PubMed Health⌕ Search

Biomedical subjects

E F Wijdicks

Publications and source records attributed to E F Wijdicks.

At least 73 records · Page 4Linked to original sources
PubMed1999

Fatal Guillain-Barré syndrome.

Fourteen of 320 patients (4%) admitted with Guillain-Barré syndrome (GBS) died as a direct result of the illness. Deaths most commonly resulted from ventilator-associated pneumonia. In comparison with 101 other patients with severe GBS admitted to the intensive care unit, the patients who died were older (p = 0.006) and more likely to have underlying pulmonary disease (p = 0.004). In a specialized center, the primary event leading to death in GBS was ventilator-associated pulmonary infection, predominantly in elderly patients with significant comorbidity.

Aged↗
PubMed1999

Cerebral hemorrhage in recipients of renal transplantation.

OBJECTIVE: The causes and circumstances of intracerebral hematoma after kidney transplantation have been poorly studied. No data are available on its impact on outcome after a successful renal grafting. PATIENTS AND METHODS: We used the Mayo Clinic medical diagnostic index to identify the patients with a diagnosis of intracerebral hematoma among the 1573 patients who received a renal transplant at the Mayo Clinic between 1966 and 1998. RESULTS: Ten intracranial hematomas occurred in 9 patients and were the cause of death in 6 (1%) of the 530 patients known to have died. The interval from renal transplantation to intracranial hematoma ranged from 12 to 114 months (average, 57 months). All patients with intracranial hemorrhage had poorly controlled hypertension. Intracranial hematoma was more frequently and significantly associated with autosomal dominant polycystic kidney disease (4/146 [2.7%]; P<.01) and with diabetes mellitus (3/410 [0.7%]; P<.01) than with other underlying causes of renal failure (2/1017 [0.2%]). CONCLUSION: In this preliminary study, the risk of cerebral hemorrhage may have increased 10-fold in patients with autosomal dominant polycystic kidney disease and 4-fold in patients with diabetes mellitus, when compared with the population of patients having other causes of renal failure. Most cerebral hemorrhages were catastrophic and fatal but appeared to be responsible for only 1% of the deaths after renal transplantation.

Aged↗
PubMed1999

Spinal epidural hematoma and high thromboembolic risk: between Scylla and Charybdis.

OBJECTIVE: To determine the optimal time for reinstitution of anticoagulant therapy after evacuation of spinal epidural hematoma in patients who have a high risk for cardiogenic embolization. MATERIAL AND METHODS: The clinical histories of all patients with a spinal epidural hematoma encountered at Mayo Clinic Rochester between 1975 and 1996 were reviewed. We present three cases of spontaneous spinal epidural hematoma and the management of anticoagulation in each case. RESULTS: Of the 17 patients identified, 3 received anticoagulant therapy at the onset of the hematoma and were at high risk for cardiogenic embolization. In two patients with a metallic heart valve and one patient with long-standing atrial fibrillation, anticoagulant therapy was discontinued for 5, 13, and 18 days, respectively, after decompressive laminectomy. Systemic embolization occurred in one patient with a previous history of embolization to the femoral artery. No systemic embolization occurred in the two patients with a metallic valve. CONCLUSION: Early resumption of warfarin therapy is indicated after a spinal surgical procedure; however, discontinuation of anticoagulation for several days seems safe while postoperative hemostasis is monitored.

Aged↗
PubMed1998

Paroxysmal sympathetic storms ("diencephalic seizures") after severe diffuse axonal head injury.

