Biomedical subjects
Publications and source records attributed to Kuo-Wei Wang.
Spinal subdural hematoma is a rare complication of cranial surgery. This study reports a case of postcraniotomy lumbosacral spinal subdural hematoma in the absence of predisposing factors. A review of the literature is also presented.
BACKGROUND: Seizures are important neurological complications of bacterial meningitis, but no information about its epidemiology and the outcomes of seizures after community-acquired bacterial meningitis (CABM) in an adult population have been reported. AIMS: To determine the frequency, clinical relevance, subtypes of seizures during the acute phase of bacterial meningitis, and the long-term outcomes of seizure complicating adult CABM. METHODS: In this 12-year retrospective study, 117 adult patients were identified with culture-proven CABM. A comparison was made between the clinical data of the patients with and without seizures during hospitalization. RESULTS: Thirty-one patients had seizures during CABM, accounting for 27% (31/117) of the episodes. The time interval between the onset of bacterial meningitis and the seizures was 1-21 days (mean, 4 days). Furthermore, 80% (25/31) of the episodes occurred within 24 h of presentation. Ten patients who had seizures progressed to status epilepticus. At follow-up after completing treatment, 10 patients completely recovered and were seizure-free, 19 died of meningitis during the acute stage and the other two progressed to chronic epilepsy. CONCLUSION: A log-rank test demonstrated that the long-term outcome of adult CABM with acute seizures produced worse outcomes than for those who had no seizures, though no difference was noted between focal and generalized seizures. None of our patients without seizures in the acute phase of bacterial meningitis developed late seizures during the follow-up periods. Poor outcome in this study may attribute to neurological complications such as seizure, hydrocephalus, infection itself, or a combination of complications.
The clinical features of 22 adult patients with Streptococcus pneumoniae meningitis, retrospectively collected over a 16-year period, were reviewed. Otopharyngeal infection, haematogenous spread and cranial neurosurgery continue to be the predominant routes of infection. Most patients acquired the infection in the community, and predisposing underlying conditions are common. The proportion of S. pneumoniae meningitis compared to all microorganisms causing meningitis in adults declined dramatically from 17% in the first 8 study years to 4% in the last 8 study years. However, all penicillin-resistant S. pneumoniae strains were found in the second half of the study period, accounting for 25% of these episodes. The overall mortality rates for the first and second halves of the study period were 43% and 63%, respectively. Third-generation cephalosporins were the antibiotics of choice for the treatment of S. pneumoniae meningitis in this study, however, the emergence of resistant strains may create a therapeutic challenge in the future. To avoid treatment failure, early diagnosis, careful monitoring of the clinical course and the choice of appropriate antibiotics according to the in vitro antimicrobial susceptibilities, are necessary.
The clinical data of 62 adult patients who suffered post-neurosurgical nosocomial bacterial meningitis, retrospectively collected over a 16-year period, were studied. Cases were divided into two groups based on the date of presentation, the first period being 1986-1993 and the second 1994-2001. Fever and progressive consciousness disturbance were the most consistent clinical features - signs that may also be attributed to other postoperative neurosurgical problems. The common pathogens included Staphylococcus aureus, coagulase negative Staphylococcus, Pseudomonas aeruginosa, Escherichia coli, and Acinetobacter baumannii. An increase in polymicrobial infections and multi-antibiotic resistance during the second period was identified. In the first half of the study, mortality was 22%, and in the second half 36%. Adult post-neurosurgical nosocomial bacterial meningitis has become an important clinical problem. The choice of appropriate empirical antibiotics is challenging and must be guided by an awareness of the relative frequency of various pathogens and the increasing incidence of resistant strains. Although high mortality rates may, in part, be related to the primary brain pathology, early diagnosis and the timely use of antibiotics based on antimicrobial susceptibility testing are essential for survival.
