assess eligibility of 2,495 potentially relevant publications. From these, 38 full-text publications were more closely assessed. Finally, 5 randomized controlled trials of endovascular treatment with predominant use of retrievable stents were selected.

DATA EXTRACTION AND SYNTHESIS

Three authors independently extracted information on participant and trial characteristics and clinical events using a standardized protocol. Random effects models were used to pool endovascular treatment effects across outcomes.

MAIN OUTCOMES AND MEASURES

The primary outcome was better functional outcome as measured on the modified Rankin Scale at 90 days of follow-up. Secondary outcomes included all-cause mortality and symptomatic intra-cerebral hemorrhage.

RESULTS

Five trials representing 1,287 patients were included. Overall, patients randomized to endovascular therapy experienced 2.22 times greater odds of better functional outcome compared to those randomized to medical management (95% CI, 1.66 to 2.98; P < 0.0001). Endovascular therapy was not associated with mortality [OR (95% CI), 0.78 (0.54, 1.12); P = 0.1056] or symptomatic intracerebral hemorrhage [OR (95% CI), 1.19 (0.69, 2.05); P = 0.5348]. Meta-regression analysis suggested that shorter times from stroke onset to groin puncture and from stroke onset to reperfusion result in better functional outcomes in ischemic stroke patients (P = 0.0077 and P = 0.0089). There were no significant differences in the beneficial effects of endovascular treatment on functional outcomes across categories of gender, age, stroke severity, ischemic changes on computed tomography, or intravenous tissue plasminogen activator administration.

CONCLUSIONS AND RELEVANCE

This meta-analysis demonstrated superior functional outcomes in subjects receiving endovascular treatment compared to medical management. Further, this analysis showed that acute ischemic stroke patients may receive enhanced functional benefit from earlier endovascular treatment.

Extracorporeal Cardiopulmonary Resuscitation (E-CPR) During Pediatric In-Hospital Cardiopulmonary Arrest Is Associated With Improved Survival to Discharge: A Report from the American Heart Association's Get With The Guidelines-Resuscitation (GWTG-R) Registry

BACKGROUND

Although extracorporeal cardiopulmonary resuscitation (E-CPR) can result in survival after failed conventional CPR (C-CPR), no large, systematic comparison of pediatric E-CPR and continued C-CPR has been reported.

METHODS AND RESULTS

Consecutive patients <18 years old with CPR events ≥10 minutes in duration reported to the Get With the Guidelines-Resuscitation registry between January 2000 and December 2011 were identified. Hospitals were grouped by teaching status and location. Primary outcome was survival to discharge. Regression modeling was performed, conditioning on hospital groups. A secondary analysis was performed with the use of propensity score matching. Of 3756 evaluable patients, 591 (16%) received E-CPR and 3165 (84%) received C-CPR only. Survival to hospital discharge and survival with favorable neurological outcome (Pediatric Cerebral Performance Category score of 1-3 or unchanged from admission) were greater for E-CPR (40% [237 of 591] and 27% [133 of 496]) versus C-CPR patients (27% [862 of 3165] and 18% [512 of 2840]). Odds ratios (ORs) for survival to hospital discharge and survival with favorable neurological outcome were greater for E-CPR versus C-CPR. After adjustment for covariates, patients receiving E-CPR had higher odds of survival to discharge (OR, 2.80; 95% confidence interval, 2.13-3.69; P<0.001) and survival with favorable neurological outcome (OR, 2.64; 95% confidence interval, 1.91-3.64; P<0.001) than patients who received C-CPR. This association persisted when analyzed by propensity score-matched cohorts (OR, 1.70; 95% confidence interval, 1.33-2.18; P<0.001; and OR, 1.78; 95% confidence interval, 1.31-2.41; P<0.001, respectively].

CONCLUSION

For children with in-hospital CPR of ≥10 minutes duration, E-CPR was associated with improved survival to hospital discharge and survival with favorable neurological outcome compared with C-CPR.

[Arteriovenous malformations of the brain: personal experience with 121 patients treated with microsurgery]

INTRODUCTION

Arteriovenous malformations (AVM) can be found in 0.1% of the population, and the most frequent presenting symptom is intracranial haemorrhage.

AIM

To conduct a descriptive analysis of a series of cases of AVM that had been treated surgically by a neurosurgeon.

