1/10. Fatal subarachnoid hemorrhage after endoscopic third ventriculostomy. Case report.In recent years, endoscopic third ventriculostomy has become a well-established procedure for the treatment of various forms of noncommunicating hydrocephalus. Endoscopic third ventriculostomy is considered to be an easy and safe procedure. Complications have rarely been reported in the literature. The authors present a case in which the patient suffered a fatal subarachnoid hemorrhage (SAH) after endoscopic third ventriculostomy. This 63-year-old man presented with confusion and drowsiness and was admitted in to the hospital in poor general condition. Computerized tomography scanning revealed an obstructive hydrocephalus caused by a tumor located in the cerebellopontine angle. An endoscopic third ventriculostomy was performed with the aid of a Fogarty balloon catheter. Some hours postoperatively, the patient became comatose. Computerized tomography scanning revealed a severe perimesencephalic-peripontine SAH and progressive hydrocephalus. Despite emergency external ventricular drainage, the patient died a few hours later. Although endoscopic third ventriculostomy is considered to be a simple and safe procedure, one should be aware that severe and sometimes fatal complications may occur. To avoid vascular injury, perforation of the floor of the third ventricle should be performed in the midline, halfway between the infundibular recess and the mammillary bodies, just behind the dorsum sellae.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
2/10. Spontaneous intracranial hypotension causing confusion and coma: a headache for the neurologist and the neurosurgeon.Spontaneous intracranial hypotension presenting with confusion and coma has rarely been reported. A case is presented and the clinical features of spontaneous intracranial hypotension are discussed.- - - - - - - - - - ranking = 5keywords = coma (Clic here for more details about this article) |
3/10. Acute transient cerebral toxicity associated with administration of high-dose methotrexate.OBJECTIVE: To report the first case of transient central nervous system toxicity after administration of high-dose methotrexate (HDMTX) in the middle east. CLINICAL PRESENTATION: A 10-year-old boy was diagnosed with osteosarcoma of the proximal end of the left tibia. He underwent primary amputation and was started on adjuvant chemotherapy, which included administration of HDMTX. He developed acute cerebral toxicity after the 5th dose of HDMTX in the form of diplopia, seizures and disorientation. He recovered completely without any complication or neurological sequelae. CONCLUSION: The acute cerebral toxicity associated with HDMTX was completely reversible and without any sequelae.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
4/10. Prolonged confusion following convulsions due to generalized nonconvulsive status epilepticus.Among patients with a prolonged confusional state after convulsive seizure, we diagnosed 8 cases as generalized nonconvulsive status epilepticus. Six had a history of seizures, and 2 had new onset. The convulsive seizures were generalized in 6 and focal in two. The postictal confusion lasted up to 36 hours in the most prolonged case, and a delayed response to anticonvulsant medications occurred in all cases. The clinical symptoms ranged from mild confusion to coma. Psychiatric manifestations or automatisms were rare. The presumed etiology was due to diverse causes, but a withdrawal state was the most common. EEG demonstrated continuous or nearly continuous generalized ictal discharges of variable morphology. These cases call attention to the fact that some prolonged confusional states following convulsive seizures are in fact due to persistent seizure activity that can be diagnosed by EEG.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
5/10. lithium toxicity presenting as mania.Acute lithium toxicity generally presents with a change in mental status, usually seen as lethargy progressing to coma as poisoning becomes more severe. We discuss three patients who presented with mild lithium toxicity. In two patients the presentation mimicked mania, but the third presented with a more typical toxic confusion state. Improvement in all cases paralleled the drop in serum lithium levels. This uncommon presentation of lithium toxicity is not adequately stressed in the literature.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
6/10. neurologic manifestations of legionnaires' disease.The neurologic manifestations of legionnaires' disease were reviewed in this paper. Nine (42.9%) of 21 patients seen at this institution had neurologic abnormalities during acute infection, comparable to 52% of patients found in the literature. Abnormal mentation was most common, occurring in all our patients and in 29.6% of patients in the literature. Encephalopathy disproportionate to metabolic disturbances varied from mild confusion to coma, was not associated with increased mortality, and tended to resolve with acute illness although some patients reported persistent memory defects. Rarely did these changes in mentation precede the development of pulmonary infiltrates. headache occurred in two (22.2%) of our patients and in 28.7% of those in the literature. headache, noted in many febrile illnesses, is common but nonspecific in legionnaires' disease. Other neurologic abnormalities including cerebellar dysfunction and focal deficits were relatively infrequent and tended to persist beyond resolution of clinical infection. In some cases these neurologic derangements may have occurred coincidentally with legionnaires' disease. Diagnostic evaluations and autopsies were frequently normal, nonspecific, or revealing of pathology unrelated to infection. Only two patients had evidence of direct invasion of the central nervous system by legionella, and the cause of encephalopathy and neurologic abnormalities in most cases remains unclear. patients with neurologic abnormalities and legionnaires' disease deserve full evaluation to exclude other entities. Only encephalopathy appears to be a characteristic manifestation of legionnaires' disease.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
