Cerebellar venous infarction: case report with clinicopathologic correlation

A diabetic man developed a severe hyperosmolar state resulting in coma. CT of the head showed bilateral cerebellar hemorrhages. Despite medical treatment, he deteriorated and died. At autopsy, the straight sinus was thrombosed. There were bilateral, hemorrhagic, cerebellar venous infarctions. This condition is rare because of abundant collateral venous drainage.     

Avances en el tratamiento de los traumatismos craneoencefálicos graves

The theoretical basis for treatment of severe head injury derives from the concept of secondary damage to the brain. This paper provides an overview of the current therapeutic approaches used in treating severe head injury and in particular those patients who develop high intracranial pressure. Special emphasis is given to the new paradigm of so-called evidence-based medicine and its influence on the present and future management of severe head injuries. A review of the recommendations suggested by the Guidelines for the Treatment of Severe Head Injury, recently published by the Brain Trauma Foundation are presented. Specific types of drugs covered in this review include sedatives, analgesics, paralytic agents, barbiturates, steroids and hyperosmolar solutions. The controversies surrounding certain treatments such as the increase of cerebral perfusion pressure with vasoactive drugs, hyperventilation, indomethacine or dihydroergotamine are outlined. We also review the historical background and the controversies over the use of steroids in these patients. The recentiy developed drugs capable of blocking the damaging neurochemical cascades identified in severe head injury are discussed. Finally, the rationale for using 21-aminosteroids (Lazaroids), calcium-antagonists, potential membrane-protectors and the different types of glutamate receptors is also presented.     

Successful switch to olanzapine after rhabdomyolysis caused by water intoxication and clozapine use

We report on a case of rhabdomyolysis induced by the correction of hyponatremia after psychogenic polydipsia and clozapine use, where the switch to a high dose of olanzapine resulted in the non-recurrence of rhabdomyolysis. The 46-year-old patient with the diagnosis of schizophrenia paranoid type, who had been on clozapine treatment for the previous 4 years, was admitted with the symptoms of generalized seizure and vomiting, and as severe hyponatremia was proved, its correction with the parallel use of clozapine treatment was done. CK concentrations increased to 48 120 U/L without any symptom of neuroleptic malignant syndrome. To prevent acute renal insufficiency, high-volume alkaline diuresis was initiated and clozapine was tapered and stopped. On the day 12 of treatment, olanzapine was started and was elevated to 30 mg/day. CK concentration began to fall returning to the normal concentration on day 20. Six months after the switch to olanzapine no recurrence of rhabdomyolysis was detected; clinical and laboratory findings were normal. We suggest that after a benzodiazepine-type antipychotic-induced rhabdomyolysis, a switch to another atypical antipsychotic can be a cautious clinical strategy.     

Low-dose venlafaxine-induced severe rhabdomyolysis: a case report

Venlafaxine is a relatively new antidepressant with selective effects. Compared with traditional antidepressants, this agent has fewer adverse side effects. However, venlafaxine overdose has been reported with severe complications such as seizure, ventricular tachycardia, serotonin syndrome, neuroleptic malignant syndrome and rhabdomyolysis. We present a 21-year-old female with bipolar depression who took a low dose of venlafaxine, but subsequently developed severe rhabdomyolysis. Her plasma level of creatine kinase increased up to 18,711 U/L in few days. These findings may serve as a reminder to physicians to be alert to the possibility of rhabdomyolysis in patients who have only taken a low dose of venlafaxine.     

重型颅脑损伤合并严重多发伤的临床救治

目的评估重型颅脑损伤合并严重多发伤的临床救治结果。方法对22例重型颅脑损伤合并严重多发伤进行回顾性总结。结果预后按GOS评分,良好者8例（36．4％）,轻残4例（18．2％）,重残2例（9％）,植物生存3例（13．6％）。死亡5例（22．7％）。结论早诊断、早治疗、积极抗休克治疗、合理的救治顺序是提高重型颅脑损伤合并严重多发伤的治疗效果,减少致残率及降低死亡率的有效措施。     

Awakenings from persistent vegetative state: report of three cases with parkinsonism and brain stem lesions on MRI

Three patients with a persistent vegetative state after severe head injury are reported. They recovered from a prolonged disturbance of consciousness after the administration of levodopa. These patients all had parkinsonian features. On magnetic resonance imaging, the distribution of lesions implied a diffuse axonal injury involving the substantia nigra or ventral tegmental area. The existence of patients whose dopaminergic systems may have been selectively damaged by a severe head injury should be recognised because such individuals may respond to levodopa treatment.     