PATIENTS AND METHODS

The cases of AVM treated surgically by the author over the period 1990 to May 2014 were selected from a hospital register, and then the clinical, demographic and angiographic aspects were reviewed, together with the clinico-radiological findings six months after surgery.

RESULTS

Of the 400 patients treated over that same period, 121 were operated on by the author, their mean age being 34.3 years (range: 5-75 years). 61.7% of the patients were diagnosed due to a brain haemorrhage, and the second most frequent presenting symptom, in 19.8% of them, was because of epileptic seizures. A superficial supratentorial localisation, occurring in 97 cases (80.2%), was the most common. Over half the patients presented a low-grade AVM, I-II, according to the Spetzler and Martin scale. Twelve patients (10%) had associated non-intranidal aneurysms. In most cases, 109 (90.1%), elective surgery was performed. Complete resection of the AVM after the last angiographic examination was achieved in 118 patients (97.5%). The clinical results were good (good recovery and moderate disability) in 114 cases (95%), and poor (great disability and death), in six (5%).

CONCLUSIONS

Surgery is the best therapeutic option for many patients with AVM, if appropriate selection criteria are used.

Possible Role of Raf-1 Kinase in the Development of Cerebral Vasospasm and Early Brain Injury After Experimental Subarachnoid Hemorrhage in Rats

This study aims to clarify the potential role of Raf-1 kinase in cerebral vasospasm (CVS) and early brain injury (EBI) after subarachnoid hemorrhage (SAH). Two experimental SAH models in rats, including cisterna magna double injection model for CVS study and prechiasmatic cistern single injection model for EBI study, were performed in this research. As a specific inhibitor of Raf-1, BAY 43-9006 was used in this study. In CVS study, time course study showed that the basilar artery exhibited vasospasm after SAH and became most severe at day 5, and the phosphorylation of Raf-1 had the same trends, while both vasospasm and the phosphorylation of Raf-1 induced by SAH were inhibited by BAY 43-9006 treatment. In addition, BAY 43-9006 treatment significantly reversed the phosphorylation of ERK1/2 and the activation of NF-κB induced by SAH and decreased the messenger RNA (mRNA) levels of IL-6 and IL-1β. In EBI study, BAY 43-9006 treatment significantly suppressed the brain injury induced by SAH. Besides, BAY 43-9006 inhibited the phosphorylation of Raf-1 and ERK1/2; decreased the protein levels of COX-2, VEGF, and MMP-9; and reversed the activation of NF-κB induced by SAH. These results demonstrate that Raf-1 kinase contributes to CVS and EBI after SAH by enhancing the activation of the Raf-1/ERK1/2 and Raf-1/NF-κB signaling pathways, and that the inhibition of these pathways might offer new treatment strategies for CVS and EBI.

Thrombin-activatable fibrinolysis inhibitor influences disease severity in humans and mice with pneumococcal meningitis

BACKGROUND

Mortality and morbidity in patients with bacterial meningitis result from the proinflammatory response and dysregulation of coagulation and fibrinolysis. Thrombin-activatable fibrinolysis inhibitor (TAFI) is activated by free thrombin or thrombin in complex with thrombomodulin, and plays an antifibrinolytic role during fibrin clot degradation, but also has an anti-inflammatory role by inactivating proinflammatory mediators, such as complement activation products.

OBJECTIVE

To assess the role of TAFI in pneumococcal meningitis.

METHODS

We performed a prospective nationwide genetic association study in patients with bacterial meningitis, determined TAFI and complement levels in cerebrospinal fluid (CSF), and assessed the function of TAFI in a pneumococcal meningitis mouse model by using Cpb2 (TAFI) knockout mice.

RESULTS

Polymorphisms (reference sequences: rs1926447 and rs3742264) in the CPB2 gene, coding for TAFI, were related to the development of systemic complications in patients with pneumococcal meningitis. Higher protein levels of TAFI in CSF were significantly associated with CSF complement levels (C3a, iC3b, and C5b-9) and with more systemic complications in patients with bacterial meningitis. The risk allele of rs1926447 (TT) was associated with higher levels of TAFI in CSF. In the murine model, consistent with the human data, Cpb2-deficient mice had decreased disease severity, as reflected by lower mortality, and attenuated cytokine levels and bacterial outgrowth in the systemic compartment during disease, without differences in the brain compartment, as compared with wild-type mice.

