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Prolonged and secondary fever in childhood bacterial meningitis.

In order to study the causes of prolonged and secondary fever in bacterial meningitis, a group of 102 infants and children with proven bacterial meningitis were studied. The causative agent was Haemophilus influenzae in 58% of patients, Streptococcus pneumoniae in 25% and Neisseria meningitidis in 17%. Prolonged fever was observed in 12% of the patients. The established causes include, in order of frequency, subdural effusion, drug fever, otitis media, gastroenteritis and urinary tract infection. Secondary fever was noted in 18% of the patients. The causes, in order of frequency, were urinary tract infection, subdural effusion, otitis media, phlebitis, pneumonia and drug fever. Neither relapse of the meningitis nor inadequate response to antibiotic therapy was the cause for prolonged or secondary fever. Neurological sequalae were observed in 21 patients. There was no correlation between prolonged or secondary fever and neurological sequalae. We conclude that prolonged and secondary fever in patients with treated bacterial meningitis is rarely caused by the primary infection.

Anti-Bacterial Agents↗

[Ventriculoperitoneal shunt using a continuously variable-resistance valve for management of hydrocephalus, especially for cases mimicking simple brain atrophy].

Twenty-two hydrocephalic patients with a ventriculoperitoneal shunt using a continuously variable flow resistance valve (Orbis-Sigma valve system; Cordis Corporation, USA) were reviewed to discuss usefulness of the shunt system. We divided the cases into two groups according to the demonstration of the cortical sulci in computed tomography (CT) as follows; A: progressive hydrocephalic cases mimicking simple brain atrophy, B: acute or subacute hydrocephalic cases with evidence of increased intracranial pressure. Patients in Group A had begun to present slowly progressive loss of activity, dementia and gait disturbance of various degrees after a long quiescent period following primary central nervous system injury. CT findings of these cases showed they were mimicking simple brain atrophy. Although the period of their deterioration was very long, ranging from 1 month to nine years, clinical signs improved in all cases after the shunt. None showed complications. Group B cases consisted of those with signs of increased intracranial pressure such as consciousness disturbance, nausea and vomiting. These cases showed poor demonstration of the cortical sulci in CT. Eleven out of thirteen cases showed satisfactory clinical improvement, though the size of the ventricle showed a slight decrease following shunt procedure. Only one case showed unilateral subdural effusion. In conclusion, this shunt system is useful for the management of ventricular enlarged cases mimicking simple brain atrophy as well as acute hydrocephalic cases. Troublesome consequences such as subdural effusion and hemorrhage rarely occur even in cases with low cerebrospinal pressure.

Adult↗

Benign hydrocephalus in infants. A computed tomographic and clinical correlative study.

During the past 3 years we studied benign hydrocephalus in 7 infants, who presented symptoms of macrocrania and mild psychomotor retardation. Computed tomography (CT) revealed dilatation of CSF space resembling brain atrophy or subdural effusion. These children were observed clinically and were found gradually to restore to normal with regard to CT changes, as well as clinically. These patients were compared with another group of patients with subdural effusion or hematoma who needed tapping or shunting.

Brain↗

Chronic subdural hematoma: comparison of two surgical techniques. Preliminary results of a prospective randomized study.

AIM: The optimal treatment for chronic subdural hematoma (CSDH) is not yet well defined and research for efficient surgical solutions continues. Burr hole craniotomy (BHC) is a common treatment and twist drill craniostomy (TDC) is a less invasive alternative. A closed-system drainage with subdural expansion catheter and suction reservoir can be used to enhance the TDC procedure. METHODS: We report preliminary results of a prospective study comparing BHC and TDC with suction drainage, in a series of 47 patients randomized into two treatment groups. One group of 22 patients underwent TDC with closed-system drainage and suction reservoir (14 men, 8 women, mean age 78.7 years). Another group of 24 patients underwent BHC with subdural irrigation and closed drainage (16 men, 8 women, mean age 76.3 years). Neurological status was assessed by Markwalder's Grading Scale on admission and at follow-up. All patients underwent computed tomography (CT) before surgery, within 4 days after it, and 1 and 2 months later. RESULTS: Preoperative clinical and radiological data were similar in the two groups. Operating times were shorter in the TDC group, while drainage time was shorter in the BHC group (P<0.0001). Length of hospitalization was similar. Recurrence rate, mortality, and neurological recovery were similar, with non significant differences in favor of the TDC group. After 2 months, CT showed complete regression of subdural effusion in 66.6% of cases in the TDC group and in 31.8% in the BHC group (P<0.05). CONCLUSIONS: Preliminary results indicate TDC and BHC as at least equally effective, however TDC favors faster regression of residual subdural effusion, is a faster procedure, and seems to be associated with fewer recurrences. If confirmed at the end of the study, these results could indicate TDC with suction as the elective surgical treatment for CSDH.

