The role of brain computed tomography in evaluating children with new onset of seizures in the emergency department.

BACKGROUND: The purpose of neuroimaging of a patient with new onset of seizures is to demonstrate cause and explore the prognosis. It was recently recommended that emergency brain computed tomography (CT) be performed only in adult seizure patients with an increased likelihood of life-threatening lesions, i.e., those with new focal deficits, persistent altered mental status, fever, recent trauma, persistent headaches, history of cancer, history of anticoagulation, or suspicion of acquired immunodeficiency syndrome. The objective of this study was to determine the diagnostic utility of emergency brain CT in children who present to the emergency department with new onset of seizures. METHODS: A 1-year retrospective chart review of all children who presented to the emergency department of the Schneider Children's Hospital with a new onset of seizures and who underwent CT of the brain, excluding children with simple febrile seizures. RESULTS: Sixty-six patients, 34 boys and 32 girls with a mean age of 4.9 years, qualified for inclusion in the study. Fifty-two patients (78.8%) had normal CT results and 14 patients (21.2%) had abnormal CT results. Seizure cause was considered cryptogenic in 33 patients, of whom 2 (6%) had abnormal CT results; neither patient required intervention. Seizure cause was considered symptomatic in 20 patients, of whom 12 (60%) had abnormal CT results (p < 0.0001). In two patients with abnormal CT scans (both acute symptomatic), the imaging findings were of immediate therapeutic significance and were predictable from the clinical history and the physical examination. None of the 13 patients with complex febrile seizure cause had an abnormal CT scan. Patients with partial convulsive seizures were more likely to have abnormal CT scans than patients with generalized convulsive seizures, but the difference was not statistically significant. CONCLUSIONS: The routine practice in many pediatric emergency departments of obtaining brain CT scans for all patients with new onset of nonfebrile seizures is unjustified. History and physical examination are sufficient to identify those patients for whom such studies are likely to be appropriate. Emergent CT is not indicated for patients with no known seizure risk factors, normal neurological examinations, no acute symptomatic cause other than fever, and reliable neurological follow-up. For these patients, referral to a pediatric neurologist for further workup, including electroencephalography and the more diagnostically valuable magnetic resonance imaging, would be more appropriate.

Lasers in ophthalmology.

This article reviews the principle uses of ophthalmic lasers, providing historical background with an emphasis on new applications and areas of investigation. Ophthalmic photocoagulation was the first medical laser application and has restored or maintained vision in millions of people. More recently, photodisruption and, increasingly, ablation have gained prominence for treating a wide range of ocular pathology. The unique properties of lasers have also been harnessed for diagnostic purposes, with optical coherence tomography representing a significant improvement over existing imaging methods. Many ophthalmic applications of lasers have been developed, but the field is a dynamic one which continues to evolve along with laser technology itself.

Lens redox fluorometry: pyridine nucleotide fluorescence and analysis of diabetic lens.

We performed both ex vivo and in vivo fluorometric analyses of pyridine nucleotides (PN) in rabbit and rat lenses. Rabbit lens PN fluorescence (99% NADH) was found to have an excitation maximum at 366 nm and an emission maximum at 462 nm (366:462). The only other fluorescent chromophore in that region of the spectrum has excitation and emission peaks at 328 and 460 nm, respectively. Anaerobic glycolysis in the lens was stimulated by KCN, a known inhibitor of mitochondrial respiration, after which a time-study of fluorescence intensities was performed. Over the course of a 3.5 hr period following treatment with KCN, the PN signal showed a statistically significant increase relative to that in the control lenses (those treated with KCl). while the 328:460 signal (which may be due to some protein involved in energy transfer with the PN) had a significantly greater decrease. We also found that fluorescence intensity of NADH in solution is linearly proportional to physiologic-range concentration. Moreover, there was a close correlation between fluorescence intensity of rat lens PN as measured on a specular microscope-coupled redox fluorometer capable of in vivo use, and the lens PN levels as determined by the analytical cycling assay technique. This fluorometer was then employed to assess the redox state in rats with streptozotocin-induced diabetes. The normalized ratio of PN to flavoproteins (Fp) in the lens epithelium increased from 0.96 +/- 0.12 in the normal state to 1.48 +/- 0.30 2 weeks after diabetes induction. In contrast, the ratio in the diabetic lens treated with an aldose reductase inhibitor, sorbinil, did not increase. The increase in the PN:Fp ratio therefore reflects activation of the polyol pathway and its associated metabolic activities, which results in an increase in the NADH:NAD ratio in the diabetic rat lenses. Our results indicate that the non-invasive, real-time method of redox fluorometry may be useful in the early detection and evaluation of cataracts and other disorders in lens metabolism, long before opacities occur. It can be used to monitor the disease process and evaluate the efficacy of such drugs as aldose reductase inhibitors on a biochemical level.

