Patients with chronic kidney disease frequently develop neurological complications including confusion and altered consciousness. Non-convulsive status epilepticus, which is characterized by a change ...in behavior and/or mental process accompanied by epileptiform discharges on electroencephalogram in the absence of convulsive seizures, is one of the overlooked causes of altered consciousness. The incidence and precise pathophysiological mechanism of non-convulsive status epilepticus in patients with kidney disease, and especially in patients with electrolyte disturbances, remains unknown. We recently treated an older patient with chronic kidney disease and severe hyperkalemia in whom non-convulsive status epilepticus developed following a correction of severe hyperkalemia.
An 82-year-old male was admitted to our hospital at midnight because of weakness of all four limbs (Day 1). He underwent urgent hemodialysis for severe hyperkalemia (9.84 mEq/L) and his serum potassium concentration decreased to 4.97 mEq/L. He regained full consciousness and his limb weakness improved on the morning of Day 2, but he became confused in the evening. Electroencephalogram revealed repeated low-voltage ictal discharges in the right occipital region and a diagnosis of non-convulsive status epilepticus was made. Following medication with fosphenytoin and phenytoin, the patient became fully alert and orientated on Day 8.
We speculate that a rapid correction of hyperkalemia was the possible cause of non-convulsive status epilepticus development. To our knowledge, this is the first report of non-convulsive status epilepticus from a potassium abnormality. We described a case of this condition in detail and summarized 78 previous case reports of non-convulsive status epilepticus with kidney disease or electrolyte disturbances.
Background: The incidence of intracranial bleeding during dabigatran treatment is lower than that during warfarin treatment. The characteristics of intracranial hemorrhage during dabigatran therapy, ...however, remain unclear. Methods and Results: The clinical data and treatment summaries of 9 intracranial bleeds that developed during dabigatran treatment in 8 patients with non-valvular atrial fibrillation were retrospectively reviewed. Five patients had small–moderate subdural hematomas, 2 had intracerebral hemorrhage and 1 had traumatic subarachnoid and parenchymal hemorrhage associated with cerebral contusion. Activated partial thromboplastin time upon admission ranged from 31.6 to 72.4s. After admission, systolic blood pressure in the 2 patients with intracerebral hemorrhage was maintained below 140mmHg, and the subdural hematomas in 4 patients were surgically treated. None of the hematomas became enlarged and outcome was good in most cases. Conclusions: Hematomas that arise due to acute intracranial bleeding during dabigatran treatment seem to remain small to moderate, hard to expand, and manageable. (Circ J 2014; 78: 1335–1341)
•ASL with dual PLDs revealing the mechanism of sulcal hyperintensity on FLAIR image in CSDH patient.•Prolonged arterial transit time causing increase in the blood pool to CSF within the ...sulcus.•Sulcal hyperintensity having relationship with the development of epilepsy.
Sulcal hyperintensity on magnetic resonance images with fluid-attenuated inversion recovery sequences (FLAIR) can occur in patients without apparent cerebrospinal fluid (CSF) abnormalities. Taoka et al. speculated that pathological increases of the blood pool to CSF ratio within the sulcus, which could be caused by alterations in regional hemodynamics including venous congestion, do not suppress water signals on FLAIR images. However, few previous reports have described sulcal hyperintensity in patients with chronic subdural hematoma (CSDH).
To demonstrate the pathophysiological mechanism and clinical significance of sulcal hyperintensity in CSDH, we retrospectively reviewed the chronological changes in clinical, electroencephalographic (EEG), and neuroradiological findings, including arterial spin labeling perfusion magnetic resonance imaging (ASL) with dual post-labeling delays (PLDs) of 1.5 and 2.5 s, of three patients who had sulcal hyperintensity.
In all three cases, sulcal hyperintensity was observed just below the CSDH with mass effect, and became more prominent as it went to the vertex. In patients 1 and 2, ASL with dual PLDs showed a prolonged arterial transit time (ATT) in the region with sulcal hyperintensity, and the sulcal hyperintensity disappeared along with the improvement of the prolonged ATT. In patient 3, in whom the degree of sulcal hyperintensity was mild, the prolongation of ATT was also very mild. In patient 2, a coinciding ictal EEG and ASL hyperperfusion findings were present in the cortex showing sulcal hyperintensity. In patients 1 and 3, the laterality of the sulcal hyperintensity was consistent with that of the epileptic symptoms, which were controlled by the administration of antiepileptic drugs.
Although further studies with a larger number of patients are needed, the pathophysiological mechanism of sulcal hyperintensity in CSDH could be explained by the idea proposed by Taoka et al. Our findings also indicate that sulcal hyperintensity has a possible relationship with the development of epilepsy in the perioperative period of CSDH.
