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Lumbar Puncture (lumbar + puncture)
Selected AbstractsLUMBAR PUNCTURE IN OLDER ADULTS: WHICH APPROACH IS SAFER?JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2010A RETROSPECTIVE COHORT STUDY No abstract is available for this article. [source] Incidence of Traumatic Lumbar PunctureACADEMIC EMERGENCY MEDICINE, Issue 2 2003Kaushal H. Shah MD Abstract Objective: To determine the incidence of traumatic lumbar puncture (LP). Methods: A retrospective study was conducted at an urban, university tertiary care referral center with 50,000 annual emergency department (ED) visits. The study population included all patients who had cerebrospinal fluid (CSF) samples sent to the laboratory between August 15, 2000, and August 14, 2001. The numbers of red blood cells (RBCs) recorded in the first and last CSF tubes, the location where the LP was performed, and the discharge summary and the discharge diagnoses from the particular visit were obtained. All patients with intracranial pathology and CSF obtained via neurosurgical procedure or fluoroscopic guidance were excluded from the study group. Given no clear definition of traumatic LP in the literature, the incidence of traumatic LP was calculated using a cutoff of greater than 400 RBCs (visual threshold for bloody fluid) and 1,000 RBCs (arbitrary threshold selected by other authors) in CSF tube 1. Proportions were compared using chi-square statistics. Results: Seven hundred eighty-six CSF samples were recorded over one year. Twenty-four samples were obtained from patients with intracranial pathology or were obtained via a neurosurgical procedure. Of the remaining 762 CSF samples in the study population, 119 (15.6%) were traumatic using a cutoff of 400 RBCs, and 80 (10.5%) were traumatic, using a cutoff of 1,000 RBCs in tube 1. Five hundred three LPs were done in the ED and 259 were attributed to all other locations in the hospital. Using a cutoff of 400 RBCs, the incidence of traumatic LP in the ED was 13.3%, compared with 20% in the rest of the hospital (p < 0.025). Similarly, using a cutoff of 1,000 RBCs, the incidence of traumatic LP in the ED was 8.9%, compared with 13.5% in the rest of the hospital (p = 0.1). The incidence of "champagne taps" (defined as zero RBCs in the first and last tubes) in the ED was 34.4%, compared with 24.3% in the rest of the hospital (p < 0.01). Conclusions: The incidence of traumatic lumbar puncture is approximately 15% using a cutoff of 400 RBCs and 10% using a cutoff of 1,000 RBCs. In this study, the rate of traumatic lumbar puncture was significantly less (with a cutoff of 400 RBCs) and the rate of champagne tap was significantly greater for LPs done in the ED compared with the rest of the hospital. [source] Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute-onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?ACADEMIC EMERGENCY MEDICINE, Issue 4 2010Robert F. McCormack MD Abstract Objectives:, The primary goal of evaluation for acute-onset headache is to exclude aneurysmal subarachnoid hemorrhage (SAH). Noncontrast cranial computed tomography (CT), followed by lumbar puncture (LP) if the CT is negative, is the current standard of care. Computed tomography angiography (CTA) of the brain has become more available and more sensitive for the detection of cerebral aneurysms. This study addresses the role of CT/CTA versus CT/LP in the diagnostic workup of acute-onset headache. Methods:, This article reviews the recent literature for the prevalence of SAH in emergency department (ED) headache patients, the sensitivity of CT for diagnosing acute SAH, and the sensitivity and specificity of CTA for cerebral aneurysms. An equivalence study comparing CT/LP and CT/CTA would require 3,000 + subjects. As an alternative, the authors constructed a mathematical probability model to determine the posttest probability of excluding aneurysmal or arterial venous malformation (AVM) SAH with a CT/CTA strategy. Results:, SAH prevalence in ED headache patients was conservatively estimated at 15%. Representative studies reported CT sensitivity for SAH to be 91% (95% confidence interval [CI] = 82% to 97%) and sensitivity of CTA for aneurysm to be 97.9% (95% CI = 88.9% to 99.9%). Based on these data, the posttest probability of excluding aneurysmal SAH after a negative CT/CTA was 99.43% (95% CI = 98.86% to 99.81%). Conclusions:, CT followed by CTA can exclude SAH with a greater than 99% posttest probability. In ED patients complaining of acute-onset headache without significant SAH risk factors, CT/CTA may offer a less invasive and more specific diagnostic paradigm. If one chooses to offer LP after CT/CTA, informed consent for LP should put the pretest risk of a missed aneurysmal SAH at less than 1%. ACADEMIC EMERGENCY MEDICINE 2010; 17:444,451 © 2010 by the Society for Academic Emergency Medicine [source] A Model for Ultrasound-Assisted Lumbar PunctureACADEMIC EMERGENCY MEDICINE, Issue 2009Matthew Herron Clinicians may find traditional lumbar puncture (LP) attempts fail due to indistinct landmarks in morbidly obese patients necessitating ultrasound localization or fluoroscopy. We believe a readily available teaching model is needed because many emergency physicians may be unfamiliar with ultrasound-assisted LP. Review of current literature shows that there are few commercially available LP models suitable for use with ultrasound. Those on the market are expensive and have limited reusability. We have succeeded in creating a low-cost reusable model for training health care professionals to perform ultrasound-assisted LP. We believe there will be many benefits to using this model including: increase in emergency department (ED) LP success rates, decrease in number of radiology consults for fluoroscopy, increase in patient satisfaction, decreased waiting time in the ED, and fewer complications due to fewer needle passes. This model effectively reproduces the sonographic appearance of the lumbar spine and overlying soft tissue and aids in teaching bedside ultrasound-assisted LP. The model has an opaque "skin" overlying a gel wax mold containing a lumbar spine. A catheter containing water is imbedded in the spine to simulate the spinal canal and cerebrospinal fluid. The skin allows for a more realistic procedure and can be removed for visual confirmation of a successful LP. In addition, successful needle placement will result in return of clear fluid. Construction of the model requires a commercially available lumbar spine and items