Interferometric technique for investigation of laser thermal retinal damage.

We describe a new technique for investigating laser-tissue interactions based on the use of an interferometric laser exposure pattern. A Michelson interferometer is used to generate a sinusoidal fringe exposure pattern. The periodicity of the fringe pattern may be adjusted from macroscopic dimensions to a scale of microns without the need for an imaging plane. Since fringe pattern periodicity is more adjustable and directly measureable than laser spot size, this technique offers significant advantages for studying the effects of thermal damage and diffusion in the irradiated tissue. In addition, the comparison of tissue response with theoretical models is simplified since the sinusoidal fringe pattern is itself an eigenfunction of the thermal diffusion equation. This technique is demonstrated for argon laser photocoagulation in the rabbit retina. Exposures at durations comparable to the thermal relaxation time produced spatially confined lesions, while those at much longer durations resulted in significant diffusion of the thermal damage beyond the primary targeted regions. The role of thermal diffusion can thus be assessed directly from the ophthalmoscopic and histologic appearances of the lesions. This technique can be employed to study thermal diffusion and other transport phenomena occurring in laser-tissue interactions for a variety of laser sources and tissue targets.

Early vitreous changes in experimental proliferative vitreoretinopathy.

Proton magnetic resonance imaging (MRI) was employed to obtain information on early vitreal changes preceding ophthalmoscopically visible proliferative vitreoretinopathy. Rabbits were injected close to the posterior pole with a suspension of 250 000 cultured homologous fibroblasts. The MRI was carried out using a 1.4-tesla (T) superconducting imager (at a proton frequency of 61.4 MHz). The images were obtained over a span of six days, prior to any detection of proliferative vitreoretinopathy with ophthalmoscopy. As early as two days after injection, an area of increased spin-spin relaxation time (T2) corresponding to the vitreal injection site became visible. The MRI observations paralleled in vitro changes in proton relaxation times (T1 [spin-lattice relaxation time] and T2) after addition of beta-N-acetylglucosaminidase to the vitreous. Our data suggest that hyaluronate disruption due to the activity of fibroblastic enzymes may result in fibroblast dispersion and movement in the vitreous and that MRI can provide early signs of vitreal changes that lead to retinal detachment.

Laser interactions with the cornea.

Principles of laser-tissue interactions in the eye are reviewed. Corneal structure and function are summarized, with particular regard for features related to laser treatment. A summary of argon and carbon dioxide laser techniques in the cornea is presented, followed by a review of studies on corneal response to ultraviolet radiation. A detailed description is then given of the characteristics of excimer laser tissue ablation. Potential applications of this process in corneal and keratorefractive surgery are reviewed.

Vitreous changes after neodymium-YAG laser photodisruption.

We investigated physicochemical changes in the vitreous body after photodisruption with a Q-switched neodymium-YAG laser. In vivo proton nuclear magnetic resonance imaging techniques were employed to assess alterations in the vitreous of irradiated rabbit eyes. Measurements of proton relaxation times (T1 and T2), viscosity, and chromatographic spectra were made in vitro on irradiated bovine and rabbit vitreous, and circular dichroism measurements were used to study changes in an irradiated sodium hyaluronate solution. Statistically significant changes in T1, were observed immediately after irradiation, but the small magnitude and reversibility of those changes, combined with the fact that the other measurements detected no changes, suggest that neodymium-YAG laser photodisruption does not have a direct deleterious effect on the structural integrity of the normal vitreous body.