- Wernicke's encephalopathy due to hyperemesis gravidarum: Clinical and magnetic resonance imaging characteristics. [Case Reports]
- JPJ Postgrad Med 2016 Oct-Dec; 62(4):260-263
- Hyperemesis gravidarum-induced Wernicke's encephalopathy (WE) is an underestimated condition. The purpose of this study is to improve its awareness and early diagnosis. We report five cases of WE sec...
Hyperemesis gravidarum-induced Wernicke's encephalopathy (WE) is an underestimated condition. The purpose of this study is to improve its awareness and early diagnosis. We report five cases of WE secondary to hyperemesis gravidarum. Classic triad of encephalopathy, ataxia, and ocular signs was seen in four out of five patients. Two unusual features noted in this series were papilledema in one patient and severe sensory-motor peripheral neuropathy in one patient. Magnetic resonance imaging (MRI) was abnormal in all the five patients, and high signal in medial thalamus and surrounding the aqueduct was the most common abnormality (5/5). Involvement of caudate nucleus was seen in two patients with severe psychosis, and two patients had bilateral cerebellar peduncle involvement. Median time delay between onset of neurological symptoms and diagnosis was 7 days. All patients improved with thiamine, but minor sequelae were seen in four patients at 12 months follow-up. One patient had a fetal demise. Hyperemesis gravidarum-induced WE is a common cause of maternal morbidity. Typical MRI findings of symmetric medial thalamic and periaqueductal signal changes may permit a specific diagnosis. A delay in diagnosis, therefore treatment, leads to worse prognosis.
- Neuro-Ophthalmological Manifestations after Intramuscular Medroxyprogesterone: A Forme Fruste of Idiopathic Intracranial Hypertension? [Journal Article]
- NINeurol Int 2016 Sep 30; 8(3):6132
- We report a case of a 22-year-old female student nurse who presented to hospital with an acute neuro-ophthalmological syndrome characterized by papilledema, ataxia, ophthalmoplegia and headache after...
We report a case of a 22-year-old female student nurse who presented to hospital with an acute neuro-ophthalmological syndrome characterized by papilledema, ataxia, ophthalmoplegia and headache after a single first time use of 150 mg medroxyprogesterone intramuscular injection. Clinical, laboratory, radiological and ophthalmological investigations were in keeping with the diagnosis of idiopathic intracranial hypertension but lumbar puncture did not show a raised cerebrospinal fluid pressure suggesting a forme fruste of this entity. Her neuro-ophthalmological clinical features responded well to acetazolamide and diagnostic/therapeutic lumbar puncture. Full recovery was achieved three months after medroxyprogesterone usage. Health care providers must be aware of this adverse drug reaction.
- Isolated central nervous system primary acute monoblastic leukemia presenting as papilledema. [Letter]
- PBPediatr Blood Cancer 2016; 63(12):2256-2257
- ED 08-4 DIAGNOSIS AND TREATMENT OF HYPERTENSIVE EMERGENCY IN CHILDREN. [Journal Article]
- JHJ Hypertens 2016; 34 Suppl 1 - ISH 2016 Abstract Book:e373-e374
- According to the seventh report of Joint National Committee (JNC 7), hypertensive emergency (HE), a kind of hypertensive crisis, is defined as a sudden and abrupt elevation in blood pressure so as to...
According to the seventh report of Joint National Committee (JNC 7), hypertensive emergency (HE), a kind of hypertensive crisis, is defined as a sudden and abrupt elevation in blood pressure so as to cause acute target organ dysfunctions, including central nervous system, cardiovascular system or kidneys. Patients with HE require immediate reduction in markedly elevated blood pressure. Currently, there are no international guidelines for children HE, so the JNC definition is commonly used. Hypertensive emergency in children is rare but a life-threatening emergency. Generally, secondary hypertension is the most common reason of hypertensive emergency. We analyzed clinical features of 16 patients with HE who were diagnosed as HE from Jan 2007 to Dec 2015 in our hospital. Results showed that all patients were diagnosed as secondary hypertension, including 10 cases associated with renal diseases, 3 cases with Takayasu arteritis,1case with hypercortisolism, 1 case with migraine, and 1 case with unknown reason. The pathophysiologic mechanisms of HE involve sympathetic hyperactivity and increasing of vasoconstricting substances, activation of renin-angiotensin system (RAS), decreasing in auto-regulation of target organs, and chronic endothelial damage and remodeling. There is strong evidence that the renin-angiotensin system plays an important role in the genesis of hypertensive crisis. Target organ dysfunctions may be manifested as hypertensive encephalopathy, acute left ventricular failure, acute renal failure and papilledema, etc. Hypertensive encephalopathy is the most common one with the symptoms of persistent headache, nausea, vomiting, altered mental status, convulsion and coma. Some patients may be revealed as reversible posterior leukoencephalopathy. Among 16 patients involved in our study, 13 patients had encephalopathy with 4 cases of reversible posterior leukoencephalopathy, 4 patients had acute heart failure with 1 case of fundus exudation, and 2 case of acute renal failure. 