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PubMed1996

Prognosis of bacterial meningitis in children.

We studied the incidence and prognosis of acute neurologic complications in 281 children under 13 years of age with a diagnosis of acute bacterial meningitis. All the patients were examined daily by the same group of neurologists, using a standardized neurological examination. Patients with signs of encephalic lesions, unsatisfactory response to antibiotics or decreased level of consciousness were submitted to brain computer tomography. The overall lethality rate was 20.3% and cases whose causative agent was identified presented a higher lethality rate (23.7%) than those in which the agent was not found. The most important neurological abnormalities were meningeal signs (88.3%) followed by decreased consciousness (47.7%), irritability (35.2%), seizures (22.4%), fontanel bulging (20.6%) and cranial nerve palsy (14.2%). Seizures, cranial nerve palsy and the absence of meningeal signs were related to higher rates of lethality. Diminished consciousness, seizures, subdural effusion, abscess and hydrocephalus were the most important complications, respectively. We can conclude that acute bacterial meningitis continues to be an important health problem in developing countries and that public health measures will be necessary to minimize the impact of sequelae and reduce the mortality rate in children with that pathology.

Child↗
PubMed2001

Menkes disease: case report of an uncommon presentation with white matter lesions.

Menkes disease is a rare X-linked disorder related to a defect in the copper metabolism. According to the current literature, the most frequent neuroimaging findings are cortical atrophy, chronic subdural effusion or hygroma, and vascular abnormalities. White matter lesions may be present before other features of the disease and may evolve into atrophy. We hereby report a case of Menkes disease with typical history and progression, and an early phase imaging study with important white matter abnormalities, which could have lead to diagnostic difficulties.

Brain↗
PubMed1989

[Enlarging skull fracture treated by early surgery. Case report].

The authors report a case in which an enlarging skull fracture was surgically repaired on the fourth day after the initial injury. A 5-month-old boy fell from his father's arms and was hospitalized with a large, irregular protrusion in the left parieto-occipital region and right hemiparesis. Plain skull films showed a diastatic linear fracture with a maximum width of 8 mm, which expanded to 11 mm by the fourth day. Computed tomography (CT) scans revealed a cerebral contusion just beneath the fracture as well as a left subdural effusion. At operation, the contused brain tissue was found to have herniated over the bone defect. Craniotomy revealed a large dural defect, which was repaired with lyophilized dura. The patient was discharged with no neurological deficit. On the basis of a review of 58 recently reported cases of skull fracture, the authors conclude that the following conditions warrant consideration of early surgery: 1) a diastatic skull fracture with a width of at least 4 mm; 2) CT demonstration of a cerebral contusion beneath the fracture; 3) overlying scalp swelling; and 4) a neurological abnormality contralateral to the fracture. Performing surgery before the fracture gap becomes scalloped will result in more rapid neurological recovery and reduce the likelihood of enlargement of the fracture.

Brain Concussion↗
PubMed1978

Computed tomography in leptomeningeal infections.

In a review of CT scans of 6,078 patients, 47 patients with well documented leptomeningeal infections were identified; 45 were infants or children. Most of the infections were bacterial; 53% were due to Haemophilus influenzae. The 47 patients were divided into two groups according to whether the initial scan was obtained during the acute illness (group A) or after initial treatment had been completed (group B). The 30 patients in the acute group A had 24 complications: 18 with areas of diminished attenuation in the brain parenchyma and six with dilated ventricles. Eleven patients had initially normal scans, but three of these subsequently developed complications. In group B, the 17 patients had 28 complications: nine with enlarged ventricles; eight with subdural effusion; seven with areas of diminished attenuation; and four with abscess formation. An unusually high percentage (40%) of the patients with areas of diminished attenuation had involvement of the anterior poles of the frontal lobes. Of the patients who showed this predilection for the frontal lobes, 72% had Haemophilus influenzae meningitis. CT was found to be useful in early detection of complications of leptomeningeal infections, as well as in evaluation of the extent of the lesions.

Adult↗
PubMedDate not supplied

Extradural haematomas: an analysis of the changing characteristics of patients admitted from 1980 to 1986. Diagnostic and therapeutic implications in 158 cases.