Aged↗

MRI changes in intracranial hypotension.

We report seven patients with the syndrome of intracranial hypotension who were referred to Memorial Sloan-Kettering, primarily because of suspicion of meningeal tumor or infection raised by the finding of meningeal enhancement on MRI. In three patients, symptoms occurred after lumbar puncture; in four, there was no clear precipitating event. Lumbar puncture after MRI in six patients revealed low CSF pressure (six patients) and pleocytosis or high protein, or both (four patients). Three patients had subdural effusions. Six patients had measurable descent of the brain on midsagittal images. Postural headache resolved in all seven patients, six of whom had follow-up MRIs. Meningeal enhancement resolved or diminished in all six. Subdural effusions resolved spontaneously in two and were evacuated (but were not under pressure) in one. Downward brain displacement improved or resolved in all patients. The clinical syndrome and MRI abnormalities generally resolve on their own. An extensive workup is not helpful and may be misleading. Patients should be treated symptomatically.

Adult↗

[X-ray computed tomography coupled with cisternography in chronic pericerebral effusions in young children].

The authors study 26 children with macrocranium and pericerebral effusion as diagnosed by C.T. Three groups are described: 10 with the classical C.T. features of subdural effusion, 12 with features of external hydrocephalus and 4 with massive pericerebral effusion. C.T. performed after lumbar subarachnoid injection of contrast medium, shows that all the effusions are subdural. In only one case, opacification of the subdural space occurred. The authors conclude that plain C.T. alone is unable to demonstrate the precise localization of pericerebral effusion in children and that all these effusions are, in their experience, subdural in localization.

Chronic Disease↗

Childhood choroid plexus papillomas: operative complications.

METHODS: Eight children (below 12 years of age) operated on for intraventricular choroid plexus papilloma (CPP) were retrospectively reviewed to identify the factors responsible for their high postoperative morbidity and mortality. Seven of these patients were aged between 2 months and 2 years and 1 was aged 12 years. Six CPP lesions were in the lateral ventricles and the remaining 2 were in the anterior third ventricle. All children presented with features of raised intracranial pressure. Due to gross hydrocephalus with severe manifestations at admission two patients required CSF diversion before definitive surgery. RESULTS: Microsurgical excision of CPPs was achieved in 7 and near total removal of the tumor in an 8th child. Brain shift was noted during operation and was attributed to acute CSF drainage and/or tumor excision in all cases. External ventricular drainage was postoperatively placed in 2 patients, who ultimately required shunt installation. One child died during definitive surgery. Due to neurological deterioration 6 of the remaining 7 patients had a postoperative CT scan within a week of surgery. One had an uneventful recovery, and pneumocephalus and subdural effusion were found in all 6 scanned children. Pneumocephalus was significant enough in 4 of them to warrant a surgical evacuation. CONCLUSION: Acute CSF drainage leading to significant intraoperative brain shift, postoperative external ventricular drainage, pneumocephalus, subdural effusion, and persistent postoperative hydrocephalus were identified as chief factors for higher morbidity in these children.

Child↗

External hydrocephalus in small children.

OBJECTIVE: Confusion exists in literature regarding the entity of external hydrocephalus which has been addressed by different terms like subdural effusion, hygroma, benign infantile hydrocephalus, etc. In this report, the author has tried to define the clinical and radiological criteria for reaching the diagnosis of external hydrocephalus. METHODS: Five children 9 months to 2 years of age with subdural fluid collection were studied prospectively for a period of 8 years. The radiological and clinical criteria sparsely described in literature were followed to study the profile of suspected cases. RESULTS: Four children presented with craniomegaly; the fifth case had tense, wide, and bulging fontanelle. CT of all five children showed hemispheric extracerebral fluid collection with enlarged subarachnoid spaces. Three children had mild to moderate ventriculomegaly without significant periventricular lucency, while the other two had borderline ventricular enlargement. All were managed conservatively. All five children were asymptomatic at follow-up from 12 weeks to 2 years. CONCLUSION: The possible conclusions from this study of rare cases are: external hydrocephalus needs differentiation from other conditions of subdural fluid collections. The radiological criteria such as (a) extracerebral fluid collection (relatively more in anterior convexity than posterior convexity), (b) dilatation of subarachnoid spaces, and (c) mild to moderate ventriculomegaly without (or with questionable) periventricular lucency may be helpful in making a radiological diagnosis of external hydrocephalus. Conservative treatment with acetazolamide helped in ameliorating the clinical features of the cases studied.

