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Biomedical subjects

E F Wijdicks

Publications and source records attributed to E F Wijdicks.

At least 55 records · Page 3Linked to original sources
PubMed2000

Neuroimaging in deteriorating patients with cerebellar infarcts and mass effect.

BACKGROUND AND PURPOSE: The decision to proceed with surgery in cerebellar infarct with mass effect (CIMASS) in deteriorating patients is based on clinical features. The potential role of neuroimaging in predicting deterioration has not been systematically studied. In this study we determine the role of neuroimaging in predicting deterioration in CIMASS. METHODS: -We retrospectively reviewed the clinical and neuroimaging features in 90 patients with cerebellar infarcts. We selected for detailed analysis CIMASS in 35 patients. RESULTS: Eighteen patients remained stable and 17 deteriorated. Of these 17 patients, 8 were treated conservatively and 9 had surgery. Radiological features indicative of progression were more common in deteriorating patients compared with stable patients: fourth ventricular shift (82.3% versus 50%, P:=0.075, OR=4. 67), hydrocephalus (76.5% versus 11.1%, P:=0.0001, OR=26), brain stem deformity (47% versus 5.6%, P:=0.0065, OR=15.1), and basal cistern compression (35.3% versus 0%, P:=0.0076, OR=20.91). Differences in upward displacement of the aqueduct and pontomesencephalic junction from Twining's line, tonsillar descent on sagittal MRI, and infarct volumes between stable and deteriorating patients were not statistically significant. CONCLUSIONS: Hydrocephalus, brain stem deformity, and basal cistern compression may herald deterioration in CIMASS. Admission to a neurological-neurosurgical intensive care unit and consideration of preemptive surgery are warranted in these patients. Vertical displacement of tonsils or aqueduct, demonstrated by MR imaging, did not predict deterioration.

Brain Stem Infarctions↗
PubMed2000

Hydrocephalus is a determinant of early mortality in putaminal hemorrhage.

BACKGROUND AND PURPOSE: Previous studies have shown that the volume of intracerebral hemorrhage and Glasgow Coma Score (GCS) on admission are powerful predictors of 30-day mortality. However, the significance of hydrocephalus associated with deep cerebral hemorrhage has not been studied extensively. The purpose of this study was to determine the prognostic indicators of 30-day mortality in patients with deep cerebral hemorrhage. METHODS: We studied 100 consecutive patients with deep cerebral hemorrhage between 1994 and 1998. Deep cerebral hemorrhage was divided into 2 groups: putaminal hemorrhage (lateral group) and thalamic and caudate hemorrhage (medial group). Univariate and multivariate logistic regression analyses were performed to determine independent prognostic indicators of 30-day mortality. RESULTS: Hydrocephalus was present in 40 of the 100 patients. The 30-day mortality was 29%, and hydrocephalus was present in 76% of those who died. Multivariate analyses showed 2 independent prognostic indicators of 30-day mortality for putaminal hemorrhage: GCS </=8 (P:=0.002, odds ratio [OR] 37.7, CI 3.6 to 396.9) and hydrocephalus (P:=0.005, OR 27.4, CI 2.7 to 282.6). However, only GCS </=8 (P:=0.0002, OR 16.5, CI 3.7 to 73.4) was predictive of 30-day mortality for thalamic and caudate hemorrhage. This model (GCS </=8 and hydrocephalus) has a sensitivity of 57% and a specificity of 91% for predicting 30-day mortality for putaminal hemorrhage. When both attributes were present in putaminal hemorrhage (GCS </=8 and hydrocephalus), 1 (11%) of 9 patients survived, and when both attributes were missing 28 (100%) of 28 patients survived. CONCLUSIONS: Obstructive hydrocephalus on admission in a comatose patient with a putaminal hemorrhage predicts 30-day mortality.

Adult↗
PubMed2000

Origin of pretruncal nonaneurysmal subarachnoid hemorrhage: ruptured vein, perforating artery, or intramural hematoma?