CONCLUSIONS

These findings suggest that TAFI plays an important role during pneumococcal meningitis, which is likely to be mediated through inhibition of the complement system, and influences the occurrence of systemic complications and inflammation.

[Clinical utility and psychometric properties of Prefrontal Symptoms Inventory (PSI) in acquired brain injury and degenerative dementias]

INTRODUCTION

The cognitive, emotional and behavioural alterations secondary to acquired brain injury and degenerative dementias can be quantitatively and quantitatively appraised by administering self-reports that ask both patients and reliable informants about the difficulties patients have in their everyday life.

SUBJECTS AND METHODS

The Prefrontal Symptoms Inventory (PSI) and the Modified Memory Failures in Everyday Life Questionnaire (MFE-30) were administered to 174 paired participants: 87 patients with brain damage or degenerative dementias and their 87 reliable informants. In addition to the psychometric goodness of the tests, the study also explored the clinical usefulness of applying these questionnaires to patients and their informants in order to obtain a rate of discrepancy in the scores as a measure of anosognosia.

RESULTS

The results show how applying the PSI-20 (20 items) or the PSI (46 items), whether administered together with the MFE-30 (30 items) or not, is a very useful procedure for assessing the symptoms in individuals with acquired brain injury or degenerative dementias, since it yields a great deal of information about patients' difficulties in their daily life.

CONCLUSIONS

We recommend that, in addition to the compulsory neuropsychological assessment, questionnaires or inventories of symptoms like those proposed here should be carried out, due to the fact that they offer a number of advantages from the clinical point of view, as well as being efficacious and effective in economic terms.

Stroke Subtypes and Topographic Locations Associated with Neurological Deterioration in Acute Isolated Pontine Infarction

OBJECTIVE

This study investigated predictors of neurological deterioration (ND) in acute isolated pontine infarction.

METHODS

Two hundred fifty-nine patients with acute isolated pontine infarctions identified using diffusion-weighted imaging were retrospectively analyzed. The patients were divided according to the presence/absence of ND, defined as increased (≥2 units) National Institutes of Health Stroke Scale scores 5 days after onset. Pontine infarctions comprised 3 stroke subtypes: vertebrobasilar large-artery disease, basilar artery branch disease (BABD), and small-artery disease (SAD), according to basilar artery atherosclerosis severity and lesion extent of the transverse axial plane. Topographic locations of longitudinal pontine infarctions in the axial plane were divided into upper, middle, lower, and whole.

RESULTS

Of the 259 patients (male : female = 136:123, 68.84 ± 10.24), only 27.4% exhibited ND. The prevalence was significantly increased in females, whereas smoking was significantly decreased in patients with ND. BABD and lower pontine infarctions were significantly more frequent in patients with ND (70.4% and 43.7%, respectively) than in patients without ND (51.6% and 30.3%, respectively). SAD and upper pontine infarctions were significantly less frequent in patients with ND (16.9% and 7.0%, respectively) than in patients without ND (30.3% and 23.4%, respectively). BABD and lower pontine infarctions were positively related to ND.

CONCLUSIONS

This is the first study to demonstrate that BABD and lower pons lesions are predictors of ND in acute isolated pontine infarction. These findings indicate the potential importance of early identification of stroke subtypes and topographic locations in the prevention of ND in patients with suspected pontine infarction.

Profile and 1-Year Outcome of Ischemic Stroke in East China: Nanjing First Hospital Stroke Registry

BACKGROUND

The profile and 1-year outcome after acute ischemic stroke (AIS) in Nanjing, China, is uncertain. This study aimed to investigate the profile and outcome after 1-year follow-up of AIS in East China.

METHODS

In a prospective cohort study, 2168 patients with AIS were recruited consecutively. The primary outcome was death or dependency defined as a modified Rankin Scale score of 3-6 at 12 months. Plausible risk factors of death or dependency, such as demographics, risk factors of cardiovascular diseases, clinical features, laboratory results, and complications after a stroke, were selected from available variables to perform multivariable logistic regression analyses.