BACKGROUND: The predictive factors, clinical relevance, and outcomes of hydrocephalus complicating adult bacterial meningitis were studied. METHODS: In this 16-year retrospective study, 136 adult patients were identified with culture-proven bacterial meningitis. A comparison was made between the clinical and cerebrospinal fluid data of patients with and without hydrocephalus on admission. RESULTS: Twenty-eight patients had hydrocephalus secondary to bacterial meningitis, accounting for 21% (28/136) of the episodes. Of the 28 patients, the initial computed tomographic scans and/or magnetic resonance imaging studies revealed hydrocephalus in 27 patients, and delayed hydrocephalus developed despite commencement of antimicrobial therapy in the remaining patient. The interval from initial symptoms to external ventricular drainage was 3.9 +/- 4.6 days (range, 1-14 days). Among them, 7 patients underwent external ventricular drainage for hydrocephalus during the acute phase of bacterial meningitis. At follow-up of at least 6 months or more, 14 patients survived and 14 died, with an overall mortality rate of 50%. CONCLUSION: In this study, disturbed consciousness and a higher mean age at the time of admission are risk factors for developing hydrocephalus during the acute phase of bacterial meningitis. Poor outcomes are also found in this specific group of patients, and these may be attributed to the infection itself, hydrocephalus, or both. Because of fulminated clinical courses and high fatality rates, surgical intervention may be suitable only for those who have progressive hydrocephalus and are neurologically stable. In spite the high fatality rate, adequate treatment of neurologic complications and aggressive antimicrobial therapy are essential in improving therapeutic outcomes.
In this study, 116 patients, at least 1 month of age but younger than 5 years, were identified with culture-proven bacterial meningitis. A comparison was made between the clinical data of the patients with and without seizures during hospitalization. Seizures during acute bacterial meningitis accounted for 47% (55/116) of the episodes. Time interval between the onset of bacterial meningitis and that of seizures was 1 to 20 days (mean, 4 days). Twelve of these 55 patients had one or more afebrile seizures after completing the treatment. At follow-up of at least 1 year after completing treatment, 26 patients had good outcomes, whereas the other 29 patients had poor outcomes. A strong correlation between the findings of abnormalities through neuroimaging and the occurrence of seizures during hospitalization was observed. The long-term outcomes of patients with infantile and childhood bacterial meningitis, who had seizures during the acute phase of bacterial meningitis, were worse than the outcomes of those who did not have such seizures. No child developed late seizures unless there were acute seizures. Factors associated with seizures during acute bacterial meningitis include disturbed consciousness on admission, abnormal neuroimaging findings, and low glucose and high concentration of total proteins in cerebrospinal fluid.
This 16-year (1986-2001) retrospective study enrolled 80 infantile patients (aged, 30-365 days old) with culture-proven bacterial meningitis. The most prevalent pathogens were Salmonellaspecies, Streptococcus (S.) agalactiae, Escherichia (E.) coli, and Haemophilus (H.) influenzae, accounting for about 59% of the episodes. Meningitis caused by Salmonella species, E. coli and H. influenzae occurs more often in the older infants, while that caused by S. agalactiae occurs more often in young infants. Our study revealed a decrease in the proportion of Salmonella meningitis from 27% in the first 8 years to 9% in the second 8 years with E. coli replacing Salmonella species as the leading pathogen of this disease during the second period. Overall mortality rate for both periods of time was 11%. However, if we take those with undesirable poor outcomes into account, 43% of patients could be considered treatment failures. The study also reveals a high prevalence of neurological complications when this disease is caused by H. influenzae, S. pneumoniae, and Salmonella species. Stepwise logistic regression analysis revealed that only initial changing levels of consciousness (P = 0.006) were independently associated with treatment failure. The most frequent neurological complications associated with this disease included subdural empyema, hydrocephalus, cerebral infarctions, and seizures. Because therapeutic regimens may require attention to the eradication of bacterial pathogen but also the neurological complications, early diagnosis and choice of appropriate antibiotics are essential to increasing the possibility of survival.
