Cases reported "Consciousness Disorders"

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1/62. 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.
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2/62. 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.
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3/62. 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.
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4/62. Unusual arachnoid cyst of the quadrigeminal cistern in an adult presenting with apneic spells and normal pressure hydrocephalus--case report.

    A 67-year-old woman was admitted to our clinic with symptoms of normal pressure hydrocephalus, lower cranial nerve pareses, and pyramidal and cerebellar signs associated with respiratory disturbances. Computed tomography (CT) and magnetic resonance imaging revealed a 4.7 x 5.4 cm quadrigeminal arachnoid cyst causing severe compression of the tectum and entire brain stem, aqueduct, and cerebellum, associated with moderate dilation of the third and lateral ventricles. Emergency surgery was undertaken due to sudden loss of consciousness and impaired breathing. The cyst was totally removed by midline suboccipital craniotomy in the prone position. Postoperatively, her symptoms improved except for the ataxia and impaired breathing. She was monitored cautiously for over 15 days. CT at discharge on the 18th postoperative day revealed decreased cyst size to 3.9 x 4.1 cm. Histological examination confirmed the diagnosis of the arachnoid cyst of the quadrigeminal cistern. The patient died of respiratory problems on the 5th day after discharge. Quadrigeminal arachnoid cysts may compress the brain stem and cause severe respiratory disturbances, which can be fatal due to apneic spells. patients should be monitored continuously in the preoperative and postoperative period until the restoration of autonomous ventilation is achieved.
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5/62. The minimally conscious state in children.

    The minimally conscious state (MCS) is a condition of severely altered consciousness in which minimal but definite behavioral evidence of self- or environmental awareness is shown. Diagnostic criteria recently have been proposed for entry into and emergence from the MCS. We present clinical and neuroimaging data on 5 children diagnosed with MCS and discuss the limited information available concerning its epidemiology, etiology, pathology, and prognosis. Issues related to the evaluation and care of children suspected of having MCS are also reviewed as well as current ethical and legal controversies.
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6/62. Recovery from marked altered consciousness in a patient with adult-onset type II citrullinemia diagnosed by dna analysis and treated with a living related partial liver transplantation.

    A 21-year-old woman was admitted with altered consciousness and hyperammonemia. She was diagnosed as having adult-onset type II citrullinemia (CTLN2) by dna analysis. The patient had mutations of the SLC25A13 gene, which were compound heterozygotes of 851 del 4 and IVS11 1G>A. CTLN2 has a poor prognosis, in spite of various intensive medications, and we performed a living related partial liver transplantation (LRLT). Over a 2-year follow-up, the patient has been well. CTLN2 can be diagnosed by the dna analysis and can be treated by LRLT.
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7/62. Star fruit (Averrhoa carambola) intoxication: an important cause of consciousness disturbance in patients with renal failure.

    Star fruit intoxication is a rare cause of consciousness disturbance in patients with renal failure. Most cases in the literature are uremic patients on maintenance dialysis. We present a patient with chronic renal failure, who was not on dialysis program yet, suffered from star fruit intoxication with presentation of consciousness disturbance and successfully managed by a session of hemodialysis.
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8/62. Ready to go.

    The patient with a decreased level of consciousness in the absence of trauma presents difficult assessment and intervention problems. This is compounded when the history is vague or nonspecific. In this case, the patient's history of embolic CVA alerted providers to the possibility of another thrombus. This patient's sudden symptoms could have resulted from a clot in the brain, heart or aorta. This patient presented with an altered level of consciousness, vomiting and low blood pressure. As is typical in elderly female patients, she had an unusual presentation of an MI. A myocardial infaction is classified as either transmural or subendocardial. A transmural infarct extends through the full thickness of the myocardium and holds greater-risk of complications due to loss of functional muscle. In a subendocardial infarct, necrosis is limited to the endocardial surface. Although many elderly patients present with subendocardial MIs, this one had a large transmural MI. In general, the circumflex artery serves the lateral and posterior walls of the myocardium, and the right coronary artery (RCA) serves the inferior wall. In an anterior MI, the left anterior descending artery (LAD) is obstructed. This vessel serves the left ventricle, parts, of the septum and paillary muscles. The LAD is often referred to as the "widowmaker" because left ventricular infarcts have a high incidence of mortality. Occlusion of LAD can cause the usual damage of an MI, and can also cause fatal damage to the valves. This patient was in profound cardiogenic shock -- the left ventricle had infarcted and was unable to maintain cardiac output. Because of her recent stroke, she was not a candidate for thrombolytic medication. With ultrasonography, a large area of the anterior wall was found to be akinetic, or not functioning at all. In this care, the sourrounding myocardium not only has to pump blood with less muscle but also to "drag" the dead tissue. This results in a progressively higher rate of O2 cnsumption within the heart, further damage to the strained heart, and death. As cigarette smoking and obesity complete for the leading preventable cause of death in the united states, familiarity with cardiac anatomy and physiology 12-lead interpretation, pharmacology and electrical therapy is essential for all emergency providers
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9/62. Reversible altered consciousness with brain atrophy caused by valproic acid.

    A 5-year-old female developed alteration of consciousness during 3 days of long-term treatment with valproic acid for localization-related epilepsy. Computed tomography revealed cerebral atrophy, and electroencephalography presented slow background activity. consciousness cleared only 12 hours after valproic acid was discontinued, and normal electroencephalography results were evident 1 week later. Cerebral atrophy was nonexistent 2 months later. This rapidly developing but reversible alteration of consciousness in parallel with brain atrophy is recognized as a rare idiosyncratic adverse effect of valproic acid.
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10/62. consciousness disturbances in megalencephalic leukoencephalopathy with subcortical cysts.

    Megalencephalic leukoencephalopathy with subcortical cysts (MLC) is a genetic disorder featuring diffuse MRI white matter abnormalities and a discrepantly mild clinical picture. It is related to different mutations in MLC1 gene encoding a putative membrane protein of still unknown function. We report on a genetically proven MLC patient who presented with a peculiar clinical course characterized by a prolonged comatose state following a minor head trauma at 12 years of age. The disturbance of consciousness lasted for over four months and then gradually improved. Proton MR spectroscopic imaging studies showed a moderately severe depletion of N-acetylaspartate restricted to the white matter with sparing of the cortical grey matter. The full recovery from coma suggests a transitory functional impairment of the structures implicated in the maintenance of consciousness.
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