RESULTS

Eight hundred thirty-seven (38.6%) patients died or suffered from dependency. Multivariate logistic regression analysis showed that age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.03-1.05), history of diabetes mellitus (OR, 1.50; 95% CI, 1.10-2.04), prior stroke (OR, 2.08; 95% CI, 1.51-2.87), National Institutes of Health Stroke Scale (NIHSS) score (OR, 23.06; 95% CI, 14.24-37.34), estimated glomerular filtration rate (OR, 1.65; 95% CI, 1.02-2.66), pulmonary infection (OR, 2.98; 95% CI, 2.17-4.09), and gastrointestinal bleeding (OR, 7.81; 95% CI, 2.76-22.09) were significantly and independently associated with higher rates of mortality or disability (all P values < .05). Male gender (P values < .001) was the only factor associated with lower mortality or disability.

CONCLUSIONS

The main dominating predictors for death or dependency were older age, female gender, diabetes mellitus, prior stroke, NIHSS score, estimated glomerular filtration rate, pulmonary infection, and gastrointestinal bleeding.

Isolated Posterior Inferior Cerebellar Artery Dissection as a Cause of Ischemic Stroke: Clinical Features and Prognosis

Background: The purpose of this study was to clarify the incidence, clinical and radiological features and outcomes of isolated posterior inferior cerebellar artery (PICA) dissection in isolated PICA territory infarctions. Methods: We retrospectively reviewed consecutive inpatients with ischemic stroke secondary to isolated PICA dissection from our stroke database between January 2004 and December 2013 and reviewed the literature with regard to those patients. Results: Of 167 consecutive patients with an isolated PICA territory infarction, a total of 10 patients (6.0%, 3 women, 48.1 ± 7.1 years) were diagnosed as having an isolated PICA dissection. Patients with PICA dissection were younger (p < 0.001), more commonly experienced headache at onset (p = 0.008), less commonly had hyperlipidemia (p = 0.044) and showed a lower modified Rankin Scale score at discharge (p = 0.002) when compared with patients without arterial dissection. In 6 of these 10 patients, PICA dissections had not been suspected on initial magnetic resonance angiography (MRA) and were confirmed by follow-up MRA or digital subtraction angiography. In the follow-up period (median 1.5 years, interquartile range 0.5-6.3 years), there were no recurrent ischemic or hemorrhagic stroke events. Conclusions: Isolated PICA dissection as an etiological mechanism in isolated PICA territory infarctions may be more common than was previously recognized to be. The diagnosis of PICA dissection is often difficult and requires close and repeated morphological evaluation. We should carefully identify PICA dissections as a possible cause of PICA territory infarctions.

[Etiology, clinical presentation and outcome of severe viral acute childhood encephalitis (ECOVE study)]

INTRODUCTION

Viral encephalitis are rare and potentially serious conditions with different etiologist, and not always identifiable. Our aim is to describe the etiological, clinical presentation and neurological outcome of viral encephalitis admitted in Paediatrics Intensive Care Units (PICUs) in Spain.

PATIENTS AND METHODS

Observational prospective multicenter study. Children with viral encephalitis admitted to 14 PICUs, for a period of 3 years (2010-2013) were included. Polymerase chain reaction for the etiological diagnosis and neurotropic virus serology in blood and cerebrospinal fluid were used. Personal history, clinical presentation, evolution and neurological status at discharge were recorded.

RESULTS

80 patients were included with a mean age of 5 years, 70% male. The most relevant clinical symptoms were decreased consciousness (86%), fever (82.4%), seizures (67%), vomiting (42%), headache (27%), agitation (25%) and dis-orientation (23%). The etiologic diagnosis was established in 35%, being more frequent herpes simplex virus and enterovirus. The outcome was discharge without sequelae in 55 patients (69%), mild to moderate sequelae in 19 (23.5%) and severe in 6 (7.5%). Two patients died.

CONCLUSIONS

In the Spanish PICU etiological diagnosis was established only in a third of cases of children with suspected acute viral encephalitis. Despite the clinical severity we observed a low mortality and morbidity rate. At discharge from the PICU, most children had no neurological sequelae or were mild.

[Assessment of therapeutic passive hypothermia in newborns with hypoxic-ischemic encephalopathy that need interhospital transport]

INTRODUCTION

Induced hypothermia for the first hours of life in a newborn is an effective treatment to reduce mortality and serious effects in neonates that had suffered a hypoxia episode. This method needs an universal attendance independently of the place of birth being usually necessary a transfer to the reference hospital.

AIM

To analyze the efficacy of the newborn with hypoxic-ischemic encephalopathy transfer in passive hypothermia.