In this 16-year (1986-2001) retrospective study, 23 childhood patients were identified with Guillain-Barré syndrome. According to clinical and electrophysiologic findings, 18 patients manifested acute inflammatory demyelinating polyradiculoneuropathy, 2 had Miller Fisher syndrome, 1 had axonal forms, and 2 were unclassified. Seasonal preponderance was evident in 39% of patients with Guillain-Barré syndrome, developing the disease in the winter (November to January) with upper respiratory infection the most frequent preceding event. The most common manifestation was limb weakness, with various degrees of motor weakness in 22 patients. Bulbar involvement was the most common cranial palsy, and it was evident in 30% of the episodes. Only one of these progressed to mechanical ventilation during hospitalization. Altogether, approximately 61% of the episodes exhibited sensory symptoms. At a follow-up of 1 year or more, 20 patients recovered and 3 had residua. Furthermore, no fatality occurred in our study. Our study also demonstrates that the clinical course of childhood Guillain-Barré syndrome has a shorter recovery time as compared with an adult patient group. Therapeutic outcome is favorable for patients who receive prompt treatment.
OBJECTIVE: To analyze predictive factors and long-term recovery in patients with Guillain-Barré syndrome (GBS) who are in need of mechanical ventilation. METHODS: In this 15-year retrospective study, 77 adult patients were identified with GBS. A comparison was made between the clinical data from patients who required mechanical ventilation and those who did not. Furthermore, the therapeutic outcomes of those 25 patients in need of mechanical ventilation during hospitalization at 1 year were determined using a modified Barthel index. A score below 12 was defined as a poor outcome, whereas a score of 12 or more was good. RESULTS: The study revealed 32% of patients (25/77) in need of respiratory support during hospitalization. At a follow-up of 1 year among the 25 ventilated patients, 7 patients (28%) had normal or minor signs and symptoms, 6 had unassisted gait, 3 had assisted gait, 6 were wheelchair- or bed-bound, and 3 died. The cause of death was septicemia with septic shock in all 3 cases. Factors that predict respiratory failure in the study GBS patients were disability grade on admission and areflexia. Those ventilated patients who had low maximal inspiratory pressure (PImax) (<14.5 cmH2O) and maximal expiratory pressure (PEmax) (<13.5 cmH2O) values at the time of intubation and the presence of complications after mechanical ventilation inevitably had worse outcomes than those who had not. CONCLUSION: If low values of PImax and PEmax at intubation were detected, aggressive respiratory management, which might include tracheostomy to allow more efficient bronchial clearing, and prevention of complications caused by prolonged course of mechanical ventilation are essential to maximize the potential for survival.
Variants of the external osteoplastic flap procedure or endoscopy have been used to approach the frontal sinus mucocele. The authors introduce a modified external approach for radical resection of the mucocele. Using the bicoronal skin incision, the skin flap exposed the right upper orbital rim. The outer table craniotomy was then performed to expose the frontal sinus cavity while carefully preserving the inner table, with radical removal of the mucocele mucosa. The sinus cavity was irrigated with hyper-oxide solution to ensure adequate destruction of possible residual mucosa. The fascia of the frontalis muscle was split, with one part placed into the mucocele cavity to plug the nasofrontal duct. The advantages of the procedures for mucocele removal include clear visualization of the frontal sinus for radical resection of the mucosa, preservation of the inner table avoiding dura manipulation, prevention of central nervous system infection, possibly lower rates of recurrence, prevention of mucosal ingrowth by plugging of the nasofrontal ducts with fascia, and favorable cosmetic outcome. The disadvantages are more intensive surgery comparable to the endoscopic approaches and execution difficulties when the frontal mucocele is small. Additional clinical studies are needed to evaluate the efficiency and safety of this procedure.