Retained medullary cord (RMC) is a condition in which the cord-like structure (C-LS) is continuous from the conus and extends to the dural cul-de-sac, causing spinal cord tethering, which is thought ...to originate from the secondary neurulation failure. Although diagnostic criteria for RMC have not yet been fully established, the following three items are generally considered important: (1) Typical morphological features on neuroimaging and intraoperative view. (2) The electrophysiological border between the conus and C-LS. (3) Ependyma-lined canal with surrounding neuroglial tissues (E-LC w/NGT) on histopathological examination of C-LS. To clarify the differences with caudal lipoma, which are also considered to be secondary neurulation disorders, in their embryological backgrounds, the clinicopathophysiological findings were compared.
Five patients with RMC and 11 with caudal lipomas participated in this study.
All five patients with RMC naturally satisfied all three items. Four patients histopathologically showed a small amount of fibroadipose tissue. Regarding the first item in caudal lipoma, neuroimages demonstrated C-LS running parallel with or in the lipoma in all patients. In terms of the second item, the electrophysiological border was identified in 3 out of 4 patients in whom a sufficient operative field was obtained. Concerning the third item, E-LC w/NGT was noted in 6 of 7 patients in whom the lipoma was resected as a column. Areas of fibroadipose tissue histopathologically accounted for more than half of the total area.
The caudal lipomas fulfilled most of the three items, and the only prominent difference between these two is the difference in the proportions of fibroadipose and fibrocollagenous tissues. These findings provide further evidence for the idea that RMC and caudal lipoma can be considered consequences of a continuum of regression failure during secondary neurulation, and it may not be possible to distinguish between the two clearly.
In the diagnosis of hypoxic encephalopathy, feasibilities of magnetic resonance images (MRI), particularly diffusion-weighted images (DWI), have been well documented. In this report, we describe a ...case in which MR perfusion image with pulsed arterial spin labeling (ASL) was useful to evaluate the pathology of hypoxic encephalopathy after cardiopulmonary resuscitation. A 72-year-old female with diabetes and fractures of humerus and olecranon was admitted to our hospital (Day 0). She suddenly developed cardiopulmonary arrest in the next morning and cardiopulmonary resuscitation (CPR) was promptly performed (Day 1). She presented with a persistent consciousness disorder, although her vital signs were maintained stable after CPR. On Day 11, the first MRI evaluation was performed and ASL showed an apparent increase in blood flow in the bilateral striatum, while DWI showed only a slight hyperintensity in the same area. In the T1-weighted images of Day 33 and Day 61, hyperintensities appeared stepwise in the striatum on both sides, while the blood flow in the same area decreased in ASL. Fujioka et al. previously reported the pathophysiology of T1 hyperintensity in the striatum after ipsilateral hemispherical transient or mild ischemia in animal models and clinical cases. The pathology of our case was considered to be consistent with their observations and occurred in both sides after hypoxia due to cardiac arrest. Addition of ASL to the conventional MRI method may improve the accuracy of image evaluation for hypoxic encephalopathy.
Limited dorsal myeloschisis (LDM) with nonsaccular (flat) skin lesions has features similar to those of congenital dermal sinus (CDS); both show a tethering tract extending from the skin lesion to ...the intraspinal space. CDS may be found within the fibroneural LDM stalk because of the shared origin of the LDM and CDS. Thus, it can be difficult to distinguish between LDM and CDS. We surgically treated a boy in whom CDS and filar lipoma were located in close proximity to each other at the dural cul-de-sac, mimicking flat LDM. Herein, we describe the comprehensive clinicopathological findings of this patient.
The patient was noted at birth to have a small dimple in the lumbosacral region. Magnetic resonance images showed a slender tethering tract that started from the skin lesion, entered the dural sac through the dural cul-de-sac, and joined the low-lying conus at L2-3, which is characteristic of LDM. However, the operative and histopathological findings revealed that the epidural stalk was pure CDS, terminating at the dura, and that the intradural stalk was a filar lipoma. Both were present in close proximity at the dural cul-de-sac and were approximately 1 mm in diameter.
The diagnosis of LDM and CDS should be established on the basis of a comprehensive analysis of clinical, neuroradiological, operative, and histopathological findings.
We here report on a rare case of Epstein‐Barr virus (EBV)‐positive diffuse large B‐cell lymphoma (DLBCL) detected in both brain parenchyma and in an organized chronic subdural hematoma (OCSH). A ...96‐year‐old man diagnosed with asymptomatic OCSH in the left frontal convexity was referred to our hospital because of a de novo mass lesion just beneath the OCSH on contrast‐enhanced magnetic resonance imaging. The size of the OCSH remained stable. We diagnosed the lesion as a malignant tumor. At surgery, the organized hematoma and the soft fragile tumor were removed. Histological examinations revealed pleomorphic lymphoid cells not only in the brain tissue but also in the OCSH component with tumor necrosis, and these were immunopositive for B‐cell markers. In situ hybridization revealed positive signals for EBV‐encoded small RNAs, consistent with EBV‐positive DLBCL. Since the membranes of the subdural hematoma were fibrous and the tumor progression resulted in necrosis of the tumor, the DLBCL may have originally developed in the OCSH and infiltrated into the brain parenchyma. We believe that this rare case provides crucial information for the understanding of DLBCLs associated with OCSH.
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