Seizure probability in animal models of acquired epilepsy: a perspective on the concept of the preictal state

The concept of a preictal state is based on the belief that it may be possible to predict seizures before they occur. The preictal state is viewed as a time period when a seizure is practically inevitable, or at least a period of greatly increased seizure probability. Changes in seizure frequency may provide insight into how seizure probability increases after brain injury. Here, time-dependent changes in the frequency of spontaneous recurrent seizures after brain injury are summarized from published, nearly continuous, electrographic (EEG) recordings of kainate-treated rats and neonatal rats subjected to hypoxia-ischemia. For these animal models, seizure frequency - and thus seizure probability - was a sigmoid function of time after the brain injury. This observation differs from the traditional view, where the development of epilepsy after brain injury is a step-function of time, and the latent period is the time between a brain injury and the first spontaneous seizure. Based on backward extrapolation of the plots of seizure frequency versus time, these data suggest that seizure probability increases continuously during the latent period. Also, spontaneous recurrent seizures frequently occurred in clusters, suggesting that the intra-cluster seizure intervals are periods of high seizure probability. Thus, seizure probability progressively increases as a function of time after an epileptogenic brain injury, and is particularly high between seizures within a cluster, as compared to the time between clusters. These data suggest that the detectors of the preictal state need to be accurate (and tested) over a very wide range of seizure probabilities, and that studies on the physiological events that occur during seizure clusters may provide insight on the properties of the preictal state.     

重型颅脑外伤后大面积脑梗死的原因及防治

目的探讨重型颅脑外伤后大面积脑梗死的原因及防治措施。方法对收治的36例重型颅脑外伤后大面积脑梗死病例进行回顾性分析。结果按格拉斯哥预后评分(Glasgow outcome scale,GOS)标准:恢复良好6例(16.7%),中残9例(25.0%),重残6例(16.7%),植物生存3例(8.3%),死亡12例(33.3%)。结论对重型颅脑外伤后大面积脑梗死患者及早明确诊断,进行积极有效的综合治疗是改善大面积脑梗死患者预后的关键。     

Exacerbation of pre-existing epilepsy by mild head injury: a five patient series

OBJECTIVE: While the risk of developing seizures following a mild head injury has been reported and is thought to be low, the effect of mild head injury on patients with a pre-existing seizure disorder has not been reported. We present a series of cases where a strong temporal relationship between mild head injury and worsening of seizure frequency was observed. METHODS: Five cases were identified and reviewed in detail. Information was derived from clinic and hospital charts with attention to the degree of injury, pre- and postinjury seizure patterns and frequency. RESULTS: One patient has primary generalized epilepsy and four have localization related epilepsy. Prior to the head injury, three of the patients were seizure free (range: two to 24 years). The patients suffered from mild head injuries with no or transient loss of consciousness and no focal neurological deficits. In all cases, the patients experienced a worsening of seizure control within days of the injury. In one case, the patient's seizure pattern returned to baseline one year after the accident, while in the remaining four cases, the patients continue to have medically refractory seizures. CONCLUSIONS: A close temporal relationship between mild head injury and a worsening of seizure control was observed in five patients with epilepsy. Although further study is required, this observation suggests that a head injury that would be considered benign in the general population can have serious consequences such as recurrence of seizures and medical intractability in patients with epilepsy.     