7/10. Neurological aspects of insulinomas.Neurological involvement occurred in every one of a series of 30 patients with an insulinoma. The episodic nature of the hypoglycaemia caused symptoms and signs to fluctuate and often led to delay in diagnosis (mean length of history was 3 years). The commonest feature at first presentation was confusion (20 instances), but as the illness evolved, coma (16 instances) and convulsions (8 instances) became more frequent. Objective weakness was found in 7 patients, with 3 examples of hemiparesis and 2 each of paraparesis and monoparesis; in all, the weakness resolved over a period of 1 hr to 3 days when normoglycaemia was maintained. Other neurological features included subjective visual disturbances, headache, dysarthria and ataxia. 220 patients with an insulinoma from 7 series in the literature were reviewed. The high incidence of neurological features was confirmed, with confusion (152 cases), coma (82 cases) and convulsions (58 cases) predominating. Visual disturbances were common, though not accurately quantified in some series. Objective evidence of weakness on the other hand was reported in only 6 of the 222 patients. Other less common symptoms included headache (18 instances) and peripheral paraesthesiae (14 instances). In the 7 series reviewed, as in our own, it was found that in any one patient, each episode of hypoglycaemia was accompanied by the same symptom complex. The presence of an insulinoma should be considered in any patient with unusual, or inexplicable neurological features, particularly when they are intermittent. The diagnosis can be confirmed by demonstrating an inappropriately high circulating insulin level, for the ambient blood glucose concentration.- - - - - - - - - - ranking = 2keywords = coma (Clic here for more details about this article) |
8/10. cimetidine neurotoxicity. EEG and behaviour aspects.cimetidine-related neurotoxicity may be characterized by signs of affective dysfunction, toxic delusional state and/or delirium, confusion and/or amnestic signs, coma, epileptic phenomena and focal neurological signs. EEG features are rarely mentioned in the literature. They are discussed here in a patient presenting with cimetidine-related mental impairment and epileptic seizures. Some of the clinical signs are related to our incomplete understanding of the neurotransmitter function of histamine in the brain. It is suggested that transient functional deafferentiation of the cortex may occur with chemical histamine receptor blockade at brain stem level. EEG monitoring may be helpful in patients at risk.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
9/10. Acute confusion induced by a high-dose infusion of 5-fluorouracil and folinic acid.A 61-year-old man was treated with combination chemotherapy incorporating cisplatinum, etoposide, high-dose 5-fluorouracil (2,250 mg/m2/24 hours) and folinic acid for an inoperable gastric adenocarcinoma. He developed acute neurologic symptoms of mental confusion, disorientation and irritability, and then lapsed into a deep coma, lasting for approximately 40 hours during the first dose (day 2) of 5-fluorouracil and folinic acid infusion. This complication reappeared on day 25 during the second dose of 5-fluorouracil and folinic acid, which were then the only drugs given. Because folinic acid was unlikely to be associated with this condition, neurotoxicity due to high-dose 5-fluorouracil was highly suspected. The pathogenesis of 5-fluorouracil neurotoxicity may be due to a Krebs cycle blockade by fluoroacetate and fluorocitrate, thiamine deficiency, or dihydrouracil dehydrogenase deficiency. High-dose 5-fluorouracil/folinic acid infusion therapy has recently become a popular regimen for various cancers. It is necessary that both oncologists and neurologists be fully aware of this unusual complication.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
10/10. Management of acute confusion in the elderly.Acute confusion in the elderly as a presenting symptom in an accident and emergency department requires just the same energy devoted to diagnosis as does, say for example, acute coma, epilepsy or haematemesis. Doctors in accident and emergency departments are reminded not to succumb to the pitfalls of assuming that acute confusion is merely part of a progressive dementia in an elderly person and therefore incapable of treatment. In this paper a number of clinical examples are given where treatment of the cause of the acute confusion has led to restoration of the patient's independent existence. In passing, the abbreviated mental test score is commended to accident and emergency doctors as being just as useful in a different context as the worldwide acceptance has been of the Glasgow Coma Score. Currently the standard abbreviated mental test score seems confined to the United Kingdom as part of the generally accepted practice.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
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