Child, Preschool↗

Sonography in pyogenic meningitis.

In this prospective study to evaluate usefulness of ultrasonography for early diagnosis and monitoring of complications of acute pyomeningitis, we performed serial sonographic examinations of skull in 50 infants (with open fontanelle) with proven pyomeningitis. One or more abnormal sonographic findings were detected in 32 infants. These were echogenic sulci (26%), ventriculomegaly with some or other complication (26%), brain abscess (20%), ventriculitis (14%), subdural effusion (6%) and cerebral edema (10%), and were detected mostly after the first week of illness. Ultrasonographic findings were in complete agreement with CT scan diagnosis of ventriculomegaly, ventriculitis, solitary brain abscess and cerebral edema. However, sonography missed cases of subdural effusion (2 out of 5), multiple brain abscesses (1 out of 2), and cerebral infarction (all the four), which were detected on CT Scan. Serial sonographic findings were useful in documenting progressive increase in ventricular size in all the 13 infants with ventriculomegaly and monitoring response to anti-edema therapy in 5 infants with cerebral edema. Sonography is a useful tool for diagnosis of complications of pyomeningitis after the first week of illness, and for monitoring the progress of ventriculomegaly.

Acute Disease↗

[Two operated cases of craniopharyngioma in patients over 70 years old].

This paper reports two cases of craniopharyngioma in the elderly (over 70 years old). The first case is a 74-year-old woman who was referred to us due to gait and visual disturbance. She was first treated conservatively because she showed signs of dementia, but her tumor grew remarkably and rapidly after placement of a ventriculoperitoneal shunt and then was partially resected. After two shunt revisions, the patient developed postoperative pneumonia, which became the main cause of her death. The second case was a 79-year-old female who was referred to us due to progressive visual disturbance. She was operated on and her tumor was totally resected. A bilateral subduroperitoneal shunt was placed to alleviate postoperative subdural effusion. Postoperatively, her visual field improved remarkably. When treating craniopharyngioma in the elderly, it is advisable to choose a conservative approach if applicable. When a more radical therapeutic approach is taken, it should be borne in mind that preexisting dementia and postoperative subdural effusion due to brain atrophy often preclude the patient's early recovery.

Aged↗

Acute subdural hematoma after lumboperitoneal shunt placement in patients with normal pressure hydrocephalus.

Acute subdural hematoma (SDH) is a rare but disastrous complication after lumboperitoneal shunt placement. Four of 206 adult patients with normal pressure hydrocephalus (1.9%) who underwent lumboperitoneal shunt placement suffered acute SDH following head trauma. The interval between shunt placement and acute SDH was one month to 7 years. Two patients had subdural effusion on computed tomography (CT) at 2- and 6-month follow up. All four patients required assistance in their daily activities before acute SDH onset. The traumatic event was a fall. On admission, CT revealed a large SDH that required surgical removal in two patients, of whom one had manifested subdural effusion after shunt placement. The other two patients had a small SDH. None of the four patients had cerebral contusions. Patients with lumboperitoneal shunts, especially those not capable of independent daily activities, are at risk for acute SDH after even minor head trauma.

Aged↗

Vascular dysfunction as an additional pathomechanism in glutaric aciduria type I.

The metabolic hallmark of glutaric aciduria type I (GA I) is the deficiency of glutaryl-CoA dehydrogenase (GCDH) with subsequent accumulation of glutaric acid, 3-hydroxglutaric acid (3-OH-GA) and glutaconic acid. Current concepts regarding pathomechanisms of GA I focus on investigations of excitotoxic effects of 3-OH-GA. To identify pathogenetically relevant genes, microarray analyses were performed using brain material from GCDH-deficient (GCDH (-/-)) and control mice. These microarray data confirmed recent pathogenic models, but also revealed alterations in genes that had previously not been correlated to the disease, e.g. genes concerning vascular biology. Subsequent in vitro and in vivo experiments confirmed direct effects of 3-OH-GA on vascular permeability and endothelial integrity. Clinical observations underscore the involvement of vascular dysfunction. In MRI scans of GA I patients, subdural effusions as well as dilated transarachnoid vascular plexuses were detected independently of encephalopathic crises. In fact, some of these findings are already detectable shortly after birth. MRI scans of a GA I patient performed during an acute encephalopathic crisis detected a dilated intrastriatal vasculature with perivascular hyperintensity, indicating local extravasation. In conclusion, we hypothesize that 3-OH-GA affects prenatal development of vessels, thus leading to an increased vulnerability of endothelial structures and subsequent vascular dysfunction. These observations display an additional pathomechanism in GA I and might explain frontotemporal hypoplasia and chronic subdural effusions in this disease. Elucidation of the pathomechanisms of vascular dysfunction may give further insights into the pathogenesis of GA I.