高氧血颈动脉灌注治疗重型颅脑损伤

目的研究高氧血颈动脉灌注存重型颅脑损伤治疗中的作用。方法对22例重型颅脑损伤患者于伤后约3．5d行高氧血颈动脉灌注治疗，监测灌注前、中、后的PbtO2、PbtCO2、pHbt值变化以及伤后三月格拉斯哥预后评分(GOS)的变化。结果高氧血颈动脉灌注能改善重型颅脑损伤后早期继发性脑缺血缺氧状态和意识状态，进而改善患者预后。结论高氧血颈动脉灌注在重型颅脑损伤的早期治疗中起着积极和重要的作用。     

重型颅脑损伤急性脑膨出术中死亡1例并相关文献复习

目的探讨重型颅脑损伤术中急性脑膨出的原因及防治对策。方法分析1例典型的重型颅脑损伤术中急性脑膨出患者的临床资料,并复习关于术中急性脑膨出形成原因及防治的文献。结果本例患者开颅术中发生急性脑膨出,在术中死亡。结论迟发性颅内血肿、弥漫性脑肿胀及大面积脑梗死是术中形成急性脑膨出的主要原因,术前正确评估及术中采取相应的对策可有效防治急性脑膨出,提高患者的生存率。     

Prior head injury accounts for the heterogeneity of the alcohol-epilepsy relationship.

Fifty-five adult male patients with alcoholism and seizures were divided into three groups. In group I, all seizures were consistently produced by alcohol withdrawal (N = 16); in group II, some seizures were clearly precipitated by alcohol withdrawal and others were not (n = 18); and in group III none of the seizures had a consistent relationship with drinking (N = 21). The three groups were compared for age, frequency of seizures, compliance, Bear-Fedio and Boston-Naming scores, those for memory of words and faces, and finger-tapping scores, and neuropsychological impairment ratings as well as EEG background frequencies. The incidence of severe head injury preceding the onset of seizure disorder was significantly higher in groups II and III. This was further supported by a greater prevalence of asymmetric alpha rhythm, abnormal CT scans and multiple seizure types in those two groups. These data indicate that a prior head injury is a major variable accounting for the heterogeneity of the alcohol-epilepsy relationship.     

Do recurrent seizure-related head injuries affect seizures in people with epilepsy?

Seizure-related head injuries (SRHIs) are among the most commonly encountered injuries in people with epilepsy (PWE). Whether head injury has an effect on preexisting epilepsy is not known. The purpose of this study was to systematically assess for any possible effects of SRHIs on seizure frequency and seizure semiology over a 2-year period. We identified 204 patients who have been followed at the Baylor Comprehensive Epilepsy Center from 2008 to 2010. SRHI occurred in 18.1% of the cohort. Most injuries (91%) were classified as mild. Though seizure frequency varied following head injury, overall seizure frequency was not significantly impacted by presence or absence of SRHI over the 2-year study period. Changes in seizure semiology were not observed in those with SRHIs. Although mild SRHI is common among PWE, it does not appear to have an effect on seizure characteristics over a relatively short period.     

A patient using ziprasidone with polydipsia, seizure, hyponatremia and rhabdomyolysis

We aimed to report a case with rhabdomyolysis related to hyponatremia and/or its correction. A 32–year–old male schizophrenic patient on ziprasidone treatment was admitted to the hospital following a seizure. Patient had primary polydipsia and secondarily developed hyponatremia. After the correction of hyponatremia, due to the high liver enzyme levels, he was diagnosed as rhabdomyolysis. Although the role of antipsychotics in this situation is speculative, development of rhabdomyolysis related to hyponatremia and/or its correction should not be underestimated and should be assesed throughly.     

Closed head injury resulting in paradoxical improvement of a seizure disorder.

People with epilepsy are prone to head injuries and these traumas are usually considered adverse events. We report the case of a 31-year-old woman who sustained a closed head injury as a result of a seizure. This accidental trauma resulted in a 1-year remission of her previously intractable complex partial seizures. The paradoxical improvement of a seizure disorder can occur as a result of a closed head injury. We postulate it simulated ablative epilepsy surgery.     