Pretruncal (perimesencephalic) nonaneurysmal subarachnoid hemorrhage (SAH) is a benign variant of SAH. Although angiography fails to show a source of the hemorrhage, mild basilar artery narrowing may be observed. The cause of pretruncal nonaneurysmal SAH has not been established. Recent imaging studies have demonstrated that the center of this type of SAH is not around the mesencephalon but is in the prepontine or interpeduncular cistern with the hemorrhage closely associated with the basilar artery. We review the possible sources of hemorrhage in these cisterns and hypothesize that pretruncal nonaneurysmal SAH is caused by a primary intramural hematoma of the basilar artery. Such an intramural hematoma would explain bleeding under low pressure, the location of the hemorrhage anterior to the brainstem, and the typical findings of hemorrhage adjacent to the basilar artery lumen on magnetic resonance imaging and mild basilar artery narrowing on angiography. Although an intramural hematoma of the basilar artery would be easily identified at surgical exploration, such surgeries have never included the extensive base-of-the-skull approaches that are necessary to visualize the artery in the prepontine cistern.

Basilar Artery↗
PubMed2000

Meningoencephalitis due to Blastomyces dermatitidis: case report and literature review.

Infection of the central nervous system by Blastomyces dermatitidis is a rare cause of meningoencephalitis. The existence of exclusive clinical infection of the meninges in the absence of pulmonary or other foci of infection has been debated. We describe a 20-year-old man presenting with meningoencephalitis caused by B dermatitidis. Blastomycotic infection was confirmed by isolation of the organism from brain tissue obtained at biopsy. Magnetic resonance imaging demonstrated progressive enhancement of basal meninges with involvement of bilateral basal ganglia and thalami. Treatment with amphotericin B arrested further neurologic decline. However, clinical and radiographic follow-up suggested damage to diencephalic structures. The diagnosis of blastomycotic meningoencephalitis is difficult to establish because no sensitive serologic test exists, and attempts to isolate the organism in cerebrospinal fluid obtained by lumbar puncture generally fail. A biopsy specimen of brain tissue is frequently necessary for the diagnosis. Survival is possible with timely initiation of therapy.

Adult↗
PubMed2000

Management of massive hemispheric cerebral infarct: is there a ray of hope?

Catastrophic infarcts of the cerebral hemisphere often involve occlusion of the middle cerebral artery. In approximately 50% of these patients, consciousness declines because of brain swelling. Management includes prevention of further systemic complications, and recent studies have suggested that decompressive hemicraniectomy or moderate hypothermia may improve outcome. Mortality may be decreased, but morbidity should be carefully evaluated in clinical trials before these interventions are accepted as standard.

Brain Edema↗
PubMed2000

Diffuse vasospasm after pretruncal nonaneurysmal subarachnoid hemorrhage.

Pretruncal (perimesencephalic) nonaneurysmal hemorrhage is a benign form of subarachnoid hemorrhage (SAH). Angiographic changes of vasospasm are uncommon in patients with this type of hemorrhage, and if vasospasm is present, it is mild and focal. We report two patients with pretruncal nonaneurysmal SAH who developed severe and diffuse vasospasm, expanding the clinical spectrum of this type of SAH. The first patient was a 40-year-old woman who suffered pretruncal nonaneurysmal SAH. Angiography performed on the seventh day post hemorrhage showed diffuse and severe vasospasm affecting both the anterior and the posterior circulation. The patient was treated with hypervolemia, and she remained asymptomatic. Follow-up angiography showed resolution of the vasospasm. The second patient was a 67-year-old woman who suffered pretruncal nonaneurysmal SAH. The results of the initial angiography were normal. Repeat angiography on the ninth day post hemorrhage showed severe vasospasm in the anterior circulation and moderate vasospasm in the posterior circulation. Nine hours later, the patient developed transient dysphasia, and she was treated with hypervolemia. Three days later, a transcranial Doppler examination showed normalization of blood velocities. The presence of diffuse and severe vasospasm does not exclude a diagnosis of pretruncal nonaneurysmal SAH.

Adult↗
PubMed1999

Acute deterioration from thrombosis and rerupture of a giant intracranial aneurysm.