This retrospective chart review describes the clinical features, pathogens, and outcomes of 46 patients with cerebrospinal fluid (CSF) shunt infections collected over 16 years. The overall CSF shunt infection rate was 2.1%, broken down into 1.7 and 9.3% in adult and pediatric groups, respectively. Fever and progressive consciousness disturbance were the most clinical features in the adult patient group, whereas disturbance of consciousness and abdominal symptoms and signs were the two most common clinical features in the pediatric patient group. The most frequently isolated microorganisms were of the Staphylococcus spp., including Staphylococcus aureus and coagulase negative Staphylococcus, which accounted for 47% of the episodes. Furthermore, increases in polymicrobial and Gram-negative bacilli infections were observed in our study. Due to the high proportion of oxacillin-resistant Staphylococcus spp. and polymicrobial infections, we recommend initial empirical antibiotics with both vancomycin and a third-generation cephalosporin for cases in which the causative bacteria has not been identified or for which the results of antimicrobial susceptibility tests are not available. For patients who develop smoldering fevers, progressive disturbed consciousness, seizures, or abdominal fullness after ventriculoperitoneal shunt procedures, CSF shunt infections should be suspected. Although some infections have been managed successfully with antimicrobial therapy alone, the timely use of appropriate antibiotics according to antimicrobial susceptibility testing and the removal of the shunt apparatus are essential for successful treatment.
Chryseobacterium meningosepticum is an uncommon pathogen causing adult bacterial meningitis. Herein, we report the case history of one 21-year-old woman with this uncommon central nervous system infection. A diagnosis of adult C. meningosepticum meningitis can only be confirmed by a positive cerebrospinal fluid (CSF) culture. The patient had insulin-dependent diabetes mellitus as the underlying condition associated with this infection. The clinical presentations were fever, headache, consciousness disturbance, and seizure. CSF analysis revealed a purulent inflammatory reaction. After a 21-day course of intravenous cefepime (6 g/day) treatment, this patient was discharged in a state of complete recovery.
Sixty patients with Guillain-Barré syndrome (GBS), aged 16-83 years, have been identified over a period of 7 years. Of 60 patients, 30 received the double filtration plasmapheresis (DFP), 4 received intravenous immunoglobulin, and the other 26 received supportive care only. Therapeutic outcomes at 1 year were determined using a modified Barthel index. At a follow-up of 1 year or longer, 31 patients (52%) had recovered, 24 (40%) had residua, and 5 (8%) had died. According to the statistical analysis, disability at the nadir and electrophysiological signs significantly influenced the long-term outcomes. Complications associated with DFP procedures included physiologic change, technique-related complications, and vascular access-related complications. None of our patients had fatal complications related to DFP treatment. Contrary to the established belief that the disease has a favorable outcome, several hospital-treated patients may still die or present residua even several months after the onset of symptoms. Because disability at the nadir influences the outcomes, early diagnosis and choice of appropriate treatment, which might include DFP, to prevent further neurological deficits, are essential to maximize the potential for survival.
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BACKGROUND: To analyze the clinical features, causative pathogens and therapeutic outcomes of bacterial meningitis in hemodialyzed patients. PATIENTS AND METHODS: Two hundred and sixty-seven patients, > or = 16 yrs, were identified with culture-proven bacterial meningitis. In addition, the causative pathogens and therapeutic outcomes between uremic and non-uremic patients with adult bacterial meningitis were analyzed. RESULTS: Nine uremic patients with bacterial meningitis, accounting for 3% (9/267) of our adult patients with culture-proven bacterial meningitis had fever, disturbed consciousness and seizures. These were the three most common manifestations in our patients. The interval between the onset of symptoms and therapy start was 5-11 days (mean: 9 days). No patients were initially diagnosed with bacterial meningitis, two patients were initially suspected of having infection of unknown origin. In the non-uremic patient group, klebsiella pneumoniae, Staphylococcus aureus, and Streptococcus pneumoniae were the most frequently detected pathogens, while pseudomonas aeruginosa and coagulase-negative Staphylococcus were the most prevalent in the uremic patients group. The overall mortality rates for the non-uremic and uremic patient groups were 33 and 78% respectively. CONCLUSION: The mortality rate for bacterial meningitis in the uremic patients group remained high. Due to non-specific manifestations and slow evolution, bacterial meningitis was commonly misdiagnosed as uremic encephalopathy. Therefore, effective treatment was usually delayed. To avoid treatment failure, early diagnosis, careful monitoring of clinical condition and appropriate antibiotic choices are necessary.