Amino Acid Metabolism, Inborn Errors↗

Subdural empyema in 10 infants: US characteristics and clinical correlates.

PURPOSE: To investigate the ultrasonographic (US) characteristics of subdural empyema (SDE) and its differentiation from reactive subdural effusion (RSE) in infants with meningitis. MATERIALS AND METHODS: Images in 10 infants with SDE with or without RSE complicating meningitis were retrospectively reviewed and correlated with clinical findings and compared with US and magnetic resonance (MR) images in four infants with meningitis and RSE. RESULTS: At US, 15 of 16 SDEs in the 10 infants were seen as heterogeneous to hyperechoic convexity collections. Hyperechoic strands were seen in 12 SDEs. Other findings included a thick, echogenic inner membrane (n = 9), increased echogenicity of pia-arachnoid and exudates in the subarachnoid space (n = 16), mass effect (n = 16), and loculated extraaxial collections (n = 2). MR imaging findings correlated well with US and surgical results. At computed tomography, SDE was misinterpreted as RSE in one patient, due to the absence of inner membrane contrast material enhancement. Clinical outcome was related to the degree of brain damage consequent to meningitis and the chronicity of SDE. RSEs in seven infants (three with concurrent SDE) were anechoic; an inner membrane was seen in six, and increased pia-arachnoid echogenicity was seen in four. CONCLUSION: SDE has complex US features that are helpful for differentiation from anechoic RSE in infants with meningitis.

Diagnosis, Differential↗

Treatment of suprasellar arachnoid cyst--two case reports.

A 10-month-old girl presented with mental retardation and enlarged head, and a 3-year-old girl presented with epilepsy, both due to suprasellar arachnoid cysts. Magnetic resonance imaging demonstrated the suprasellar arachnoid cyst and the relationship between the cyst and surrounding structures. The 10-month-old patient with accompanying hydrocephalus was treated by fenestration of the cyst wall into the basal cistern. Postoperatively, bilateral subdural effusion appeared and subdural-peritoneal shunting was required. Thereafter, she regained the ability to walk. Two years postoperatively, the cyst reenlarged but communication between the cyst and surrounding cisterns and her development was normal, so she has been followed conservatively. The 3-year-old patient presented without hydrocephalus and was treated by cyst-peritoneal shunting using a Codman-Medos programmable valve through craniotomy. Postoperatively, the cyst was reduced and there has been no recurrence for 2 years and 5 months. We consider that cyst-peritoneal shunting is the most effective treatment for suprasellar arachnoid cyst.

Arachnoid Cysts↗

[Acute meningococcemia in a 4-month-old infant].