2 patients died with 3 target organ dysfunctions, including encephalopathy, acute heart failure, and acute renal failure, which showed that multiple organ dysfunction may increase the mortality of HE, so earlier identification of target organ dysfunction to take steps is important. As to the key points of diagnosis of HE, one is the level of blood pressure and its elevation speed, the other is to identify target organ dysfunction earlier. Detailed medical history and complete physical examination are important. Additionally, serum electrolytes, complete blood counts, blood urea nitrogen, creatine, urinalysis, chest radiography, electrocardiogram, enchocardiography, brain MRI and fundoscopy may be needed in some situation. It is worth mentioning that 8 patients had hypokalemia, and hypokalemia is associated with the activation of RAS. It indicates the possibility that hypokalemia may be a predictive factor of HE. The treatment of HE is based on the differentiation of acute, chronic or acute attack on chronic hypertension. Once HE is confirmed, intravenous drugs should be emergently applied. It is suggested that the targeted drop of mean arterial pressure in the first 6∼8 hours should reach 25% of the difference between the original value and the target value, and should be followed by a gradual reduction to the target value within 24∼48 hours. Safe and efficacious drugs with rapid onset of action are favorable. According to our experience, sodium nitroprusside and phentolamine are the most useful and effective in our hospital. It's notable that lowering intracranial pressure is more important than decreasing blood pressure for those patients with a high intracranial pressure who are diagnosed as encephalopathy. However, rapidly decreasing blood pressure levels may result in decreasing blood flow of brain, causing ischemia and infarction. To patients with acute left heart failure, management including sedation, oxygen supplement, cardiotonics, diuresis, and vascular dilation should be necessary. Long-acting oral anti-hypertensive medications should be introduced in conscious child after the blood pressure has been reasonably controlled within 24-48 hours. According to our experience, these patients with HE should need more than 2 kinds of anti-hypertensive drugs. In summary, the key points of diagnosis and treatment of HE are earlier identification and effective therapy to control the development of acute target organ dysfunctions.
- Posterior reversible encephalopathy syndrome in a 5-year-old boy with steroid-dependent nephrotic syndrome. [Case Reports]
- SJSaudi J Kidney Dis Transpl 2016 Sep-Oct; 27(5):1021-1025
- Posterior reversible encephalopathy syndrome (PRES) is a rare clinical and radiological phenomenon is encountered in children compared to adults. In our center, a 5-yearold boy with steroid-dependent...
Posterior reversible encephalopathy syndrome (PRES) is a rare clinical and radiological phenomenon is encountered in children compared to adults. In our center, a 5-yearold boy with steroid-dependent nephrotic syndrome (SDNS) presented with headache and blurring of vision during relapse after a long course of immunosuppressive therapy. Evaluation by computed tomography scan of the brain showed that the child had hypodense areas throughout the occipital region of the brain. All signs of PRES, except papilledema, resolved after seven days of supportive treatment evidenced by subsequent radiological evaluation. PRES should be kept in mind in any nephrotic child who is on prolonged immunosuppressive therapy.
- Evaluation and Management of the Swollen Optic Disc in Cryptococcal Meningitis. [Review]
- SOSurv Ophthalmol 2016 Oct 14
- Cryptococcal meningitis (CM) is the most common and severe form of cryptococcal infection. In addition to infiltrative and inflammatory mechanisms, intracranial hypertension commonly complicates CM a...
Cryptococcal meningitis (CM) is the most common and severe form of cryptococcal infection. In addition to infiltrative and inflammatory mechanisms, intracranial hypertension commonly complicates CM and may cause significant visual and neurological morbidity and mortality. The mainstays of treatment for CM include standard antifungal therapy, management of intracranial hypertension, and treatment of underlying immunosuppressive conditions. Early and aggressive management of intracranial hypertension in accordance with established guidelines reduces the risk of long term visual and neurological complications and death. Traditional recommendations for treating elevated intracranial pressure in idiopathic intracranial hypertension (IIH) including acetazolamide, weight loss, and avoiding serial lumbar punctures-- all of which are not helpful in CM and may be harmful.
- Swelling Superimposed on Atrophy Masks Optic Nerve Pathology. [Journal Article]
- JPedJ Pediatr 2016 Oct 14
- Venous sinus stenting in idiopathic intracranial hypertension: a safer surgical approach? [Journal Article]
- COCurr Opin Ophthalmol 2016; 27(6):481-485
- CONCLUSIONS: Patients whose sight is threatened by medically refractory IIH must often consider invasive procedures to control their disease. Venous sinus stenting may offer equal efficacy and lower failure and complication rates than traditional surgical approaches such as optic nerve sheath fenestration and cerebrospinal fluid diversion.
- Update on the evaluation of pediatric idiopathic intracranial hypertension. [Journal Article]
- COCurr Opin Ophthalmol 2016; 27(6):493-497
- CONCLUSIONS: There appears to be characteristic findings on MRI, OCT, and ultrasound studies in pediatric IIH patients. Although ultrasound is rarely used for monitoring these patients nowadays, MRI and OCT can be useful in the evaluation and management of these individuals.
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- [Idiopathic intracranial hypertension: Experience over 25 years and a management protocol]. [Journal Article]
- APAn Pediatr (Barc) 2016 Oct 13
- CONCLUSIONS: Characteristics and outcomes of patients overlap every year. IIH usually has a favourable outcome, although it may be longer in children than in infants. It can cause serious visual disturbances, so close ophthalmological control is necessary. The protocol is useful to ease diagnostic decisions, monitoring, and treatment.