found in craft stores with a total cost of approximately $100. [source] Competence of New Emergency Medicine Residents in the Performance of Lumbar PuncturesACADEMIC EMERGENCY MEDICINE, Issue 7 2005Richard L. Lammers MD Abstract Background: Medical students are taught some procedural skills during medical school, but there is no uniform set of procedures that all students learn before residency. Objective: To determine the level of competence in the performance of a lumbar puncture (LP) by new postgraduate year 1 (PGY1) emergency medicine (EM) residents. Methods: An observational study was conducted at three EM residencies with 42 PGY1 residents who recently graduated from 26 various medical schools. The LP procedure was divided into 26 major and 44 minor steps to create a scoring protocol. The model, procedure, and scoring protocol were validated by experienced emergency physicians. Subjects performed the procedure without interruption or feedback on an LP training model using a standard LP kit. A step was scored as "performed correctly" if two of the three evaluators concurred. Pre- and poststudy questionnaires assessed subjects' prior instruction and clinical experience with LP, self-confidence, sense of relevance, motivation, and fatigue. Results: Subjects completed an average of 14.8 (57%; 95% confidence interval [95% CI] = 53% to 61%) of the major steps (range: 4,26) and 19.1 (43%; 95% CI = 42% to 45%) of the minor steps (range: 7,28) in 14.3 minutes (range: 3,22). Sixty-nine percent failed to obtain cerebrospinal fluid from the model. Subjects' levels of confidence changed slightly on a five-point scale from 2.8 ("little-to-some") before the test to 2.5 after the test. Eighty-three percent of the subjects previously performed LPs on patients during medical school (average attempts = 2.2; range: 0,10), but only 40% of those who did so were supervised by an attending during their first attempt. Conclusions: In the cohort studied, new PGY1 EM residents had not attained competence in performing LPs from training in medical school. Most new PGY1 residents probably require training, practice, and close, direct supervision of this procedure by attending physicians until the residents demonstrate competent performance. [source] Viral meningoencephalitis: a review of diagnostic methods and guidelines for managementEUROPEAN JOURNAL OF NEUROLOGY, Issue 8 2010I. Steiner Background:, Viral encephalitis is a medical emergency. The prognosis depends mainly on the pathogen and host immunologic state. Correct immediate diagnosis and introduction of symptomatic and specific therapy has a dramatic influence upon survival and reduces the extent of permanent brain injury. Methods:, We searched the literature from 1966 to 2009. Recommendations were reached by consensus. Where there was lack of evidence but consensus was clear, we have stated our opinion as good practice points. Recommendations:, Diagnosis should be based on medical history and examination followed by CSF analysis for protein and glucose levels, cellular analysis, and identification of the pathogen by polymerase chain reaction amplification (recommendation level A) and serology (level B). Neuroimaging, preferably by MRI, is essential (level B). Lumbar puncture can follow neuroimaging when immediately available, but if this cannot be performed immediately, LP should be delayed only under unusual circumstances. Brain biopsy should be reserved only for unusual and diagnostically difficult cases. Patients must be hospitalized with easy access to intensive care units. Specific, evidence-based, antiviral therapy, acyclovir, is available for herpes encephalitis (level A) and may also be effective for varicella-zoster virus encephalitis. Ganciclovir and foscarnet can be given to treat cytomegalovirus encephalitis, and pleconaril for enterovirus encephalitis (IV class evidence). Corticosteroids as an adjunct treatment for acute viral encephalitis are not generally considered to be effective, and their use is controversial, but this important issue is currently being evaluated in a large clinical trial. Surgical decompression is indicated for impending uncal herniation or increased intracranial pressure refractory to medical management. [source] Viral encephalitis: a review of diagnostic methods and guidelines for managementEUROPEAN JOURNAL OF NEUROLOGY, Issue 5 2005I. Steiner Viral encephalitis is a medical emergency. The spectrum of brain involvement and the prognosis are dependent mainly on the specific pathogen and the immunological state of the host. Although specific therapy is limited to only several viral agents, correct immediate diagnosis and introduction of symptomatic and specific therapy has a dramatic influence upon survival and reduces the extent of permanent brain injury in survivors. We searched MEDLINE (National Library of Medicine) for relevant literature from 1966 to May 2004. Review articles and book chapters were also included. Recommendations are based on this literature based on our judgment of the relevance of the references to the subject. Recommendations were reached by consensus. Where there was lack of evidence but consensus was clear we have stated our opinion as good practice points. Diagnosis should be based on medical history, examination followed by analysis of cerebrospinal fluid for protein and glucose contents, cellular analysis and identification of the pathogen by polymerase chain reaction (PCR) amplification (recommendation level A) and serology (recommendation level B). Neuroimaging, preferably by magnetic resonance imaging, is an essential aspect of evaluation (recommendation level B). Lumbar puncture can follow neuroimaging when immediately available, but if this cannot be obtained at the shortest span of time it should be delayed only in the presence of strict contraindications. Brain biopsy should be reserved only for unusual and diagnostically difficult cases. All encephalitis cases must be hospitalized with an access to intensive care units. Supportive therapy is an important basis of management. Specific, evidence-based, anti-viral therapy, acyclovir, is available for herpes encephalitis (recommendation level A). Acyclovir might also be effective for varicella-zoster virus encephalitis, gancyclovir and foscarnet for cytomegalovirus encephalitis and pleconaril for enterovirus encephalitis (IV class of evidence). Corticosteroids as an adjunct treatment for acute viral encephalitis are not generally considered to be effective and their use is controversial. Surgical