From January to June 1986, 158 patients with extradural haematoma were admitted to our neurosurgical unit. They were divided into four groups, reflecting their clinical features: A. 46 cases (GCS less than or equal to 12) in whom a condition of coma/stupor had occurred at the time of injury and persisted to the time of surgical decompression; B. 41 cases showing deterioration of consciousness (GCS less than or equal to 12) after a lucid interval; C. 46 cases of 'asymptomatic' patients (GCS consistently greater than or equal to 13, no neurological deficits, no signs of increased intracranial pressure); D. 25 cases arriving at our unit in a conscious state, but restless and/or with neurological deficits. The location of the haematoma (temporal in only 35%), the incidence of associated lesions such as cerebral lacerations and/or subdural effusion (30.3%), and the age of the patients (28.4 +/- 18.4 years were similar in the four groups. The size of the haematoma and the displacement of the midline structures were significantly greater in comatose/stuporose patients (groups A and B). The overall mortality was 12% (19 patients), with a morbidity of 14% (22 patients). Factors statistically significant in determining mortality and morbidity were: degree of coma as assessed by GCS; displacement of midline structures: age of the patient; size of the haematoma. There was no mortality or morbidity in those patients who remained conscious (groups C and D). A pronounced increase in the number of CT examinations performed in patients with head injury in our area of referral has caused profound changes in the population of patients admitted to our centre, resulting in a greater proportion of extradural haematomas detected in patients who are still conscious, and in whom operative mortality and morbidity are negligible. One further therapeutic implication of the increase in the number of patients with EDH admitted while asymptomatic may be the option of conservative management in those patients who remain in a good clinical condition, with haematomas of less than 1 cm in thickness and no displacement of midline structures.

Adolescent↗
PubMed1999

Management of patients with normal-pressure hydrocephalus by using lumboperitoneal shunt system with the Codman Hakim programmable valve.

Thirty-two patients with normal-pressure hydrocephalus were managed using the lumboperitoneal (LP) shunt system in which the Codman Hakim programmable valve was utilized. The initial opening pressure was set at 100 mm H(2)O in three cases, 80 mm H(2)O in two, 70 mm H(2)O in three cases, 50 mm H(2)O in 23, and 30 mm H(2)O in one case (mean pressure 57.8 mm H(2)O). In 12 patients the valve pressure required reprogramming. The final valve pressure was 30 mm H(2)O in four cases, 50 mm H(2)O in 19, 70 mm H(2)O in three, 80 mm H(2)O in one, 100 mm H(2)O in two, 130 mm H(2)O in one, 140 mm H(2)O in one, and 170 mm H(2)O in one case (mean 62.5 mm H(2)O). Lumboperitoneal shuntography was performed in five patients by injection of contrast medium into the prechamber. In two patients a shunt obstruction developed between the valve and the lumbar catheter. Complications occurred in eight patients. Low-pressure symptoms such as headache and vomiting were observed in four patients but disappeared after increasing the valve pressure. One patient, whose shunt pressure was set at 50 mm H(2)O developed a slight asymptomatic subdural effusion, which resolved after increasing the valve pressure to 100 mm H(2)O. Convulsions developed in two aged patients but were easily controlled with anticonvulsant medication. Surgery-related wound infection was observed in one patient. The major advantage in the use of this valve is the ability to modify the pressure noninvasively. Another important advantage of the LP shunt system in which this valve is incorporated is the lower pressure of 30 mm H(2)O that can improve symptoms caused by underdrainage of cerebrospinal fluid.

Journal Article↗
PubMed1996

Multiple burr-hole operation for adult moyamoya disease.

Excellent results from multiple burr-hole operations for adult moyamoya disease are reported in this study. Ten patients had between one and four burr holes (mean 2.1) drilled in each hemisphere. In four patients new burr holes were added on the opposite side after depression of cerebral blood flow (CBF) was detected by follow-up single-photon emission computerized tomography imaging of the brain with N-isopropyl-p-[123I]iodoamphetamine. The postoperative follow-up period ranged from 6 to 62 months (mean 34.7 months). Beginning at 6 months postsurgery, angiograms disclosed rich neovascularization at 41 of 43 burr holes, first from the middle meningeal artery, then from the superficial temporal artery. Neovascularization did not occur at two burr holes at which there was subdural effusion and local cerebral atrophy, respectively. Progression of stenosis of the major vessels was seen in six patients. Moyamoya vessels were decreased at six sites in four patients. The CBF study revealed that the reactivity to acetazolamide improved in all six patients tested. Transient ischemic attacks disappeared in all six patients presenting with this symptom, and preoperative symptoms improved in both of the patients who presented with cerebral infarction and in both patients with intraventricular hemorrhage. There was no mortality or morbidity, and no new neurological deficits or rebleeding developed during the follow-up period. The authors strongly recommend the multiple burr- hole operation as the surgical treatment of choice for adult moyamoya disease because of its safety and effectiveness.

