1/137. A 13-year-old with an acute change in mental status. A 13-year-old boy with Lennox-Gastaut syndrome characterized by absence, myoclonic, complex-partial, and secondarily generalized tonic-clonic seizures, presents with progressive obtundation and loss of motor and verbal skills over a 2-day period. Initial evaluation revealed therapeutic phenytoin serum concentrations. This article discusses the differential diagnosis and management approach used in this setting, as well as the appropriate interpretation of antiepileptic drug serum concentrations. ( info) |
2/137. A case of marchiafava-bignami disease: MRI findings on spin-echo and fluid attenuated inversion recovery (FLAIR) images. marchiafava-bignami disease (MBD) was diagnosed in a 56-year-old man. Spin-echo (SE) magnetic resonance imaging (MRI) at the acute phase showed normal signal areas in the central layer of the corpus callosum (CC), although the intensity of these areas revealed abnormal hyperintensity on fluid attenuated inversion recovery (FLAIR). On follow-up SE MRI at the late phase, the central layer of the CC showed fluid-like intensity. On FLAIR MRI, the lesions of the CC turned into hypointense cores surrounded by hyperintense rims indicating central necrosis and peripheral demyelination. Degenerative changes of the CC in MBD were clearly demonstrated by FLAIR MRI. ( info) |
3/137. A case of sinus pause due to the proarrhythmia of pilsicainide. A 74-year-old man received oral administration of pilsicainide, a pure sodium channel blocker with slow recovery kinetics, to convert paroxysmal atrial fibrillation to sinus rhythm and developed loss of consciousness two days later. The ECG monitoring revealed sinus pause with markedly prolonged PQ interval and QRS width. Two days after the drug was discontinued, the duration of the QRS complex was normalized. This drug is rapidly absorbed from the gastrointestinal tract, most of which is excreted from the kidney. The plasma concentration of pilsicainide, although not measured, must have been very high, since his renal function was impaired. When pilsicainide is prescribed in patients with coronary artery disease or renal dysfunction, close attention must be paid to avoid life-threatening arrhythmias due to high plasma concentrations of the drug. This is an interesting case because the proarrhthmia of the drug was not tachyarrhythmia, such as ventricular tachycardia or torsades de pointes, but sinus pause. ( info) |
4/137. Cerebral embolization presenting as delayed, severe obtundation in the postanesthesia care unit after total hip arthroplasty. Catastrophic neurologic events occur rarely postoperatively and must be diagnosed quickly. A 63-year-old woman who had undergone uneventful total hip arthroplasty experienced obtundation after admission to the postanesthesia care unit. Cranial magnetic resonance imaging revealed multiple lesions consistent with ischemia or infarction, and fat cerebral embolism was diagnosed. We describe the numerous complications that may occur in patients in the postanesthesia care unit and review the differential diagnosis of altered mental status in such patients. Paradoxical cerebral fat embolization must be considered in the differential diagnosis of altered mental status after pelvic or long bone fracture or lower extremity major joint replacement, and this condition may occur despite normal pulmonary function and no patent foramen ovale or right-to-left intracardiac shunt. magnetic resonance imaging with T2-weighted sequences is the cranial imaging study of choice for early evaluation of patients with sudden multifocal neurologic deficits and suspected fat embolism syndrome. ( info) |
5/137. Conceptual dilemmas in evaluating individuals with severely impaired consciousness. States of severely impaired consciousness (SIC) are characterized by cognitive and motor limitations. This case report describes a 45-year-old female with impaired consciousness who began to 'walk'. She initially presented to the hospital unresponsive and was subsequently diagnosed with metabolic encephalopathy due to severe hypoglycaemia. Traditional indices of consciousness indicated a low level of responsiveness; however, during physical therapy, she displayed reciprocal walking movements when lifted to a standing position by two therapists. Despite her ability to walk increased distances during and after neurorehabilitation, she was unable to consistently demonstrate responses indicative of higher levels of consciousness. This case illustrates the challenge of rating patients with limited behavioural repertoire using established measures of impaired consciousness. ( info) |