We describe a patient with a severe traumatic head injury who exhibited paroxysmal sympathetic storms, similar to those described in "diencephalic seizures." No epileptiform activity was evident on electroencephalography, and therapeutic levels of anticonvulsants failed to alter the spells; however, use of morphine sulfate abolished them. The features of this and several previously reported cases refute the primary roles of the diencephalon and seizures in this syndrome. Rather, in the setting of already compromised autonomic neuronal integrity, subtle fluctuations in intraventricular pressure or activation of reflexes triggered from muscle mechanoreceptors or chemoreceptors during episodes of hypertonia are more likely. "Paroxysmal sympathetic storms," a more appropriate descriptive term for these phenomena, should be recognized; thus, unnecessary diagnostic evaluations can be minimized, and appropriate therapy can be initiated.

Adolescent↗
PubMed1998

Stroke in the medical intensive-care unit.

OBJECTIVE: To analyze the occurrence and outcome of new-onset stroke in critically ill patients admitted to a medical intensive-care unit. MATERIAL AND METHODS: We reviewed the medical records of patients admitted to the medical intensive-care units of two hospitals between 1985 and 1995. In addition, computed tomographic scans or scan reports were assessed. RESULTS: We identified 19 patients with a critical medical illness and a new-onset stroke. Of this study group, ischemic stroke developed in 10 patients, 8 of whom were found to have bihemispheric infarction. A single territory infarct (the middle cerebral artery territory) was noted in two patients. The presumed mechanisms for ischemic stroke were disseminated intravascular coagulation (N = 6), cholesterol embolization (N = 1), discontinuation of warfarin therapy before an invasive procedure (N = 1), septic emboli (N = 1), and cardioversion (N = 1). In nine patients, an intracranial hemorrhage developed. Seven patients had a single lobar hematoma, whereas multiple intracerebral hematomas were found in two patients. Disseminated intravascular coagulation and rupture of a mycotic aneurysm in proven infective endocarditis were the most common mechanisms for hemorrhagic stroke. In all patients with an ischemic stroke, sudden hemiparesis rapidly progressed to coma. In patients with an intracranial hematoma and sudden onset of coma, unilateral fixed pupil was the most common initial manifestation. Of the 19 patients, 17 died and 2 remained severely disabled. CONCLUSION: Coma is a common initial manifestation of stroke in patients with a critical medical illness, and disseminated intravascular coagulation has a major etiologic role. New-onset stroke in the setting of critical medical illness generally is a complication in a terminally ill patient.

Acute Disease↗
PubMed1998

The dilemma of discontinuation of anticoagulation therapy for patients with intracranial hemorrhage and mechanical heart valves.

BACKGROUND: Anticoagulant-related hemorrhage occurs with an incidence of approximately 1%/patient-year in mechanical heart valve recipients. Intracranial hemorrhage poses a difficult clinical choice; continuing anticoagulation therapy may enlarge the volume of the hemorrhage, early reinstitution of anticoagulation therapy may predispose patients to recurrence, and reversal of anticoagulation therapy may place patients at risk for systemic embolization involving the brain. The risk of embolization may also be greater for patients with atrial fibrillation, cage-ball valves in the mitral position, and reduced ventricular function. This dilemma exists because of a lack of data for a large series of patients. METHODS: We reviewed the medical records and neuroimaging studies for a consecutive group of patients admitted with intracranial hemorrhage and mechanical heart valves. We reviewed neurological presenting data, cardiac risk factors for systemic embolization (atrial fibrillation, enlarged atrial chambers, reduced ventricular function, and the type and location of the metallic valve), and hospital management. RESULTS: We studied 39 patients with intracranial hemorrhage and mechanical heart valves (median age, 69 yr). Four patients had experienced previous transient ischemic attacks or minor strokes. The time from valve replacement to intracranial hemorrhage ranged from 2 months to 19 years (median, 6 yr). The type of intracranial hemorrhage was acute subdural hematoma (n = 20), lobar hematoma (n = 10), subarachnoid hemorrhage (n = 4), cerebellar hematoma (n = 3), or basal ganglionic hematoma (n = 2). Thirteen patients died within 2 days of admission. All 26 surviving patients received fresh frozen plasma and vitamin K. Fifteen patients underwent evacuation of acute subdural hematoma, and in one patient an anterior communicating aneurysm was clipped. The duration of discontinuation of anticoagulation therapy varied from 2 days to 3 months (median, 8 d). None of the patients developed transient ischemic attacks, ischemic strokes, valve thrombosis, or systemic embolization. No recurrence of intracranial hemorrhaging was observed during hospitalization and reinstitution of anticoagulation or antiplatelet agent administration. CONCLUSION: Temporary interruption of anticoagulation therapy seems safe for patients with intracranial hemorrhage and mechanical heart valves but without previous evidence of systemic embolization. For most patients, discontinuation for 1 to 2 weeks should be sufficient to observe the evolution of a parenchymal hematoma, to clip or coil a ruptured aneurysm, or to evacuate an acute subdural hematoma.

