Secuelas neurológicas tardías en la intoxicación por monóxido de carbono. Reporte de un caso pediátrico

Introducción: la intoxicación por monóxido de carbono (CO) es un problema grave de salud. La aparición de secuelas neurológicas tardías incluye trastornos cognitivos, mentales, síntomas piramidales o extrapiramidales. Caso clínico: paciente de 12 años, sexo femenino, luego de 15 días de una intoxicación aguda grave por CO, presenta movimientos coreoatetoideos de miembros superiores, distonías de cuello, discinesias de cara, bradipsiquia y dificultades en la memoria. Resonancia magnética: lesiones isquémicas en globo pálido bilateral, sustancia blanca de hipocampo y cerebelo. Discusión: es fundamental el seguimiento posterior al alta para reconocer las secuelas neurológicas tardías, incluyendo la realización de pruebas neuropsicológicas estandarizadas.

Introduction: Carbon monoxide poisoning is a severe health problem. The appearance of delayed neurological sequelae includes cognitive and mental disorders and pyramidal or extrapyramidal symptoms. Case presentation: A 12-year-old female patient, after 15 days of severe acute CO poisoning, presents choreoathetoid movements of the upper limbs, neck dystonias, face dyskinesias, bradypsychia, and memory difficulties. Magnetic resonance imaging: ischemic lesions in bilateral globus pallidus, the white matter of hippocampus and cerebellum. Discussion: A follow-up visit after discharge is essential to recognize delayed neurological sequelae, including performing standardized neuropsychological tests.

Treatment of acute carbon monoxide poisoning with induced hypothermia

OBJECTIVE: The effect of induced hypothermia on severe acute carbon monoxide (CO) poisoning remains to be addressed further. We investigated the effect of induced hypothermia on severe acute CO poisoning. METHODS: Retrospective chart review was conducted for patients who diagnosed as severe acute CO poisoning in emergency department and underwent induced hypothermia from May 2013 to May 2014. Hospital courses with critical medication and major laboratory results were investigated through the chart review. RESULTS: Among total 227 patients with acute CO poisoning during the period of study, patients with severe acute CO poisoning were 15. All patients underwent induced hypothermia with a temperature goal 33°C. Initial and follow-up levels of S100B protein after induced hypothermia were 0.47 μg/L (interquartile range, 0.11 to 0.71) and 0.10 μg/L (interquartile range, 0.06 to 0.37), respectively (P = 0.01). The mean Glasgow Coma Scales at emergency department admission was 6.87 ± 3.36. Except 1 patient who expired after cardiopulmonary resuscitation, Glasgow Coma Scales at 30-day of hospital discharge were 15 in 10 patients (71.4%), 14 in 1 patient (7.1%), 13 in 1 patient (7.1%), and 6 in 2 patients (14.2%). Seven patients (46.7%) developed delayed neurologic sequelae. Four patients showed mild types of delayed neurologic sequelae and 3 showed moderate to severe types of delayed neurologic sequelae. CONCLUSION: Most of patients underwent induced hypothermia had a good recovery from severe acute CO poisoning. Therefore, induced hypothermia may be considered as a possible treatment in severe acute CO poisoning.

Bilateral Abducens Nerve Palsy in Pediatric Patients with Epstein-Barr Virus Encephalitis

PURPOSE: To report 2 cases that presented with bilateral abducens nerve palsy associated with Epstein-Barr virus (EBV) encephalitis in children. CASE SUMMARY: Case 1. A 14-month-old boy presented with fever and esodeviation of the left eye that started 5 days earlier. On the ophthalmic examination, 45-PD esotropia of the left eye and limitation of abduction in both eyes were observed. On neurological examination, there were no abnormalities. Serologic test and polymerase chain reaction (PCR) from cerebrospinal fluid (CSF) were positive for EBV. The patient was treated with systemic acyclovir and prednisolone. Part-time occlusion therapy of the right eye for 2 hours/day was also prescribed. The patient underwent a 6.5-millimeter recession of the medial rectus and a 6-millimeter resection of the lateral rectus on the left eye 7 months after the presentation. The patient showed orthotropia 1 week after the surgery without neurologic sequelae. Case 2. A 13-year-old boy presented with headaches and fever that started 5 days before and altered consciousness with seizures 2 days previously. Serological test for viral infection was normal, except for EBV, and CSF examination showed viral infection. After the patient recovered consciousness, he complained of diplopia. A 30-PD esotropia of his left eye with bilateral limitation of abduction was present. Alternating full-time occlusion of both eyes was prescribed. At 4 months after presentation, diplopia disappeared and the patient showed orthotropia without abduction limitation; however, anticonvulsants were prescribed to control seizures. CONCLUSIONS: In children, EBV encephalitis can be accompanied by acquired bilateral abducens nerve palsy. Residual nerve palsy and other neurologic sequelae can remain after several months.