6/137. Transcendental meditation, altered reality testing, and behavioral change: a case report. This paper presents the case of a 39-year-old woman who, several weeks following initiation into transcendental meditation (TM), experienced altered reality testing and behavior. We discuss the course of this episode, present evidence for a causal relationship between her practive of TM and altered behavior, and discuss the appropriate treatment of such phenomena. ( info) |
7/137. Type II (adult onset) citrullinaemia: clinical pictures and the therapeutic effect of liver transplantation. OBJECTIVE: adult onset type II citrullinemia is an inherited disorder of amino acid metabolism caused by a deficiency of liver specific argininosuccinate synthetase activity. Most of the patients with this disease were reported in japan and therefore, this disease has not been well recognised outside this country. The detailed clinical pictures of the patients with type II citrullinaemia are reported and their outcomes after liver transplantation referred to. methods: Ten patients with this disease were evaluated. Seven of them underwent liver transplants using a graft obtained from a healthy family member. RESULTS: There were six men and four women; the age of onset of encephalopathy ranged from 17 to 51 years. The initial symptom in nine patients was sudden onset disturbance of consciousness, and one patient had long been regarded as having a chronic progressive psychotic illness. High concentrations of plasma citrulline and ammonia were commonly seen on admission. Although brain CT or MRI lacked any consistent findings, the EEG was abnormal in all patients, showing diffuse slow waves. Additionally, in five patients chronic pancreatitis preceded the onset of encephalopathy. After liver transplantation the metabolic abnormalities, including abnormal plasma concentrations of citrulline and ammonia, were immediately corrected and all neuropsychic symptoms soon disappeared, except for impaired cognitive function in one patient. Six out of these seven patients returned to their previous social lives, including work. CONCLUSIONS: The clinical concept of adult onset type II citrullinaemia coincides well with the range of hepatic encephalopathy, and liver transplantation is a very promising therapeutic approach. ( info) |
8/137. Late recovery from head injury: case report and review. Some problems of prognosis in patients with head injury are reviewed, and a case of late and unexpected recovery from post-traumatic dementia presented. The possible mechanism of recovery is discussed with particular reference to normal pressure hydrocephalus. ( info) |
9/137. Infra-posterior inferior cerebellar artery aneurysm arising after occlusion of the ipsilateral vertebral artery--case report. An 85-year-old woman had subarachnoid hemorrhage due to rupture of a very rare left infra-posterior inferior cerebellar artery (pica) aneurysm, a saccular aneurysm located proximally at the junction of vertebral artery (VA) and pica. Right vertebral angiography demonstrated the aneurysm since the left VA was occluded in the extracranial portion. The aneurysm projected in the opposite direction to common VA-pica aneurysms. The angiographical and intraoperative findings imply this rare aneurysm resulted from the hemodynamic changes caused by the VA occlusion. Detailed exploration of angiography is emphasized to detect such rare aneurysms among the diversity of hemodynamic patterns in elderly patients with subarachnoid hemorrhage. ( info) |
10/137. Operationalizing trance II: clinical application using a psychophenomenological approach. Although many clinicians use the word "trance" to describe the subjective effects associated with being hypnotized, heretofore there has been no means to operationalize that concept. In a prior paper (Pekala & Kumar, 2000) the authors operationalized the notion of trance by using a retrospective, self-report instrument, the Phenomenology of consciousness Inventory (PCI), to quantify the subjective experience of being hypnotized. Trance was operationalized in terms of: hypnotic depth via a pHGS (predicted Harvard Group Scale) score (derived from regression analysis using subdimensions of the PCI) that gives a quantitative measure of subjective trance depth; and trance typology profiles (derived from cluster and discriminant analyses of the PCI dimensions and subdimensions) that give a qualitative measure of empirically derived clusters of subjective trance experiences. These measures, when used in conjunction with data on the individual PCI dimensions and subdimensions, provide the clinician with specific information on phenomenological events experienced by the client during hypnosis which can be used in better adapting hypnotic suggestions to the client's phenomenological world. Two clinical cases are presented in which use of the above approach has been helpful in facilitating treatment planning. ( info) |