Cases reported "Coma"

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1/8. Tight Sylvian cisterns associated with hyperdense areas mimicking subarachnoid hemorrhage on computed tomography--four case reports.

    Four patients with supratentorial mass lesions (two chronic subdural hematomas, one acute epidural hematoma, and one acute subdural hematoma) showed hyperdense sylvian cisterns on computed tomography (CT). association of subarachnoid hemorrhage was suspected initially, but was excluded by intraoperative observation or postoperative lumbar puncture. CT showed disappearance of the hyperdense areas just after evacuation of the mass lesions. The hyperdense areas are probably a result of the partial volume phenomenon or concentrations of calcium deposits rather than abnormally high hematocrit levels, which were not found in these patients.
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2/8. Intrathecal saline infusion in the treatment of obtundation associated with spontaneous intracranial hypotension: technical case report.

    OBJECTIVE AND IMPORTANCE: Spontaneous intracranial hypotension is an increasingly recognized cause of postural headache. However, appropriate management of obtundation caused by intracranial hypotension is not well defined. CLINICAL PRESENTATION: A 43-year-old man presented with postural headache followed by rapid decline in mental status. Imaging findings were consistent with the diagnosis of spontaneous intracranial hypotension, with bilateral subdural hematomas, pachymeningeal enhancement, and caudal displacement of posterior fossa structures and optic chiasm. INTERVENTION: Despite treatment with lumbar epidural blood patch, worsening stupor necessitated intubation and mechanical ventilation. Contrast-enhanced magnetic resonance imaging and computed tomographic myelography of the spine failed to demonstrate the site of cerebrospinal fluid fistula. The enlarging subdural fluid collections were drained, and a ventriculostomy was performed. Postoperatively, the patient remained semicomatose. To restore intraspinal and intracranial pressures, intrathecal infusion of saline was initiated. After several hours of lumbar saline infusion, lumbar and intracranial pressures normalized, and the patient's stupor resolved rapidly. Repeat computed tomographic myelography accomplished via C1-C2 puncture demonstrated a large ventrolateral T1-T3 leak, which was treated successfully with a thoracic epidural blood patch. Follow-up magnetic resonance imaging demonstrated resolution of intracranial hypotension, and the patient was discharged in excellent condition. CONCLUSION: Spontaneous intracranial hypotension may cause a decline of mental status and require lumbar intrathecal saline infusion to arrest or reverse impending central (transtentorial) herniation. This case demonstrates the use of simultaneous monitoring of lumbar and intracranial pressures to appropriately titrate the infusion and document resolution of intracranial hypotension. Maneuvers aimed at sealing the cerebrospinal fluid fistula then can be performed in a less emergent fashion after the patient's mental status has stabilized.
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3/8. Rapid cognitive decline following lumbar puncture in a patient with a dural arteriovenous fistula.

    BACKGROUND: Dural arteriovenous fistulas (DAVFs) are frequently accompanied with raised intracranial pressure and clinical findings suggestive of pseudotumor cerebri. However, unlike pseudotumor cerebri, the clinical response to lumbar cerebrospinal fluid (CSF) removal can vary from beneficial to acute clinical deterioration leading to death. The criteria for the safe use of lumbar puncture (LP) in patients with a DAVF are not well established. methods: A 61-year-old man presented with visual difficulty. magnetic resonance imaging (MRI) and angiography revealed a left transverse sinus DAVF. He underwent multiple embolizations of arterial feeders over 3 years. He was then noted to have cognitive deficits in short term memory, listening, and concentrating. Over several days after an LP he became increasingly lethargic but arousable. Within hours after a repeat LP there was a rapid deterioration in the patient's level of consciousness and he became unarousable. RESULTS: A brain MRI revealed extensive dilated cortical veins and left temporal lobe venous ischemia without tonsillar herniation. A cerebral angiogram showed an extensive left transverse sinus DAVF with an occluded lateral transverse sinus and increased retrograde venous drainage. Embolization of the arterial feeders in combination with trans-venous coil embolization of the left transverse sinus reversed the patient's neurologic decline. He was discharged neurologically intact except for his chronic visual acuity problems. CONCLUSION: We speculate that when a DAVF manifests retrograde venous flow sufficient to cause cognitive deficits, lumbar CSF drainage must be undertaken with extreme caution.
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4/8. survival after treatment of rabies with induction of coma.