Adult↗
PubMed2002

Spontaneous intracranial hypotension due to thoracic disc herniation. Case report.

Spontaneous intracranial hypotension is frequently idiopathic. The authors report on a patient presenting with symptomatic intracranial hypotension caused by a transdural calcified thoracic disc herniation. Cranial magnetic resonance (MR) imaging revealed classic signs of intracranial hypotension, and a combination of spinal MR and computerized tomography myelography confirmed a mid-thoracic transdural calcified herniated disc as the cause. The patient was treated with an epidural blood patch and burr hole drainage of the subdural effusion on two occasions. Postoperatively the headache resolved and there was no neurological deficit. Thoracic disc herniation may be a cause of spontaneous intracranial hypotension.

Adult↗
PubMed1999

Fatal pulmonary embolism in a child undergoing extra-ventricular drainage surgery--a case report.

Thromboembolism is rather common in neurological patients and patients with brain tumor, who are bed-ridden or with partial immobile limb. In serious instances morbidity and mortality are inevitable. We present a case report on a fatal pulmonary embolism in a 2-year-old girl who underwent extra-ventricular drainage procedure under general anesthesia for occipital subdural effusion, a sequela of the former surgery undertaken to remove the choroid plexus papilloma 13 days ago. Sudden cardiac arrest occurred during induction of anesthesia and she finally succumbed in spite of vigorous cardiopulmonary resuscitation. Transthoracic and transesophageal echocardiography performed in the course of resuscitation disclosed thrombi of various sizes scattering in right atrium, the right ventricle, main pulmonary trunk, and the left pulmonary artery. The cause of death was thought to be severe obstruction of right ventricular outflow tract by large thrombi. The etiological factors which possibly led to the thrombosis were discussed, and the methods of diagnosis and treatment were also explored.

Brain Neoplasms↗
PubMed1999

[Clinical experience with the Sp[hy adjustable valve in the treatment of adult hydrocephalus. A series of 147 cases].

OBJECTIVE: Evaluate the advantages, results and drawbacks of the Sophy adjustable valve (SV) in the treatment of hydrocephalus in the adult. MATERIAL AND METHODS: One-hundred and forty-seven adult hydrocephalic patients (mean age = 64.5 years) shunted with a SV between 1990 and 1997 were retrospectively reviewed. Etiologies of hydrocephalus were: "normal pressure" chronic hydrocephalus (NPH) in 124 and tumoral hydrocephalus with intracranial hypertension in 23 patients. One-hundred fifty shunts were established in 147 patients: 14 ventriculoatrial and 136 ventriculoperitoneal shunts. The initial pressure settings of the SV were: high pressure: 12 times (8%), medium pressure: 136 times (90.6%) and low pressure: 2 times (1.3%). RESULTS: Sixteen patients were lost to follow-up. Two patients died within hours following the procedure. So, the results were analyzed in the 129 remaining patients, with a follow-up of 16.7 months (+/- 17.8). Three patients died from shunted-related causes (2.3%). Eighty-four patients had good results (65%), 25 had fair results (19.5%) and 20 failed to improve or deteriorated (15.5%) after shunting. Fifty-three reoperations were performed in 44 patients (34%), including 37 procedures for mechanical obstruction and 6 for septic complications. Subdural effusions (SDE) occurred in 16 patients (12.5%): 10 surgical evacuations were required in 7 patients; 8 patients were successfully treated using uprating of the SV pressure alone; one was managed conservatively. Fifty-eight pressure readjustments were performed in 47 patients. The pressure settings were uprated 28 times in patients showing clinical or computerized tomographic (CT) features suggesting overdrainage; 20 of those proved to be successful (71.5%). The pressure settings were lowered 30 times in patients showing a lack of improvement after shunting, attributed to underdrainage; only 12 of those proved to be successful (40%). Spontaneous changes of the pressure settings were observed in 14 patients (10.8%). After a MRI exposure, SV pressure changes were observed in 64% of patients. DISCUSSION: The technological refinements that have been proposed to eliminate the overdrainage which occurs in most usual cerebrospinal fluid shunts are reviewed. The SV valve has allowed non-invasive adjustments of its opening pressure in patients showing complications ascribed to inappropriate drainage. The need for additional surgery was eliminated in 20% to 25% of patients of the present series. Because of frequent spontaneous and magnetic resonance-induced pressure changes, the need for repeated controls of valve pressure is to be reemphasized. CONCLUSION: This experience suggests that the SV represents a substantial improvement over standard fixed-pressure valves.