Predicting Factors for Neurologic Outcome in Full-term Neonates with Hypoxic-Ischemic Encephalopathy

PURPOSE:Hypoxic injury during delivery and subsequent ischemic encephalopathy is still remained as one of the important cause of neonatal death and associated with neurologic complication. We investigated the predicting factors for neurologic outcome in full-term hypoxic-ischemic encephalopathy (HIE). METHODS:Twenty-two full-term neonates with HIE stage II or III from Jan. 2001 to Dec. 2004 were enrolled. We reviewed the medical records retrospectively including obstetric history, initial pH, creatine kinase (CK), ionized calcium, seizure type and duration, EEG, cranial sonography, CT or MRI, and neurologic outcome. RESULTS:Among 22 patients, outborn was 86.3%, vaginal delivery 68.2%, and male 72.7%. Regarding the obstetrical events, two-thirds had meconium staining or aspiration and prolonged rupture of membrane. Initial arterial pH, CK and ionized calcium were not significantly different between normal and abnormal neurologic outcome group. All of 5 patients recovered from seizure after more than 5 days had neurologic sequelae (P= 0.008). Eight of 16 cases with abnormal EEG showed abnormal development, and all of 4 cases with normal EEG showed normal development. Eight of 12 cases with abnormal imaging study showed neurologic sequelae, however, all of 10 cases with normal study showed normal outcome (P=0.005). CONCLUSION:This study suggests that seizure duration and imaging study are the best predicting factors for prognosis in full-term HIE. Although the EEG finding was not signigicant, the normal finding is expected to have good prognosis. The initial laboratory findings had no prognostic significance because of delayed blood sampling in most patients, who transferred from other hospitals after immediate postnatal resuscitation. We encourage the maternal transport especially when the high-risk delivery is anticipated.

Prognostic Value of Repeated Cerebrospinal Latex Agglutination Testing in Bacterial Meningitis

PURPOSE: Bacterial meningitis is a serious infection of childhood associated with a significant morbidity and mortality. Repeated cerebrospinal fluid(CSF) examination is a useful prognostic indicator and a delayed sterilization is associated with a higher incidence of neurologic abnormalities. In this study we tried to determine the prognostic value of repeated CSF latex agglutination testing. METHODS: We retrospectively evaluated 19 patients admitted to Ewha Womans University Mokdong Hospital for bacterial meningitis from January 1997 to June 2002. Bacterial meningitis was confirmed by a positive CSF culture and a positive CSF latex agglutination test. Repeated CSF examinations were done at three, seven, 14, 21 and 28 days after antibiotics therapy. Neuroradiologic studies were performed. RESULTS: The mean age was 10.6 +/- 12.3 months(range; two to 33 months). The male to female ratio was 2.8 : 1. The causative organisms were Haemophilus influenzae type b 57.9%, Group B Streptococcus 21.1%, Streptococcus pneumoniae 15.7% and Escherichia coli 5.3%. Three days after the initiation of antibiotics therapy, repeated CSF latex agglutination tests persisted as positive in nine (47.4%) out of 19 cases, but all CSF cultures became negative. In those cases with negative latex agglutination tests three days after antibiotics therapy, neuroradiologic findings were completely normal. But, in cases with positive latex agglutination tests three days after antibiotics therapy, neuroradiologic abnormalities such as cerebral infarction, encephalomalasia occurred in 44.4%. CONCLUSION: Repeated CSF latex agglutination testing was valuable as a prognostic factor in bacterial meningitis. Neuroradiologic abnormalities may occur in cases with delayed clearance of CSF latex agglutination tests more often than in cases with negative latex agglutination tests three days after antibiotics therapy.