decompression is indicated for impending uncal herniation or increased intracranial pressure refractory to medical management. [source] Adult T-cell lymphoma involving the leptomeninges associated with a spinal cord schwannomaNEUROPATHOLOGY, Issue 3 2001Toshiko Nagashima Adult T-cell lymphoma (ATL-L) developing initially in the meninges is rare. An autopsy case of ATL-L with an acute onset of meningitis and generalized lymphadenopathy in association with a cervical cord schwannoma is reported here. A 78-year-old woman with sensori-motor weakness of both arms over a 1-year period, developed febrile episodes and drowsiness with neck stiffness. Lumbar puncture revealed an increased protein content (161 mg/dL) and increased cell count (463/3) consisting of 99% of lymphocytes which contained atypical lymphocytes with multilobulated nuclei (,flower cells'), which are characteristic of ATL-L. Viral titers were positive only for HTLV-I antibodies (serum 3 640: CSF 3 16). Biopsy of an enlarged retroperitoneal lymph node revealed malignant lymphoma of the T-cell type. Brain MRI was negative, whereas an intradural extramedullary mass was found at the C4 level. With a diagnosis of ATL-L stage IV, chemotherapy was commenced, which was effective in reducing the generalized lymphadenopathy as well as the cervical mass and restoring the CSF findings to normality. The cervical cord mass was verified to be a solitary schwannoma, and ATL-L involvement was found not only in the leptomeninges, but also within the cervical cord schwannoma. [source] Model for Ultrasound-Assisted Lumbar Puncture TrainingACADEMIC EMERGENCY MEDICINE, Issue 2009Melissa Bollinger Lumbar puncture is an important diagnostic procedure in emergency medicine. Data have been published showing improved success rate with ultrasound assistance and the ability of emergency medicine physicians to recognize sonographic lumbar spinous anatomy. However, with educational models and the push for improved patient safety, procedural skills should be practiced on phantoms rather than the "see one, do one, teach one" of the past. There are no currently available phantoms for ultrasound-assisted lumbar puncture training. We have produced a phantom that can be used to train physicians on ultrasound-assisted lumbar puncture with respect to both imaging and procedural competency. A plastic fluid-filled bladder was immersed in gelled opacified mineral oil, a safe and easily used tissue mimic that obscures direct visualization of structures. Spinous anatomy is replicated with the use of wooden struts supporting wooden disks that mimic lumbar spinous processes. The spine analog was mounted over the plastic bladder and surrounded with gelled mineral oil. The phantom produces images similar to human lumbar anatomy. The phantom allows insertion of spinal needles into the "interspinous spaces" with inability to pass the needle outside of those locations. Fluid collection and repeated punctures can be performed on the phantom. Appearance and performance of the phantom were evaluated by physicians with expertise in ultrasound-assisted lumbar puncture. The only limitation is that external appearance is not realistic. This model performs well, is made from readily available materials, and can be used to train physicians in ultrasound-assisted lumbar puncture. [source] Lumbar puncture in thrombocytopenic childrenBRITISH JOURNAL OF HAEMATOLOGY, Issue 2 2004J. J. van Veen First page of article [source] Is AZOOR an autoimmune disease?ACTA OPHTHALMOLOGICA, Issue 2007SF SEIDOVA Purpose: Acute zonal occult outer retinopathy (AZOOR) is one of the "white dot syndromes" a clinically heterogeneous group of inflammatory chorioretinopathies. The etiology is not yet clear. Methods: We present a 50 years female patient with a prior history of migraine. She experienced progressive visual loss and visual field defects in the last 3 years. Preceding each episode she experienced blue flickering photopsias. Results: Visual acuity was 0,3 in the right eye and 0,6 in the left eye. Biomicroscopy showed a normal anterior segment, fundus exam revealed pigment epithelial atrophy more pronounced in the worse eye. Electrophysiology showed a marked reduction in the photopic ERG in the more affected eye. MRI demonstrated multiple white matter lesions including a corpus callosum location. Lumbar puncture showed oligoclonal bands. Further tests demonstrated hearing impairment. Therapy was instituted during the three years course of the disease with steroids, immune suppressants and plasmapheresis with visual loss being progressive. New photopsia is currently present. Conclusions: The etiology of AZOOR remains unclear. With our patient being one of the few described in the literature with concomitant multiple sclerosis, the question remains on whether there is an underlying common process of inflammatory autoimmune reactions. Whether treatment is possible, remains to be evaluated. [source] Competence of New Emergency Medicine Residents in the Performance of Lumbar PuncturesACADEMIC EMERGENCY MEDICINE, Issue 7 2005Richard L. Lammers MD Abstract Background: Medical students are taught some procedural skills during medical school, but there is no uniform set of procedures that all students learn before residency. Objective: To determine the level of competence in the performance of a lumbar puncture (LP) by new postgraduate year 1 (PGY1) emergency medicine (EM) residents. Methods: An observational study was conducted at three EM residencies with 42 PGY1 residents who recently graduated from 26 various medical schools. The LP procedure was divided into 26 major and 44 minor steps to create a scoring protocol. The model, procedure, and scoring protocol were validated by experienced emergency physicians. Subjects performed the procedure without interruption or feedback on an LP training model using a standard LP kit. A step was scored as "performed correctly" if two of the three evaluators concurred. Pre- and poststudy questionnaires assessed subjects' prior instruction and clinical experience with LP, self-confidence, sense of relevance, motivation, and fatigue. Results: Subjects completed an average of 14.8 (57%; 95% confidence interval [95% CI] = 53% to 61%) of the major steps (range: 4,26) and 19.1 (43%; 95% CI = 42% to 45%) of the minor steps (range: 7,28) in 14.3 minutes (range: 3,22). Sixty-nine percent failed to obtain cerebrospinal fluid from the model. Subjects' levels of confidence changed slightly on a five-point scale from 2.8 ("little-to-some") before the test to 2.5 after the test. Eighty-three percent of the subjects previously performed LPs on patients during medical school (average attempts = 2.2; range: 0,10), but only 40% of those who did so were supervised by an attending during their first attempt. Conclusions: In the cohort studied, new PGY1 EM residents had not attained competence in performing LPs from training in medical school. Most new PGY1 residents probably require training, practice, and close, direct supervision of this procedure by attending physicians until the residents demonstrate competent performance. [source] Witnessing invasive paediatric procedures, including resuscitation, in the emergency department: A parental perspectiveEMERGENCY MEDICINE AUSTRALASIA, Issue 3 2005Jonathon Isoardi Abstract Objective:, To determine whether parents prefer to be present during invasive procedures performed on their children in the ED. Methods:, A prospective study using a written survey was carried out in the ED of a secondary level regional hospital in south-east Queensland. The survey conducted between August 2003 and November 2003 consisted of parental demographics, seven theoretical paediatric procedural scenarios with increasing level of procedural invasiveness (including resuscitation) and reasons for the decisions of parents to either stay with the child or leave the room. Parents of children with Australasian Triage Scale (ATS) triage category 3, 4 and 5 were surveyed. Results:, Of 573 surveys collected, 553 (96.5%) were completed correctly. The number of parents expressing a desire to be present during a procedure performed on their child was 519 (93.9%) for phlebotomy or i.v. cannulation of an extremity, 485 (87.7%) for nasogastric tube insertion, 461 (83.4%) for lumbar puncture, 464 (83.9%) for urinary catheter insertion, 430 (77.8%) for suprapubic bladder aspiration, 519 (93.4%) during procedural sedation and 470 (85%) during a resuscitation where the possibility existed that their child may die. The most common reason for wanting to be present was to provide comfort to their child (542/98%). The most common reason for not wanting to be present was a parental concern of getting in the way (181/33%). Conclusion:, Most parents surveyed would want to be present when invasive procedures are performed on their children in the ED. With increasing invasiveness, parental desire to be present decreased. However, the overwhelming majority of parents would want to be in attendance during procedural sedation or resuscitation. [source] Incidence of Traumatic Lumbar PunctureACADEMIC EMERGENCY MEDICINE, Issue 2 2003Kaushal H. Shah MD Abstract Objective: To determine the incidence of traumatic lumbar puncture (LP). Methods: A retrospective study was conducted at an urban, university tertiary care referral center with 50,000 annual emergency department (ED) visits. The study population included all patients who had cerebrospinal fluid (CSF) samples sent to the laboratory between August 15, 2000, and August 14, 2001. The numbers of red blood cells (RBCs) recorded in the first and last CSF tubes, the location where the LP was performed, and the discharge summary and the discharge diagnoses from the particular visit were obtained. All patients with intracranial pathology and CSF obtained via neurosurgical procedure or fluoroscopic guidance were excluded from the study group. Given no clear definition of traumatic LP in the literature, the incidence of traumatic LP was calculated using a cutoff of greater than 400 RBCs (visual threshold for bloody fluid) and 1,000 RBCs (arbitrary threshold selected by other authors) in CSF tube 1. Proportions were compared using chi-square statistics. Results: Seven hundred eighty-six CSF samples were recorded over one year. Twenty-four samples were obtained from patients with intracranial pathology or were obtained via a neurosurgical procedure. Of the remaining 762 CSF samples in the study population, 119 (15.6%) were traumatic using a cutoff of 400 RBCs, and 80 (10.5%) were traumatic, using a cutoff of 1,000 RBCs in tube 1. Five hundred three LPs were done in the ED and 259 were attributed to all other locations in the hospital. Using a cutoff of 400 RBCs, the incidence of traumatic LP in the ED was 13.3%, compared with 20% in the rest of the hospital (p < 0.025). Similarly, using a cutoff of 1,000 RBCs, the incidence of traumatic LP in the ED was 8.9%, compared with 13.5% in the rest of the hospital (p = 0.1). The incidence of "champagne taps" (defined as zero RBCs in the first and last tubes) in the ED was 34.4%, compared with 24.3% in the rest of the hospital (p < 0.01). Conclusions: The incidence of traumatic lumbar puncture is approximately 15% using a cutoff of 400 RBCs and 10% using a cutoff of 1,000 RBCs. In this study, the rate of traumatic lumbar puncture was significantly less (with a cutoff of 400 RBCs) and the rate of champagne tap was significantly greater for LPs done in the ED compared with the rest of the hospital. [source] Cerebrospinal fluid biomarkers of white matter lesions , cross-sectional results from the LADIS studyEUROPEAN JOURNAL OF NEUROLOGY, Issue 3 2010M. Jonsson Background and purpose:, White matter lesions (WMLs) caused by small vessel disease are common in elderly people and contribute to cognitive impairment. There are no established biochemical markers for WMLs. We aimed to study the relation between degree of WMLs rated on magnetic resonance imaging of the brain and cerebrospinal fluid (CSF) levels of structural biomarkers associated with Alzheimer's disease (AD) and subcortical vascular dementia. Methods:, Fifty-three non-demented elderly individuals with WMLs were subjected to lumbar puncture. Degree of WMLs was rated using the Fazekas scale. Volumetric assessment of WMLs was performed. CSF samples were analyzed for the 40 and 42 amino acid fragments of amyloid ,, ,- and ,-cleaved soluble amyloid precursor protein, total tau (T-tau), hyperphosphorylated tau (P-tau181), neurofilament light protein (NFL), sulfatide and CSF/Serum-albumin ratio. Results:, Fifteen subjects had mild, 23 had moderate and 15 had severe degree of WMLs. CSF-NFL levels differed between the groups (P < 0.001) and correlated with the volume of WMLs (r = 0.477, P < 0.001). CSF sulfatide concentration displayed similar changes but less strongly. T-tau, P-tau181 and the different amyloid markers as well as CSF/S-albumin ratio did not differ significantly between the groups. Conclusions:, The association of increased CSF-NFL