Adult↗
PubMed1998

Fibromuscular dysplasia of the internal carotid artery associated with alpha1-antitrypsin deficiency.

OBJECTIVE: A deficiency of alpha1-antitrypsin has been implicated in the development of various disorders affecting medium-sized arteries, including intracranial aneurysms, cervicocephalic arterial dissections, and fibromuscular dysplasia (FMD). We performed alpha1-antitrypsin phenotyping in three consecutive patients who underwent bypass surgery for FMD of the extracranial internal carotid artery to test the hypothesis that alpha1-antitrypsin deficiency is a genetic risk factor for the development of FMD. METHODS: The study population consisted of three women (aged 37, 49, and 53 years, respectively) who had bilateral internal carotid artery stenosis caused by FMD. The indications for surgery included ocular or cerebral ischemic symptoms in two patients and progressive stenosis in one patient. The diagnosis of FMD was confirmed by histological examination of the resected segment of artery. The alpha1-antitrypsin phenotype was determined by isoelectric focusing in polyacrylamide gels. RESULTS: Two of the three patients had a heterozygous alpha1-antitrypsin deficiency (PiMZ phenotype). Pathological examination of the resected arterial segment showed typical medial FMD with focal intimal fibroplasia in both patients with the PiMZ phenotype. CONCLUSION: These findings suggest that a heterozygous alpha1-antitrypsin deficiency may be a genetic risk factor for the development of FMD of the internal carotid artery.

Adult↗
PubMed1998

Measurement of impaired consciousness in the neurological intensive care unit: a new test.

Neurological deterioration in alert patients with an acute CNS disorder can be subtle, but current coma scales may not clearly capture changes in level of alertness. Many coma scales include components such as eye opening and content of speech, features that are difficult to assess in intubated patients and patients with facial trauma. Two new tools have been devised by the authors. The components are a continuous performance test (patient is asked to raise his hand every time he hears a certain letter in a standardised sentence) and the three consecutive hand position test ("thumbs up-fist-victory sign"). Variation within and between observers was assessed with three neurologists, two junior neurology residents, and two neuroscience nurses, and compared with the Glasgow coma score. The average agreements had comparable ranges for both scores, 65% to 89% for both tests and 60% to 88% for the Glasgow coma score. On the first visit 49% of all tests with a maximum Glasgow coma score had a negative continuous performance test as opposed to 13% of tests with a less than maximum Glasgow coma score. For the consecutive hand position test, these numbers were respectively 25% and 2%. These tests may be a reasonable alternative to the Glasgow coma score to monitor patients, in particular when the verbal and eye response cannot be reliably tested.

Analysis of Variance↗
PubMed1998

MR imaging in pretruncal nonaneurysmal subarachnoid hemorrhage: is it worthwhile?