    We report the survival of a 15-year-old girl in whom clinical rabies developed one month after she was bitten by a bat. Treatment included induction of coma while a native immune response matured; rabies vaccine was not administered. The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Probable drug-related toxic effects included hemolysis, pancreatitis, acidosis, and hepatotoxicity. Lumbar puncture after eight days showed an increased level of rabies antibody, and sedation was tapered. paresis and sensory denervation then resolved. The patient was removed from isolation after 31 days and discharged to her home after 76 days. At nearly five months after her initial hospitalization, she was alert and communicative, but with choreoathetosis, dysarthria, and an unsteady gait.
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5/8. Brainstem anaesthesia after retrobulbar block: a rare cause of coma presenting to the emergency department.

    Local anaesthesia, in particular retrobulbar block, is commonly used to perform cataract surgery. Known complications of retrobulbar block include cranial nerve palsies, seizures and cardiorespiratory arrest. We report a case of brainstem anaesthesia causing apnoea and loss of consciousness in a man who received retrobulbar block. The likely mechanism is inadvertent dural puncture of the optic nerve sheath and local anaesthetic injection into the cerebrospinal fluid space. As in this case, the literature reports a short-lived period of anaesthesia with usually no long-term sequelae. Although rare, it is a life-threatening complication if the patient is not appropriately resuscitated. This case highlights the need for trained personnel, with suitable monitoring and adequate resuscitation facilities in order to perform this technique.
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6/8. Treatment of impaired consciousness with lumbar punctures in a patient with cryptococcal meningitis and AIDS.

    A 50 year old man with AIDS, cryptococcal meningitis and a normal CT-scan developed impaired consciousness and even deep coma associated with very high CSF pressure. After lumbar CSF drainage consciousness improved dramatically. We conclude that in patients with cryptococcal meningitis who have impaired consciousness and a normal CT scan, CSF drainage to improve the level of consciousness should be considered.
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7/8. acupuncture treatment of syncope based on differentiation of signs and symptoms.

    1. The three typical cases reported above were syncopic patients of different types. Case 1 belonged to yin-depletion syndrome, case 2 pertained to yang-depletion syndrome, and case 3 Jue syndrome due to disturbance between qi and the blood induced by deficiency of qi and accumulation of phlegm. All of the three cases were satisfactorily cured with acupuncture and moxibustion though they did not respond to western medicines. 2. The rationale of acupuncture treatment for syncope includes: 1) Regulating yin and yang: For yin-depletion syndrome, reinforcing method is mainly adopted for nourishing water to promote reproduction of the body fluids and replenishing yin to restore yang; in case of yang-depletion syndrome, moxibustion and needle-warming methods are mainly used for recuperating the depleted yang to rescue the patient from collapse and for invigorating yang to restore yin. 2) Resuscitating the patient by regulating qi and the blood and dredging the channels to activate the circulation. After a successful resuscitation, the patient should be radically treated with appropriate herbal medicines so as to consolidate the therapeutic efficacy. 3. An emergency treatment for syncopal patients with acupuncture and moxibustion must be based on a conscientious differentiation of the signs and symptoms. The treatment should strictly follow the therapeutic principles: reinforce for the deficiency, reduce for the excess, cool the heat and warm the cold.
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8/8. Can seizures be the sole manifestation of meningitis in febrile children?

    OBJECTIVE. It is frequently taught that lumbar puncture is a mandatory procedure in many or all children who have fever and a seizure, because the convulsion may represent the sole manifestation of bacterial meningitis. We attempted to determine the incidence of this occult manifestation of meningitis. DESIGN. Retrospective case series. SETTING AND patients. 503 consecutive cases of meningitis in children aged 2 months to 15 years seen at two referral hospitals during a 20-year period. MAIN OUTCOME MEASURES. signs and symptoms of meningitis in patients having associated seizures. RESULTS. meningitis was associated with seizures in 115 cases (23%), and 105 of these children were either obtunded or comatose at their first visit with a physician after the seizure. The remaining 10 had relatively normal levels of consciousness and either were believed to have viral meningitis (2) or possessed straightforward indications for lumbar puncture: nuchal rigidity (6), prolonged focal seizure (1), or multiple seizures and a petechial rash (1). No cases of occult bacterial meningitis were found. CONCLUSION. In our review of 503 consecutive children with meningitis, none were noted to have bacterial meningitis manifesting solely as a simple seizure. We suspect that this previously described entity is either extremely rare or nonexistent. Commonly taught decision rules requiring lumbar puncture in children with fever and a seizure appear to be unnecessarily restrictive.
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