levels with increasing severity of WMLs in non-demented subjects suggests that NFL is a marker for axonal damage in response to small vessel disease in the brain. This manifestation may be distinct from or earlier than the neurodegenerative process seen in AD, as reflected by the lack of association between WMLs and AD biomarkers. [source] Post-Dural Puncture Headache: Part II , Prevention, Management, and PrognosisHEADACHE, Issue 9 2010David Bezov MD Post-dural puncture headache (PDPH) is a frequent complication of lumbar puncture, performed for diagnostic or therapeutic purposes or accidentally, as a complication of epidural anesthesia. As PDPH can be disabling, clinicians who perform these procedures should be familiar with strategies for preventing this disorder. Since the best preventative measures sometimes fail, clinicians should also be familiar with the therapeutic approaches for PDPH. Herein, we review the procedure-related risk factors for PDPH, the prognosis of PDPH and the studies of PDPH treatment. We divide the therapeutic approach to PDPH into 4 stages: conservative management, aggressive medical management, conventional invasive treatments, and the very rarely employed less conventional invasive treatments and provide management algorithm to facilitate treatment. [source] Acute Intracranial Hemorrhage in the Brain Caused by AcupunctureHEADACHE, Issue 5 2000Daniel Chung Ann Choo MD A 44-year-old Chinese man developed severe occipital headache, nausea, and vomiting during acupuncture treatment of the posterior neck for chronic neck pain. Computed tomography of the head showed hemorrhage in the fourth, third, and lateral ventricles. A lumbar puncture confirmed the presence of blood. Magnetic resonance angiography with gadolinium did not reveal any saccular aneurysms or arteriovenous malformations. The patient's headache resolved over a period of 28 days without any neurological deficits. Acupuncture of the posterior neck can cause acute intracranial hemorrhage. [source] Prevalence of Herniation and Intracranial Shift on Cranial Tomography in Patients With Subarachnoid Hemorrhage and a Normal Neurologic ExaminationACADEMIC EMERGENCY MEDICINE, Issue 4 2010Larry J. Baraff MD Abstract Objectives:, Patients frequently present to the emergency department (ED) with headache. Those with sudden severe headache are often evaluated for spontaneous subarachnoid hemorrhage (SAH) with noncontrast cranial computed tomography (CT) followed by lumbar puncture (LP). The authors postulated that in patients without neurologic symptoms or signs, physicians could forgo noncontrast cranial CT and proceed directly to LP. The authors sought to define the safety of this option by having senior neuroradiologists rereview all cranial CTs in a group of such patients for evidence of brain herniation or midline shift. Methods:, This was a retrospective study that included all patients with a normal neurologic examination and nontraumatic SAH diagnosed by CT presenting to a tertiary care medical center from August 1, 2001, to December 31, 2004. Two neuroradiologists, blinded to clinical information and outcomes, rereviewed the initial ED head CT for evidence of herniation or midline shift. Results:, Of the 172 patients who presented to the ED with spontaneous SAH diagnoses by cranial CT, 78 had normal neurologic examinations. Of these, 73 had initial ED CTs available for review. Four of the 73 (5%; 95% confidence interval [CI] = 2% to 13%) had evidence of brain herniation or midline shift, including three (4%; 95% CI = 1% to 12%) with herniation. In only one of these patients was herniation or shift noted on the initial radiology report. Conclusions:, Awake and alert patients with a normal neurologic examination and SAH may have brain herniation and/or midline shift. Therefore, cranial CT should be obtained before LP in all patients with suspected SAH. ACADEMIC EMERGENCY MEDICINE 2010; 17:423,428 © 2010 by the Society for Academic Emergency Medicine [source] Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute-onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?ACADEMIC EMERGENCY MEDICINE, Issue 4 2010Robert F. McCormack MD Abstract Objectives:, The primary goal of evaluation for acute-onset headache is to exclude aneurysmal subarachnoid hemorrhage (SAH). Noncontrast cranial computed tomography (CT), followed by lumbar puncture (LP) if the CT is negative, is the current standard of care. Computed tomography angiography (CTA) of the brain has become more available and more sensitive for the detection of cerebral aneurysms. This study addresses the role of CT/CTA versus CT/LP in the diagnostic workup of acute-onset headache. Methods:, This article reviews the recent literature for the prevalence of SAH in emergency department (ED) headache patients, the sensitivity of CT for diagnosing acute SAH, and the sensitivity and specificity of CTA for cerebral aneurysms. An equivalence study comparing CT/LP and CT/CTA would require 3,000 + subjects. As an alternative, the authors constructed a mathematical probability model to determine the posttest probability of excluding aneurysmal or arterial venous malformation (AVM) SAH with a CT/CTA strategy. Results:, SAH prevalence in ED headache patients was conservatively estimated at 15%. Representative studies reported CT sensitivity for SAH to be 91% (95% confidence interval [CI] = 82% to 97%) and sensitivity of CTA for aneurysm to be 97.9% (95% CI = 88.9% to 99.9%). Based on these data, the posttest probability of excluding aneurysmal SAH after a negative CT/CTA was 99.43% (95% CI = 98.86% to 99.81%). Conclusions:, CT followed by CTA can exclude SAH with a greater than 99% posttest probability. In ED patients complaining of acute-onset headache without significant SAH risk factors, CT/CTA may offer a less invasive and more specific diagnostic paradigm. If one chooses to offer LP after CT/CTA, informed consent for LP should put the pretest risk of a missed aneurysmal SAH at less than 1%. ACADEMIC EMERGENCY MEDICINE 2010; 17:444,451 © 2010 by the Society for Academic Emergency Medicine [source] Uncommon skin lesion in a patient with ataxia-telangiectasiaINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 10 2008Chinedu Ivonye MD A 20-year-old African-American man, with a history of ataxia-telangiectasia diagnosed at the age of one year, presented to the hospital with fever, cough, and headache of 2 days' duration. The fever was of high grade, associated with chills and rigors. The headache was frontal in