PATIENTS AND METHODS

Descriptive study of series of cases with retrospective character of newborn from Cadiz's province that need induced hypothermia. 46 newborn were included in the study: 33 of them (71.74%) needed being transfer by the Critical Patients Transport service (CPT group), the rest (28.26%) were born into the reference hospital.

RESULTS

Both groups are similar in age gestational at birth, sex, weight and hypoxic-ischemic encephalopathy degree. It analyzed variables related to hypothermia therapy and in addition in CPT group transfer specific variables. At discharge, it does not exist significant differences between groups in the efficiency-consequence of neuroprotection therapy with hypothermia (p = 0.159). It does not find complications derived from the interhospital move.

CONCLUSIONS

Neonatal inter-hospital transfer in passive therapeutic hypothermia is effective, safe and necessary for the therapy compliance. It is required reach an agreement between the attendance and the reference service, setting up guides for the support and suitable range of temperature.

'A disease that makes criminals': encephalitis lethargica (EL) in children, mental deficiency, and the 1927 Mental Deficiency Act

Encephalitis lethargica (EL) was an epidemic that spread throughout Europe and North America during the 1920s. Although it could affect both children and adults alike, there were a strange series of chronic symptoms that exclusively affected its younger victims: behavioural disorders which could include criminal propensities. In Britain, which had passed the Mental Deficiency Act in 1913, the concept of mental deficiency was well understood when EL appeared. However, EL defied some of the basic precepts of mental deficiency to such an extent that amendments were made to the Mental Deficiency Act in 1927. I examine how clinicians approached the sequelae of EL in children during the 1920s, and how their work and the social problem that these children posed eventually led to changes in the legal definition of mental deficiency. EL serves as an example of how diseases are not only framed by the society they emerge in, but can also help to frame and change existing concepts within that same society.

Two Cases of Hemodialysis-associated Chronic Portal-systemic Shunt Encephalopathy (CPSE) with Opposite Changes in the Blood Ammonia Concentrations during Hemodialysis: A Case Report and Literature Review

The onset of hyperammonemia due to the flow of ammonia-rich portal vein blood through a portal-systemic shunt causes a type of encephalopathy known as chronic portal-systemic shunt encephalopathy (CPSE). We herein report two cases of CPSE that presented with opposite changes in the blood ammonia concentrations during hemodialysis. It is curious that the encephalopathy was ameliorated by hemodialysis in case 1, but not case 2. Therefore, it is necessary to recognize CPSE and assess the blood ammonia concentrations in dialysis patients who develop a disturbance of consciousness, even if the serum transaminase level is normal.

[Stroke in children. Experience in an emergency service]

AIMS

To describe the characteristics of cerebrovascular disease (CVD) in patients treated in a paediatric emergency department and to detect clinical differences, depending on whether the condition was ischaemic or haemorrhagic.

PATIENTS AND METHODS

An analytical, observation-based, retrospective study was conducted in the paediatric emergency department of a tertiary care hospital. The sample included patients aged between 1 month and 18 years who were treated in the service over a period of 10 years (January 2001 to December 2011) with a final diagnosis of CVD. Haemorrhages due to traumatic injury or secondary to tumours, thrombosis of the venous sinuses and patients who were not treated in the service were all excluded.

RESULTS

The final sample consisted of 61 patients, 39 (63.9%) of whom were males, with a mean age of 4.6 years (range: 1.3 months-17.5 years). Of them, 26 (42.6%) presented ischaemic CVD and 35 (57.4%) had haemorrhagic CVD. Headache (n = 20; 57.1%; p = 0.008) and vomiting (n = 25; 71.4%; p = 0.001) are more frequent in haemorrhagic CVD, and hemiparesis (n = 17; 65.4%; p < 0.001) and facial palsy (n = 7; 26.9%; p = 0.001) in ischaemic CVD. The main causes of haemorrhagic CVD are arteriovenous malformations (n = 17; 38.6%) and the ischaemic ones are triggered by arteriopathies (n = 6; 42.3%). On discharge from hospital, 27 (44.3%) presented different degrees of disability and 6 (9.8%) died.

CONCLUSIONS

CVD is a rare entity, although it presents a high morbidity and mortality rate. Haemorrhagic CVD is seen to predominate slightly and it is observed how haemorrhagic CVD presents more often with signs of intracranial hypertension, while the ischaemic form tends to have more neurological focus.