重型颅脑损伤后脑积水──附23例报告

重型颅脑损伤后脑积水,在临床上并非少见,作者回顾了近年来我科收治的重型颅脑损伤后脑积水的病例,对其发病机理、临床特点进行了简述,同时对治疗结果进行了分析,认为早期发现,早期治疗,可使更多的外伤性脑积水的病人得以挽救。     

亚低温治疗重型颅脑损伤患者的血清S-100B蛋白含量分析

目的 通过检测亚低温治疗后重型颅脑损伤患者血清S-100B蛋白含量的变化来证实亚低温治疗的脑保护作用,探讨其可能的作用机制.方法 选取100例正常体检者为对照组,选取100例重型颅脑损伤患者(GCS≤8分1并分为亚低温治疗组50例和常温治疗组50例,分别于伤后早期(2～6 h)及伤后不同时间(1 d、3 d、5 d、7 d、10 d)采血,检测血清中S-100B蛋白含量,比较其在伤后不同时期的血清S-100B蛋白含量.结果 正常体检者血清S-100B蛋白含量测定结果证实,正常人血清S-100B蛋白含量与年龄、性别无关.亚低温治疗组、常温治疗组患者伤后血清S-100B蛋白含量与对照组相比差异有统计学意义(P<0.01).伤后1 d、3 d、5 d、7 d、10 d时亚低温治疗组血清S-100B含量明显低于常温治疗组,差异有统计学意义(P(0.05).结论 血清S-100B蛋白在重型颅脑损伤的诊断巾有高度敏感性和特异性,是一种有效的生化指标.亚低温治疗对重型颅脑损伤具有脑保护作用.     

颅脑损伤合并非酮性高血糖高渗性昏迷

目的 探讨颅脑损伤并发非酮性高血糖高渗性昏迷病人的诊断、治疗及预后。方法 对1997年7月～2002年1月期间收治的17例中、重型颅脑损伤合并非酮性高血糖高渗性昏迷的病人进行回顾性分析。结果 17例颅脑损伤合并非酮性高血糖高渗性昏迷的病人，除1例之外，其余均在静滴胰岛素及胃内注水治疗后2d内，高血糖、高血渗得到控制。17例非酮性高血糖高渗性昏迷病例占同期中、重型颅脑损伤病人的1．76％。死亡3例，死亡率17．6％。结论 对非酮性高血糖高渗性昏迷，静滴胰岛素极其有效，救治的关键是及早发现行采取有效的治疗措施。治疗中连续性监测血糖、血清渗透压、电解质、严密的病情监护，及时有效调整胰岛素用量至关重要。     

The frequency and consequences of head injury in epileptic seizures.

The frequency and sequelae of head injury in epileptic seizures were assessed. Two hundred and fifty five resident patients with chronic long term epilepsy (165M, 90F) of average age 54 years were studied for a year and 43 patients in a short term assessment unit (22M, 21F) of average age 26 years were studied for a month. A total of 27,934 seizures were recorded, of which 12,626 (45.2%) were associated with falls. There were 766 significant head injuries. Four hundred and twenty two required simple dressing and observation, and 341 required sutures (average number of sutures 4.5). There was one confirmed skull fracture, one confirmed extradural haemorrhage and one confirmed subdural haemorrhage. Thus 2.7% of all seizures resulted in a head injury (6.1% of seizures associated with falling). Simple dressing was required in 1.5%; 1.2% required sutures. Only one in every 9311 seizures (one in every 4208 seizures associated with falls) resulted in skull fracture, extradural or subdural haemorrhage. Minor seizure related head injury is therefore relatively common, while severe head injury is rare.     

Induced and Sustained Hypernatremia for the Prevention and Treatment of Cerebral Edema Following Brain Injury

Cerebral edema develops in response to and as a result of a variety of neurologic insults such as ischemic stroke, traumatic brain injury, and tumor. It deforms brain tissue, resulting in localized mass effect and increase in intracranial pressure (ICP) that are associated with a high rate of morbidity and mortality. When administered in bolus form, hyperosmolar agents such as mannitol and hypertonic saline have been shown to reduce total brain water content and decrease ICP, and are currently the mainstays of pharmacological treatment. However, surprisingly, little is known about the increasingly common clinical practice of inducing a state of sustained hypernatremia. Herein, we review the available studies employing sustained hyperosmolar therapy to induce hypernatremia for the prevention and/or treatment of cerebral edema. Insufficient evidence exists to recommend pharmacologic induction of hypernatremia as a treatment for cerebral edema. The strategy of vigilant avoidance of hyponatremia is currently a safer, potentially more efficacious paradigm.