location, constant, pounding in nature, and associated with photophobia and phonophobia; there was no neck pain, no neck stiffness, and no blurring of vision. The patient complained of facial pain. There were no relieving or aggravating factors. The family denied any change in mental status. ,The cough was productive of yellowish sputum. There was associated rhinorrhea. The patient complained of nausea and vomiting with the headache. A review of other systems was negative. ,On presentation in the emergency room, the patient was tachypneic, febrile, and tachycardic. He was oriented to time, place, and person. His neck was supple and meningeal signs were negative. He had maxillary sinus tenderness. Neurologic examination revealed nystagmus, ocular telangiectasia (Fig. 1), ataxia, and globally decreased muscle strength. Skin examination showed hypopigmented areas on all four extremities, the face, and neck (Figs 1,4), without involvement of the trunk. The rest of the physical examination was unremarkable. Figure 1. Area of vitiligo on the neck with premature graying of the hair Figure 2. Vitiligo on the hands Figure 3. Vitiligo involving the legs Figure 4. Ocular telangiectasia ,The leukocyte count was elevated at 19,600/mcL, with a differential of neutrophils (84%), monocytes (11%), and lymphocytes (5%). Hemoglobin and hematocrit were normal. Chemistry and chest X-ray were normal. ,Computed tomography scan of the head showed acute sinusitis and cerebellar atrophy consistent with ataxia-telangiectasia. ,A lumbar puncture was performed, and cerebrospinal fluid findings were suggestive of aseptic meningitis. ,The patient was treated for aseptic meningitis and acute sinusitis with acyclovir and ceftriaxone. The leukocyte count normalized, the patient remained afebrile, and was asymptomatic after 2 days of treatment with antimicrobials. The rest of the hospital stay was uneventful. [source] Acyclovir-induced neuropsychosis successfully recovered after immediate hemodialysis in an end-stage renal disease patientINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 8 2007Hung-Hsu Yang MD A 70-year-old man developed herpes zoster over the right L5,S2 region for 3 days and was admitted for acyclovir therapy. He had a medical history of rectal cancer status post-colostomy and end-stage renal disease undergoing thrice weekly hemodialysis. Without a prior loading dose, acyclovir 500 mg (7.7 mg/kg) daily was given intravenously in two divided doses. On the third dosage, the patient became confused and agitated and developed insomnia. Within the following 24 h, delirium, visual and auditory hallucinations, disorientation to place and time, as well as impaired recent memory occurred. At the same time, a transient low grade fever (38 °C) was noted but resolved spontaneously after ice pillow (Fig. 1). Figure 1. The clinical and treatment course of the patient The etiology was vigorously explored. He had no history of any neurological or psychiatric disorders. Drug history was reviewed, but no other medications besides acyclovir were currently being used. Physical examination revealed neither meningeal signs nor focal neurological deficits. Serum blood urea nitrogen, glucose, and electrolytes were within normal limits except for an elevated creatinine level at 6.2 and 5.7 mg/dl (before and after neuropsychotic symptoms, respectively). Complete blood count with differentiation was also unremarkable. Cerebrospinal fluid examination was not possible as the patient's family refused the lumbar puncture. Moreover, an electroencephalograph study and head computed tomography scan disclosed no abnormalities. Acyclovir-induced neurotoxicity was suspected. Therefore, acyclovir was discontinued. Subsequently, serum acyclovir and CMMG were checked by enzyme-linked immunosorbent assay. Serum acyclovir level was 1.6 mg/l (normal therapeutic level, 0.12,10.8 mg/l) and CMMG level was 5 mg/l. Emergent hemodialysis (4-h/session) was given; the neuropsychotic symptoms, including agitation, delirium, and visual and auditory hallucinations, greatly abated after the second session. The patient fully recovered after three consecutive days of hemodialysis; the serum was rechecked and revealed that the acyclovir level was below 0.5 mg/l and the CMMG level was undetectable. At the same time, his herpetic skin lesions resolved well. [source] Cryptococcal infection in sarcoidosisINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 11 2002Khosrow Mehrany MD A 48-year-old man with a history of sarcoidosis was transferred to the Mayo Clinic for evaluation and management of progressive neurologic decline. Two years before admission, he was admitted to a local hospital with mental status changes accompanied by ataxia and severe headache. A diagnosis of pulmonary and central nervous system sarcoidosis was made based on computed tomography of the head, lumbar puncture, and chest radiography. A mediastinoscopy with lymph node biopsy exhibited noncaseating granulomas and negative stains for microorganisms. Prednisone therapy was initiated at 80 mg/day. Clinical improvement was apparent for 13 months during steroid therapy until the slow taper reached a dosage of 20 mg/day. At that time, the patient was readmitted to the local hospital with severe confusion and skin lesions. When intravenous methylprednisolone therapy for presumed central nervous system sarcoidosis did not improve the patient's mental status, he was transferred to the Mayo Clinic. Physical examination of the thighs revealed large, well-marginated, indurated, irregularly bordered, violaceous plaques and rare, umbilicated, satellite papules with central hemorrhagic crusts (Fig. 1A). Superficially ulcerated plaques with a similar appearance to the thigh lesions were coalescing around the lower legs (Fig. 1B). A skin biopsy specimen of the thigh demonstrated abundant numbers of encapsulated organisms and minimal inflammatory response (Fig. 2). Skin, blood, and cerebrospinal fluid cultures confirmed the presence of Cryptococcus neoformans. Amphotericin and flucytosine combination therapy was initiated, and steroid dosages were gradually tapered. A test for human immunodeficiency virus was negative. The patient was dismissed from hospital after a complicated 2-month course resulting in improved mental status but progression of the lower extremity ulcerations as a result of polymicrobial infection. Figure 1. (A) Violaceous plaque with satellite papules on thigh. (B) Ulcerating plaques coalescing around leg Figure 2. (A) Sparse