Neurologic Sequelae Following Spinal Anesthesia / 대한마취과학회지

Spinal anesthesia is a safe anesthetic technique and relative easy to perform, but occasionally neurologic injuries after spinal anesthesia have been reported. A 53-year old female patient visited the emergency room due to abdominal pain and she was diagnosed with acute appendicitis. Thus, an emergent appendectomy was planned. During the preoperative evaluation, we noticed that she had a history of intermittent low back pain for the previous 5 years. However, because her stomach was not fully empty, we decided to administer spinal anesthesia. When the spinal needle passed the subarachnoid membrane, she suddenly complained of severe paresthesia on her right posterior thigh. However the parethesia subsided soon, and 2.2 cc of 0.5% bupivacaine was injected via a spinal needle, and aftewards, an appendectomy was done without any complications. As she recovered from the spinal anesthesia, she started complaining of shooting, stabbing and burning pain on her right buttock and posterior thigh Because a neurologic injury after spinal anesthesia was suspected, we inserted an epidural catheter to the same lumbar vertebral level for administering the mepivacaine and ketamine mixture and we also performed a right second sacral nerve root block and a lumbar sympathetic ganglion block. Magnetic Resonance Imaging showed spondylosis of lumbar spine and associated disc degeneration and a bulging disc at the L3-4, L4-5 and L5-S1 level. After treatments, her symptoms improved gradually. When she was discharged on the 16th hospital day, she complained of only minor discomfort on her right posterior thigh.

Correlation between the Grade of Brain MRI and Clinical Features of Periventricular Leukomalacia

PURPOSE: Periventricular leukomalacia(PVL) is associated with various neurologic sequelae such as cerebral palsy and cortical blindness. The aim of this study was to analyse the correlation between the degree of PVL on MRI and clinical features or its severity. METHODS:Thirty-eight children with PVL on MRI among children brought to Pusan National University Hospital between January 1996 and August 1999 with development delay, cerebral palsy or epilepsy were included into the study group. We reviewed medical records of the patients including the gestational age, birth weight and neurologic sequelae. The grade for PVL was divided into 1 to 3, and it was based on abnormally increased signal intensity in periventricular white matter or a reduced amount of periventricular white matter or both, and compensatory focal ventricular enlargement. We analysed the relationship of the grade of PVL and various clinical findings. RESULTS: The age ranged from 11 months to 13 years old with a mean of 42 months. History of cesarean delivery and ventilator care were significantly frequent for the severe grade of PVL. Birth weight was significantly lower according to grade of PVL. Gestational age was lower according to the grade of PVL, but was not significant statistically. Incidence of cerebral palsy was significantly higher on the severe grade of PVL. Incidence of epilepsy and mental retardation were 34.2Yo and 23.9M, not associated with the grade of PVL. CONCLUSION: Incidence of cerebral palsy was associated with the severe grade of PVL, so we think MRI can be helpful in predicting neurodevelopmental outcome. (J Korean Pediatr Soc 2000;43 798-805)

Factros Related to the Outcome of Neonatal Seizures

PURPOSE: Seizures during the neonatal period may be an important indicator of serious neurologic abnormalities and can cause permanent neurologic sequelae. We attempted to find and analyze the factors related to the outcome of neonatal seizures. METHODS: Seventy-six newborns with seizure were reviewed. The outcomes were analyzed according to etiologic diseases, gestational ages, characteristics of seizure, and neuroimaging and electroencephalographic study findings. RESULTS: Of the 76 patients, 29 showed normal outcome, 27 had neurologic sequelae(NS), 7 expired, 7 hopelessly discharged, and 6 were lost during follow-up. Of the 40 with perinatal problems, the outcomes were normal in 19 and NS was found in 16. Of the 36 without perinatal problem, 10 showed normal outcome and 11 had NS. Ten out of 25 with hypoxia showed NS, whereas only 1 out of 11 with late hypocalcemia had NS. Of the 19 whose seizure began within the first 24 hours, 8 had NS, 3 expired and 2 discharged hopelessly. Of the 27 with generalized tonic seizures, 11 were normal and 13 showed NS. Of the 49 with brief but repetitive seizures, 16 showed NS, 6 expired and 5 discharged hopelessly. Twenty-five out of 39 with abnormal neuroimaging findings had abnormal outcomes, whereas 5 out of 20 with normal findings showed NS. Sixteen out of 27 with EEG background abnormalities and 24 out of 46 with epileptiform discharges had NS. CONCLUSION: Neuroimaging and electroencephalographic findings rather than etiologic factors were more important in predicting neurologic outcomes in newborns with seizure.

The Effects of Perfusion Variables on the Neurologic Sequelae in the Infants Who had Arterial Switch Operation Using Continuous Flow Cardiopulmonary Bypass / 대한마취과학회지

BACKGROUND: Neurologic sequelae of open heart surgery for congenital heart disease were related with preexisting brain lesion as well as intraoperative causes. These causes are microemboli, blood flow, and blood distribution. METHODS: This study was designed to examine neurologic sequelae and postoperative course in patients with arterial switch operation using continuous flow cardiopulmonary bypass through retrospective chart review. RESULTS: Of 22 patients 4 had neurologic sequelae. Cooling rate, extubation time, and duration of ICU admission and hospital admission were statistically different between the patients with neurologic sequelae or not. Patients with neurologic sequelae had more rapid cooling rate and longer duration of intubation, ICU stay, and hospital admission than patients without neurologic sequelae. CONCLUSIONS: Cooling rate (time to lower 1oC body temperature) is the only factor among perfusion variables to affect on neurologic sequelae. Neurologic complications make it longer to wean the mechanical ventilation, and to stay at ICU and hospital.