BACKGROUND AND PURPOSE: The cause of pretruncal (perimesencephalic) nonaneurysmal subarachnoid hemorrhage is not known. MRI of the brain or spine is often performed to exclude any other vascular abnormalities. Its diagnostic value is not known. METHODS: We used MR imaging of the brain with routine sequences, gadolinium enhancement, and additional thin T1-weighted axial sections following a triple dose of contrast. RESULTS: We performed MR imaging of the brain in 18 patients with a pretruncal nonaneurysmal subarachnoid hemorrhage. The focal nature of the subarachnoid hemorrhage exclusively in front of the brain stem was confirmed in 14 patients studied within 7 days of the ictus. No vascular abnormalities were found in 17 cases, including 14 patients with gadolinium enhancement. An incidental capillary telangiectasia was found in 1 patient. Fluid-attenuated inverse recovery MR additionally documented blood in the sulci due to cerebrospinal fluid recirculation of blood. Five patients underwent MR imaging of the spine, and no arteriovenous malformations were found. CONCLUSIONS: MR imaging did not reveal a source of pretruncal subarachnoid hemorrhage. The cost of MR imaging probably outweighs the benefit in the evaluation of this variant of subarachnoid hemorrhage.

Brain↗
PubMed1998

Heritable connective tissue disorders in cervical artery dissections: a prospective study.

We prospectively evaluated 15 consecutive patients with spontaneous cervical artery dissections. Three patients (20%) had a heritable connective tissue disorder, each with a unique phenotype. None of these patients met the criteria of any of the named syndromes, and collagen and fibrillin analyses were normal. Heritable connective tissue disorders are common among patients with spontaneous cervical artery dissections, but, despite intensive investigations, the type of disorder usually cannot be identified. The underlying arteriopathy in cervical artery dissections is likely to be heterogeneous.

Adult↗
PubMed1998

Ischemic stroke after surgical procedures: clinical features, neuroimaging, and risk factors.

OBJECTIVE: To describe risk factors and explore mechanisms of ischemic strokes after general surgery. BACKGROUND: Strokes follow general surgery in about 0.08% to 2.9% of cases. Patients with previous cerebrovascular disease, atrial fibrillation, hypertension, advanced age, or atherosclerosis were found to have an increased risk. Knowledge of factors involved may guide physicians in determining the overall risk of surgery. METHODS: This case-control study was performed in a referral center. A total of 61 patients identified through a computerized database with ischemic strokes after surgical procedures-excluding heart, brain, vessels, or neck-between July 1986 and July 1996 were studied. Procedures included 11 urogenital, 16 gastrointestinal, 17 orthopedic, 12 pulmonary, and 5 other. A total of 122 randomly selected controls were matched for age, sex, procedure, and year of procedure. Main outcome measures included arterial territory, timing, risk factors, and perioperative events. Differences were expressed as adjusted odds ratios (AOR) with 95% confidence limits (CL), using multivariate conditional logistic analyses for matched case-control design. RESULTS: Arterial territory included 37 middle cerebral artery, 11 posterior circulation, 7 borderzone, and 6 multiple. Median procedure to stroke interval was 2 days (range, 0 to 16); 10 patients had intraoperative strokes. Three major risk factors emerged: previous cerebrovascular disease (AOR 12.57, 95% CL 2.14/73.70), chronic obstructive pulmonary disease (COPD) (7.51, 1.87/30.12), and peripheral vascular disease (PVD) (5.35, 1.25/22.94). After adding stroke-related factors, PVD (14.70, 2.01/107.71) and COPD (10.04, 1.90/53.14) remained the strongest variables; blood pressure (1.05, 1.01/1.10) and urea (1.04, 1.01/1.07) contributed slightly. Hypotension did not contribute. Four patients (6.6%) and no controls had diffuse intravascular coagulation (p = 0.01). Four stroke patients had myocardial infarction (6.6% versus 0%; p = 0.01). CONCLUSIONS: Ischemic strokes after general surgery most commonly occur after an asymptomatic interval. Previous cerebrovascular disease, COPD, and PVD greatly increase the risk. Hypotension rarely accounts for postoperative strokes. Major comorbidity of the patient at risk seems more important than complicating events during surgery.

Adult↗