INTRODUCTION: What causes meningococcial diseases (MD) is a Gramm-negative diplococcus Neisseria meningitidis (meningococcus). Most frequently it manifests itself in the form of meningitis and meningococcemia. The mortality rate of those suffering from MD has not significantly changed for three decades and ranges from 7% to 19%, and for meningococcemia from 18% to 53%. According to the data presented by domestic authors, of the total of the diseased with bacterial meningitis 75% are children with mortality rate from 6% to 15%. Severe forms of meningococcemia sometimes have extremely rapid development and lethal outcome within a few hours. Key elements for establishing the diagnosis of meningococcemia are presence of hemorrhagic rash with high fever, loss of interest in the environment, loss of consciousness and paleness. CASE REPORT: The boy was admitted to hospital as an emergency case on 29 December 1988 at 11:45. The disease manifested abruptly the day before. He burst into tears easily, would take very little food and in the evening his temperature rose T degree 40.8 degrees C. Before midnight, in the village he was given injections of: lincomycin 300 mg and lasdol 250 i.m. During admittance the infant was agitated, kept moaning. His skin was pail gray with dot-like and spot-like hematoma which were more numerous and intense on the left ear, lower part of the body, scrotum and legs. The infant breathed heavily and fast (FR: 100/min) Cardiologist's finding showed: tahicardia over 200/min, buffled tones, gallop rhythm, pulsating neck veins and edema point to acute heart failure. Large fontanelles remained swollen even after lumbar puncture (LP) and extraction of 15 ml of clear cerebro-spinal fluid. Soon after admittance the boy stopped moaning but didn't cry when pricked and slipped deeper into coma. During the third hour of treatment generalized convulsions began which lasted approximately 10 minutes and stopped after i.v. administered diazepam. The boy remained in coma the second day in lethargy and with swollen fontanelles on the third day, so the first subdural puncture was then performed bilaterally. On that occasion only from the right side 8 ml of reddish liquid was obtained. Right after he was admitted we began permanent transfusion, which lasted 17 days. On the first day he received fresh blood transfusion. He was administered benzinpenicilline, chloramphenicol-succinate, lanatoside, human albumins, dexamethasone.... Blood oxygenation was carried out in the first few days of illness during the exhibited cardio-respiratory failure. DISCUSSION: Among risk factors, which contribute to occurrence of meningococcemia, is also artificial infant food. The reported boy was incorrectly fed with overdiluted cow milk. That and apparent hemostasis brake-down only worsened anemia and increased susceptibility to infections. Although LP was performed when the boy was admitted and the nutritious foundation was soaked with cerebro-spinal fluid, no bacteria were isolated or their presence confirmed in cerebro-spinal fluid colored after Gramm's method, because the child was given linkomycin the previous night. CONCLUSION: On the basis of clinical findings, hemorrhagic rush, convulsions, coma and acute heart failure as well as the laboratory findings it was concluded that it was a case of severe meningococcemia, meningitis and subdural effusion. Listed therapy and six subdural punctures led to full recovery of the patient. Further examination by a pediatrician and a psychologist eliminated the possibility of mental deficiency. The boy is now a good fifth grade elementary school pupil.

Acute Disease↗

Cefuroxime in bacterial meningitis.

In order to find an alternative antimicrobial treatment for childhood bacterial meningitis 30 infants and children with meningitis, due to Haemophilus influenzae (n = 13), Neisseria meningitis (n = 9), Streptococcus pneumoniae (n = 5), or meningitis of unknown aetiology (n = 3), were treated with cefuroxime, 200 mg/kg a day, as the only antibiotic. Prompt clinical and bacteriological responses were noted and every patient was cured. Cefuroxime concentrations in cerebrospinal fluid ranged from 1.1 to 18.8 (mean 7.0) mg/l at the beginning and from 0.5 to 4.1 (mean 1.6) mg/l at the end of treatment. Three infants developed symptomatic sterile subdural effusions which were managed by repeated subdural aspirations while still on antibiotics. Cefuroxime concentrations in the subdural fluid ranged from 17.4 to 32.4 mg/l. At follow-up 2 patients had moderate unilateral hearing loss and one had mild ataxia. We conclude that cefuroxime is effective and safe for the treatment of childhood bacterial meningitis caused by any of these common organisms.

Cefuroxime↗

Hypotension during surgery for subdural hematoma and effusion in infants.

A retrospective study of subdural hematoma was conducted in 36 patients ranging in age from 2 months to 9 years. Hypotension occurred in 41% of the children during the evacuation of the subdural hematoma. This study suggests that hypovolemia was caused, in part, by the blood loss into the subdural hematoma. In patients with hematoma larger than 8% of the intravascular volume, the frequency of the hypotension was high (88%). Infants, in particular, had larger hematomas, ranging in size from 8-27% of intravascular blood volume and, therefore, were at high risk to develop hypotension. These larger hematomas may be due to the infants' higher ratio of subdural space to the body weight. The study also suggests that the preoperative infusion of adequate fluid and blood is a significant factor in preventing hypotension during the hematoma evacuation.

Age Factors↗

[Ultrasonographic screening of the cranium in risk newborn (author's transl)].

This article goes into the question whether prophylactic examination of the cranium of risk newborn via ultrasonography would be meaningful or not. A total of 443 patients was examined during the period January to September 1980. Of these, 160 had shown clinical signs, whereas the remaining 283 clinically apparently normal risk newborn were subjected to ultrasonography before discharge. In 21 cases, findings were pathological (7.4%). Ventricles which were pathologically deformed and of plump shape, represented the main group, followed by hydrocephalus, subdural effusion and intraventricular haemorrhage.

Brain Diseases↗