Evaluation of outcome after acute carbon monoxide poisoning by brain CT

Of 129 patients with carbon monoxide (CO) poisoning, 62(48.0%) had characteristic computed tomographic (CT) findings. The most common finding, seen in 42 patients, was low-density in the cerebral white matter, and the second characteristic feature, seen in 33 patients, was low-density in both globus pallidi. Abnormal CT findings tended to increase in accordance with the duration of unconsciousness during acute CO poisoning, but such findings occurred even when the mental state was clear during acute illness. The prognosis of acute CO poisoning depended on low-density lesions of the cerebral white matter rather than those of the globus pallidus. There also seemed to be a significant correlation between the cerebral white matter changes in the initial CT scan and the development of delayed neurologic sequelae after acute CO poisoning, particularly in middle age or older patients, but no correlation between the CT findings and the clinical outcome of delayed neurologic sequelae.

Technetium-99m HM-PAO SPECT in patients with delayed neurologic sequelae after carbon monoxide poisoning

We used single photon emission computed tomography (SPECT) with technetium-99m hexamethylpropylene amine oxime (99mTc-HM-PAO) in 14 studies on 6 patients with delayed neurologic sequelae from carbon monoxide (CO) poisoning to determine whether any changes in cerebral blood flow could be correlated with clinical or computed tomographic evidence of delayed deficits. Among the six initial CT brain scans, two showed low density of both basal ganglia and two showed decreased density of the cerebral white matter. There was no correlation between the clinical outcome and the findings of the follow-up CT brain scans. Of the two SPECTS with 99mTc-HM-PAO performed during acute anoxic insult, one showed focal hypoperfusion which appeared 20 days prior to the onset of delayed neurologic sequelae after CO poisoning. Seven SPECTs in the six patients performing the delayed phase showed diffuse patched patterns of hypoperfusion which improved on follow-up images. There was good correlation between the clinical outcome and the findings of the 99mTc-HM-PAO SPECT. In preliminary conclusion, 9Tc-HM-PAO brain SPECT can be used for predicting or evaluating the outcome of delayed neurologic sequelae after CO poisoning. Cerebral vascular changes may be the possible cause of hypoperfusion in patients with CO poisoning.

Clinical Study on Carbon Monoxide Intoxication in Children

Carbon monoxide intoxication has long been one of the most serious public health problems in Korea. This is mainly due to the wide use of anthracite coal briquettes as domestic fuel for cooking and under-the floor heating. One hundred and seven cases of CO intoxicated children hospitalized at Yonsei Medical center from January 1970 to December 1986 have been investigated clinically. The sex ratio was 1.3:1 (male 60 cases, female 47 cases) with the peak incidence occuring in patients between 12 and 14 years of age (28%). The most common symptoms were vomiting convulsions and headache; and the most frequent signs were altered mental state, increased deep tendon reflex and a positive Babinski sign. The outcome of patients was as follows: 4 cases (3.7%) expired, 77 cases (72.0%) recovered without neurologic sequelae and 26 cases (24.3%) survived with neurologic sequelae. The neurologic sequelae included persistent convulsions (7 cases), cortical blindness (3 cases), peripheral neuropathy (2 cases) and delayed neurologic sequelae (11 cases). Neurologic sequelae occurred most frequently in comatose patients (45.5%) and least often in mentally alert patients (6.1%), more frequently m patients exposed to CO gas for more than 8 hours than in those exposed for less than 8 hours, and in patients who did not receive hyperbaric oxyen therapy(29.4%) than in those who did(19.6%). Delayed neurologic sequelae were mental retardation (72.7%), epilepsy (36.4%), mutism (18.2%) etc. The lucid interval in 11 cases of delayed neurologic sequelae ranged from 2 to 20 days. The results of this study suggest that every patient exposed to CO gas should receive prompt and efficient oxygenation including hyperbaric oxygen therapy and that expeditious reduction of cerebral edema maybe of value. The importance of providing follow-up facilities in anticipation of a relapse of the delayed neurologic sequelae has been established.