Adult↗
PubMed2000

Primary low grade B-cell lymphoma of the dura in an immunocompetent patient.

Primary central nervous system lymphomas (PCNSL) represent only 1% of all non-Hodgkin's lymphomas (NHLs). A 66 year-old woman was hospitalized due to multiple episodes of syncope and seizures which occurred the week before admission to the hospital. A computerized tomography (CT) scan of the brain showed a right parietal lesion suggesting a subdural effusion. The patient was operated and a dural lesion extending to the epidural space and cerebral cortex was excised. Histologic findings suggested diagnosis of a low-grade lymphoma of the mucosa associated lymphoid tissue (MALT) type. The patient was treated with radiation therapy and has now completely recovered 12 months after surgery.

Aged↗
PubMed1975

Surgical management of bacterial meningitis.

A variety of associated lesions may require the neurosurgeon's assistance in the management of bacterial meningitis. As treatment of this infection of the central nervous system proceeds, the surgeon will have to decide about the concurrent or subsequent operative treatment of congenital dysraphic states, paraneural infections, compound fractures or penetrating wounds of thecranium or spine, or infected bypass shunts for cerebrospinal fluid (CSF). In patients with intractable meningitic infections the surgeon may have to insert a ventricular drainage-irrigation system to permit adequate perfusion of the CSF pathways with antibiotic. Hydrocephalus or subdural effusions complicating meningitis may bring the patient to the surgeon long after the infection has been cured. This paper examines these problems and outlines the current principles of management.

Age Factors↗
PubMed1964

SEQUELAE OF BACTERIAL MENINGITIS IN INFANTS.

Electroencephalograms, developmental tests and intelligence tests indicated that six of ten children under two years of age who had purulent meningitis, had apparent permanent neurological damage. The data suggested that this damage may be related in part to the occurrence of subdural effusions. Serial electroencephalograms and developmental tests appeared useful for suggesting which patients might retain a high risk of compromised brain function. The lack of further decrease in mortality from this disease in recent years may be because of cases in which meningitis is "secondary" to a primary disease of the central nervous system-that is, due to operation for brain tumor or myelomeningocele which affords direct entry of organisms. The incidence of permanent sequelae following this disease may not be decreasing.

Brain↗
PubMed1955

Meningitis; a review of one year's cases from an active children's hospital service.

Fifty-six cases of bacterial meningitides, other than tuberculous, observed in a period of one year on an active children's hospital medical service were reviewed. All age groups were involved but most commonly infected were patients in the first year of life. There was no inordinate incidence of infection with any one kind of organism in any specific age bracket, except possibly for infection with enteric organisms which in the present series occurred preponderantly in infants less than six months old. Meningococcus and H. influenza type B were the most common organisms; they were the infecting agents in 71 per cent of cases. Of the immediate complications noted, subdural effusions were the most common (23 per cent of this series). In all except two cases, effusion was resolved by multiple aspirations. In two cases craniotomy was done with good results. Ten electroencephalograms were made and all were abnormal. In most of the patients, multiple antibiotic and chemotherapeutic drugs were used, parenterally during the first few days of hospitalization and then orally as tolerated. Intraspinal therapy was not given. Four of the 56 patients died.

Anti-Bacterial Agents↗
PubMed1992

[Choroid plexus papilloma of the third ventricle in infancy: a case report].

The incidence of choroid plexus papilloma is about 0.5% of all intracranial tumors, but they are only infrequently found in the third ventricle. This is a case report of choroid plexus papilloma of the third ventricle in an infant. A make child in his 7th month of age was admitted because of large head circumference, on the 28th February, 1989. CT scan demonstrated hydrocephalus caused by a tumor in the third ventricle. Total removal of the tumor was performed on the 8th of March. Histologically the tumor was found to be choroid plexus papilloma. The patient suffered from postoperative subdural effusion and convulsions, so we performed ventriculoperitoneal shunt on the 14th April, and convulsions were controlled by zonisamid.

Age Factors↗