inflammatory infiltrate and abundant encapsulated organisms (hematoxylin and eosin; × 20). (B) Cryptococcal organisms (Gomori's methenamine silver; × 40) [source] Maximizing Clinical Research Participation in Vulnerable Older Persons: Identification of Barriers and MotivatorsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2008Edward R. Marcantonio MD OBJECTIVES: To identify barriers and motivators to participation in long-term clinical research by high-risk elderly people and to develop procedures to maximize recruitment and retention. DESIGN: Quantitative and qualitative survey. SETTING: Academic primary care medicine and pre-anesthesia testing clinics. PARTICIPANTS: Fifty patients aged 70 and older, including 25 medical patients at high risk of hospitalization and 25 patients with planned major surgery. MEASUREMENTS: Fifteen- to 20-minute interviews involved open- and closed-ended questions guided by an in-depth script. Two planned study protocols were presented to each participant. Both involved serial neuropsychological assessments, blood testing, and magnetic resonance brain imaging (MRI); one added lumbar puncture (LP). Participants were asked whether they would be willing to participate in these protocols, rated barriers and incentives to participation, and were probed with open-ended questions. RESULTS: Of 50 participants (average age 78, 44% male, 40% nonwhite), 32 (64%) expressed willingness to participate in the LP-containing protocol, with LP cited as the strongest disincentive. Thirty-eight (76%) expressed willingness to participate in the protocol without LP, with phlebotomy and long interviews cited as the strongest disincentives. Altruism was a strong motivator for participation, whereas transportation was a major barrier. Study visits at home, flexible appointment times, assessments shorter than 75 minutes, and providing transportation and free parking were strategies developed to maximize study participation. CONCLUSION: Vulnerable elderly people expressed a high rate of willingness to participate in an 18-month prospective study. Participants identified incentives and barriers that enabled investigators to develop procedures to maximize recruitment and retention. [source] Seizures, ataxia, developmental delay and the general paediatrician: Glucose transporter 1 deficiency syndromeJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 5 2006David J Coman Aim Glucose transporter 1 deficiency syndrome (GLUT1-DS) is an important condition for the general paediatrician's differential armamentarium. We describe a case series of eight patients in order to raise awareness of this treatable neurometabolic condition. The diagnosis of GLUT1-DS is suggested by a decreased absolute cerebrospinal fluid (CSF) glucose value (<2.2 mmol/L) or lowered CSF: plasma glucose ratio (<0.4). Methods This is a review of eight Queensland patients with GLUT1-DS. The clinical presentation, clinical course, laboratory investigations and treatment outcomes are discussed. Results The clinical features noted in our patient cohort include combinations of ataxia, developmental delay and a severe seizure disorder that is refractory to anticonvulsant medications. Seizures are the most common clinical manifestation and may be exacerbated by phenobarbitone. The paired CSF: plasma glucose results ranged from 0.2 to 0.39 (normal <0.6) with an average of 0.33. 3-O-Methyl-D-Glucose uptake and GLUT1 Genotyping analysis have been performed on five patients thus far. Rapid and impressive seizure control was observed in 100% of our patients once the ketogenic diet was instituted, with half of the cohort being able to wean completely from anticonvulsants. Conclusion Children presenting with a clinical phenotype consisting of a refractory seizure disorder, ataxia and developmental delay should prompt the consideration of Glucose transporter 1 deficiency syndrome. While the diagnostic test of lumbar puncture is an invasive manoeuvre, the diagnosis provides a viable treatment option, the ketogenic diet. GLUT1-DS displays clinical heterogeneity, but the value of early diagnosis and treatment is demonstrated by our patient cohort. [source] Cure of Acanthamoeba cerebral abscess in a liver transplant patientLIVER TRANSPLANTATION, Issue 3 2008Konrad Tang-Tat Fung Acanthamoeba-related cerebral abscess and encephalitis are rare but usually fatal, being caused by free-living amoebic infections usually occurring in immunocompromised patients. In patients receiving transplants, a literature review showed that the infection is universally fatal. The diagnosis is often missed despite appropriate investigations including lumbar puncture, computerized tomography, and brain biopsy. We present the first reported liver transplant patient with Acanthamoeba cerebral abscess. The diagnosis was made in brain tissue removed at decompressive frontal lobectomy. He was successfully treated with a 3-month course of co-trimoxazole and rifampicin. There was no recurrence of the disease after 11 years of follow-up. Liver Transpl 14:308,312, 2008. © 2008 AASLD. [source] Propofol or propofol,alfentanil anesthesia for painful procedures in the pediatric oncology wardPEDIATRIC ANESTHESIA, Issue 8 2004Margareta von Heijne MD PhD Summary Background :,For children with cancer receiving curative treatment, the pain of diagnostic and therapeutic procedures is often worse than that of the disease itself. In order to evaluate if light propofol anesthesia in the pediatric oncology ward (POW) could improve the management of procedure pain and anxiety, a questionnaire was developed. Methods :,After prolonged EMLA application, 65 propofol anesthetics were performed successfully in 28 children during lumbar puncture and/or bone marrow aspiration in the POW, with short recovery time and without major adverse events. The questionnaire was mailed to the parents of the 28 children who were included in the survey. Results :,The return of questionnaire compliance was 89% (25 of 28), 12 females and 13 males, mean age was 7 years (range 2,16). Among those who replied, the diagnoses were acute lymphatic leukemia in 21, lymphoma in two and tumor in the other two. In the questionnaire, all parents/patients reported advantages with anesthesia in the POW compared with the operating room. In the list of stated advantages, 88% marked ,familiar nurses and doctors', 84%,familiar environment', 80%,closer to own room', 68%,the child more calm', 72%,shorter waiting-time', 60%,faster recovery', 44%,shorter fasting-time' and 44%,parents