The authors describe a patient with an unusual clinicopathologic picture of giant aneurysmal hemorrhage followed by sudden deterioration due to acute intra-aneurysmal thrombosis and fatal rebleeding. This patient underscores the poor natural history associated with this devastating disease and serves to highlight the dangers inherent in the delayed treatment of these life-threatening lesions.

Female↗
PubMed1999

Oral cyclosporine decreases severity of neurotoxicity in liver transplant recipients.

Neoral is a new formulation of cyclosporine that permits reliable absorption in patients with external biliary drainage. The authors reviewed 227 liver transplant patients receiving primary treatment with Neoral. Headache occurred in 24 patients (11%), mild tremors in 12 patients, paresthesia in 5 patients, acute confusional state in 4 patients, and seizures in 2 patients. It is apparent that Neoral has profoundly reduced the severity of neurotoxicity in liver transplant recipients.

Administration, Oral↗
PubMed1999

Tracheostomy in Guillain-Barré syndrome.

Specific treatment has been shown to shorten the duration of mechanical ventilation in Guillain-Barré syndrome (GBS) and could obviate the need for tracheostomy in a significant proportion of patients. However, the factors predictive of prolonged ventilation are undetermined, and the timing and use of tracheostomy in patients with GBS have not been systematically studied. The medical records of 60 patients ventilated for GBS were reviewed. Only 13 patients (22%) could be weaned within 3 weeks. Patients ventilated longer were significantly older (P = 0.04), and 21% had underlying pulmonary disease. Median duration of ventilation in patients treated with plasma exchange (n = 31) was not shortened. Fifty-two patients (87%) received a tracheostomy at a median of 9 days after intubation. In this series, where patients with comorbidity were included, tracheostomy was still necessary in the majority of ventilated patients. This procedure can be anticipated in elderly patients and in the presence of preexisting pulmonary disease.

Adolescent↗
PubMed1999

Intra-arterial thrombolysis for vertebrobasilar circulation ischemia.

Acute basilar artery occlusion is usually associated with a poor prognosis despite therapy with antiplatelet and anticoagulant agents. The natural history of this disorder should be fully understood before clinicians make decisions on therapy. Recent advances in angiography technique and the use of newer mobile microcatheters have made intra-arterial thrombolysis therapy feasible. There have been several small, uncontrolled series of intra-arterial thrombolysis in basilar artery occlusion with promising results.

Angioplasty, Balloon↗
PubMed1999

Predicting deterioration in patients with lobar haemorrhages.

OBJECTIVE: To study the clinical course and determine predictors of deterioration in patients with lobar haemorrhages). METHODS: A comprehensive review of 61 consecutive patients with lobar haemorrhages was performed. Neurological deterioration was defined as (1) decrease in Glasgow coma sum score by 2 points, (2) new neurological deficit, or (3) clinical signs of brain herniation. A univariate logistic regression was performed and expressed in odds ratios. RESULTS: Sixteen of 61 (26%) patients with lobar haemorrhages deteriorated after admission. In a univariate analysis, only a Glasgow coma score <14 predicted deterioration (75% of deteriorators v 24% who did not deteriorate; p<0.0001). Initial CT characteristics predictive of deterioration included haemorrhage volume >60 ml (63% v 16%, p< 0.0001), shift of the septum pellucidum (75% v 36%, p<0.01), effacement of the contralateral ambient cistern (33% v 0%, p<0.0001), and widening of the contralateral temporal horn (50% v 0%, p<0.0001). Patients presenting and deteriorating within 12 hours of ictus declined due to enlargement of the haemorrhage. Those who deteriorated more than 12 hours after initial neurological symptoms, showed increased mass effect secondary to oedema. CONCLUSION-Patients with lobar haemorrhages presenting immediately after ictus are at risk for deterioration from enlargement of the haemorrhage and predictors of deterioration may be absent. Patients with large volume lobar haemorrhages presenting to the emergency department with decreased level of consciousness and shift on CT are at risk for further deterioration from worsening oedema. These patients require close observation and early aggressive management may be warranted.

Brain↗