more calm', as benefits. For future procedures requiring anesthesia to reduce pain, discomfort and/or anxiety, 92% of the parents/patients preferred anesthesia in the POW. Conclusions :,If anesthesia is chosen for invasive procedures, this study suggest that propofol anesthesia in the POW is preferred by parents and children. [source] Studies on cerebrospinal fluid ionized calcium and magnesium concentrations in convulsive childrenPEDIATRICS INTERNATIONAL, Issue 4 2004Yusaku Miyamoto AbstractBackground:,The concentrations of ionized calcium (iCa) and ionized magnesium (iMg) were measured in the cerebrospinal fluid (CSF) of convulsive and non-convulsive children, to investigate the relationship between seizure manifestation and CSF iCa and iMg concentrations. Standard concentrations of CSF iCa and iMg were also established. Methods:,CSF samples from 23 patients, ages 0,15 years, with various forms of seizures and 26 age-matched non-convulsive children were collected by lumbar puncture. CSF was obtained anaerobically and the concentrations of CSF iCa and iMg were measured with an electolyte analyzer (Stat Profile Ultra M1, NOVA, USA) immediately after the lumbar puncture. Results:,The concentrations of CSF iCa were significantly higher in non-convulsive children younger than 11 months old compared with children older than 12 months. The concentrations of CSF iMg in non-convulsive children did not differ significantly with aging. The concentrations of CSF iCa in convulsive children did not differ significantly from the concentrations of non-convulsive children. The concentrations of CSF iMg in convulsive children were significantly lower than in non-convulsive children. Conclusion:,These results suggest that seizure manifestation is related to age-dependent changes in iCa and decreased iMg in the developing brain. [source] The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure Hydrocephalus,THE LARYNGOSCOPE, Issue 2 2005Ricardo L. Carrau MD Abstract Objectives/Hypothesis: The transnasal endoscopic approach has become the preferred technique for the surgical management of patients with cerebrospinal fluid (CSF) leaks of the anterior, sellar, and parasellar skull base. The literature has reported an 85% to 100% success rate for the endoscopic repair of CSF leaks, which compares favorably with that reported after transcranial repair. Despite an adequate repair, a subpopulation of patients remain at high risk for recurrence of the CSF leak attributable to undiagnosed high-pressure hydrocephalus. Patients at high risk for high-pressure hydrocephalus include those who have had a subarachnoid hemorrhage as a result of trauma (accidental or surgical) or stroke and those with spontaneous CSF leaks. Study Design: With the goal of reducing the risk of recurrence, the authors developed a protocol for the identification and management of patients with CSF leaks who are at risk for high-pressure hydrocephalus. Methods: The protocol includes endoscopic repair, temporary CSF diversion, measurement of CSF pressure after the repair, and immediate ventriculoperitoneal shunting if necessary. Results: During the period of September 1999 to April 2002, the authors repaired 25 CSF leaks through an endonasal endoscopic approach. Nineteen patients were considered at high risk for high-pressure hydrocephalus. Using the protocol described, the authors identified six patients (31%) with CSF leaks that could be associated with undiagnosed high-pressure hydrocephalus. All CSF leaks were successfully repaired using a transnasal endoscopic repair. Six patients with high-pressure hydrocephalus underwent ventriculoperitoneal shunting after repair of the CSF Leak. No recurrence has been observed at a follow-up ranging from 24 to 84 months (median period, 30 mo). Conclusion: Patients with high-pressure hydrocephalus may be identified in a prospective fashion to prevent recurrence or persistence of the CSF leaks. The presence or absence of high-pressure CSF may be established by means of direct CSF pressure measurement through lumbar puncture postoperatively. This allows early intervention and prevention of recurrence. [source] Hip flexion for lumbar puncture , not easy in obstetric practiceANAESTHESIA, Issue 10 2001F. Plaat No abstract is available for this article. [source] Concentrations of ketone body and antidiuretic hormone in cerebrospinal fluid in response to the intra-ruminal administration of butyrate in suckling calvesANIMAL SCIENCE JOURNAL, Issue 6 2009Tsunenori IRIKI ABSTRACT The aim of the present study was to elucidate the mechanism by which ketone bodies increase antidiuretic hormone (ADH) secretion. Four male Holstein calves (5 weeks of age) were utilized. Four levels of butyrate (0 g, 11 g, 22 g and 44 g) were administrated intra-ruminally in a 4 × 4 Latin square design and cerebrospinal fluid (CSF, six-position lumbar puncture), blood plasma and urine were collected. The concentration of total plasma and CSF protein was 5.5,5.6 g/dL and 27.5,28.3 mg/dL, respectively. CSF concentrations of a specific ketone body, 3-hydroxybutyric acid, were significantly higher in the 22 g and 44 g butyrate groups than in the control group. CSF concentrations of ADH in the 11 g and 44 g butyrate groups were significantly higher than in the control group. Plasma concentration of 3-hydroxybutyric acid was increased by intraruminal administration of butyrate within 15 min in a dose-dependent manner, and it was higher in the 22 g and 44 g butyrate group than in the control group from 15 min to 4 h. With the exception of the 11 g butyrate group, plasma concentrations of ADH also increased in response to butyrate treatment, and it was higher in the 44 g butyrate group than in the 22 g butyrate group from 15 min to 1.5 h. The duration of the elevated plasma concentrations of ADH was shorter than that of the plasma concentration of 3-hydroxybutyric acid. The relationship between the plasma concentrations of ADH and 3-hydroxybutyric acid was statistically significant but the correlation between the two concentrations was not high. Butyrate treatment elevated the plasma concentration of ADH and also resulted in reduced urine volume and increased urine osmolality. Haematocrit (Ht) values, and the osmolality of CSF and plasma were not different among the groups. Our results suggested that the increased ADH secretion observed in suckling calves fed dry feeds was caused by butyrate-derived ketone body that crossed the blood-brain barrier rapidly. [source] | ||||||||||||||||||||||||||||