Viral encephalitis can lead to serious neurological sequelae and death among younger children. It is also known that the mortality rate in encephalitis with cerebral edema or transtentorial brain herniation is higher. A 4-year-old boy visited our emergency department exhibiting mental change. The patient had a high fever for four and a whole-body rash for three days prior to his visit. He had displayed irritable symptoms and been vomiting for six hours before his visit, accompanied by seizure. After 13 hours of admission, the patient's right pupil became fixed and fully dilated, and the left pupil also became fixed and fully dilated within 30 minutes. Brain computed tomography (CT) was performed immediately, and severe brain swelling with transtentorial brain herniation was found. The mannitol dose was increased and dexamethasone was also added. Hyperventilation was performed through intubation to reach PaCO₂ levels of 25 to 30mmHg. Fifteen hours later, pupillary reflex was observed and the cerebral edema and transtentorial brain herniation was found to be improving in follow-up brain CT. He was transferred to a general ward after 11 days and discharged on the thirteenth hospital day without any neurological sequelae. Human herpesvirus type 6 (HHV-6) was detected in the serological polymerase chain reaction (PCR) examination.
Brain ; Brain Edema* ; Child ; Child, Preschool ; Dexamethasone ; Emergency Service, Hospital ; Encephalitis* ; Encephalitis, Viral ; Exanthema ; Fever ; Follow-Up Studies ; Humans* ; Hyperventilation ; Intubation ; Male ; Mannitol ; Mortality ; Patient Rights ; Patients' Rooms ; Polymerase Chain Reaction ; Pupil ; Reflex, Pupillary ; Seizures ; Vomiting

OBJECTIVE: To show the effect of dual monitoring including cardiac output (CO) and intracranial pressure (ICP) monitoring for severe traumatic brain injury (TBI) patiens. We hypothesized that meticulous treatment using dual monitoring is effective to sustain maintain minimal intensive care unit (ICU) complications and maintain optimal ICP and cerebral perfusion pressure (CPP) for severe TBI patiens. METHODS: We included severe TBI, below Glasgow Coma Scale (GCS) 8 and head abbreviation injury scale (AIS) >4 and performed decompressive craniectomy at trauma ICU of our hospital. We collected the demographic data, head AIS, injury severity score (ISS), initial GCS, ICU stay, sedation duration, fluid therapy related complications, Glasgow Outcome Scale (GOS) at 3 months and variable parameters of ICP and CO monitor. RESULTS: Thirty patients with severe TBI were initially selected. Thirteen patients were excluded because 10 patients had fixed pupillary reflexes and 3 patients had uncontrolled ICP due to severe brain edema. Overall 17 patients had head AIS 5 except 2 patients and 10 patients (58.8%) had multiple traumas as mean ISS 29.1. Overall complication rate of the patients was 64.7%. Among the parameters of CO monitoring, high stroke volume variation is associated with fluid therapy related complications (p=0.043) and low cardiac contractibility is associated with these complications (p=0.009) statistically. CONCLUSION: Combined use of CO and ICP monitors in severe TBI patients who could be necessary to decompressive craniectomy and postoperative sedation is good alternative methods to maintain an adequate ICP and CPP and reduce fluid therapy related complications during postoperative ICU care.
Brain Edema ; Brain Injuries* ; Cardiac Output* ; Cerebrovascular Circulation* ; Decompressive Craniectomy ; Fluid Therapy ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Head ; Humans ; Injury Severity Score ; Intensive Care Units ; Intracranial Pressure* ; Monitoring, Physiologic ; Multiple Trauma ; Reflex, Pupillary ; Stroke Volume

PURPOSE: We report a rare case of unilateral acute macular neuroretinoapthy in a young male. CASE SUMMARY: A 35-year-old male presented with a 2-day history of paracentral scotoma. He had suffered for 2 days from a flu-like illness, and his best corrected visual acuity was 20/20 OD and 20/20 OS. Pupillary reflex was normal and no relative afferent pupillary defects were not found. Ocular movement test was normal and pain on ocular movement was not noticed. Ophthalmoscopic examination of the left eye revealed multiple exudates lining the nasal macula toward the fovea. A Humphrey visual field study identified small paracentral scotoma. Spectral domain optical coherence tomography (SD-OCT, Heidelberg Engineering, Heidelberg, Germany) of the lesions showed a hyper-reflective lesion located in the outer plexiform layer and inflammatory cell infiltration. Fluorescent angiography was normal in the macula but showed late leak at the disc. The multifocal electroretinogram (mfERG) showed decreased foveal P1 amplitude in the left eye. The patient was diagnosed with acute macular neuroretinopathy and was treated with 60 mg of prednisolone. His subjective symptoms were improved, the paracentral scotoma disappeared, and the lesions appeared different upon SD-OCT; specifically, the hyper-reflective lesion disappeared and the outer plexiform layer showed thinning. CONCLUSIONS: Acute macular neuroretinopathy is a rare disease, and we report a case using SD-OCT and mfERG.
Adult ; Angiography ; Exudates and Transudates ; Humans ; Male* ; Prednisolone ; Pupil Disorders ; Rare Diseases ; Reflex, Pupillary ; Scotoma ; Tomography, Optical Coherence ; Visual Acuity ; Visual Fields

PURPOSE: To determine the normal ranges of various indexes of the pupillary light reflex measured by automated pupillometry in Koreans. METHODS: We retrospectively analyzed 90 healthy adults who did not have any ocular diseases other than refractive errors. The direct pupillary light reflex was measured with an automated dynamic pupillometer (PLR-200, NeurOptics Inc., Irvine, CA, USA). A total of 7 indices were measured as follows; the maximum and minimum pupil diameters, constriction latency, constriction ratio, maximum constriction velocity, average constriction velocity and average dilation velocity. RESULTS: There were no significant differences in quantitative indexes of the pupillary light reflex between fellow eyes. A significant decrease in maximum pupil diameter, minimum pupil diameter, maximum constriction velocity, average constriction velocity and average dilation velocity were observed with aging. In contrast, a significant increase in constriction latency was observed with aging. There were no differences in quantitative pupil measurements according to gender (p<0.001). CONCLUSIONS: Quantitative measurements of the pupillary light reflex by dynamic pupillometry showed no significant differences between fellow eyes. A significant decrease in pupil size, constriction velocity and dilation velocity, and an increase in pupil constriction latency were observed with aging.
Adult ; Aging ; Constriction ; Humans ; Pupil ; Reference Values ; Reflex* ; Reflex, Pupillary ; Refractive Errors ; Retrospective Studies

A 46-year-old female patient was admitted to the intensive care unit (ICU) after liver transplantation. About an hour later after the ICU admission, she had no pupillary light reflex. Both pupils were also fixed at 5 mm. Patients who undergo liver transplantation are susceptible to neurologic disorders including hepatic encephalopathy, thromboembolism and intracranial hemorrhage. Abnormal pupillary light reflex usually indicates a serious neurologic emergency in these patients; however, benign neurologic disorders such as peripheral autonomic neuropathy or Holmes-Adie syndrome should also be considered. We experienced a case of fixed pupillary light reflex after liver transplantation diagnosed as peripheral autonomic neuropathy.
Adie Syndrome ; Emergencies ; Female ; Hepatic Encephalopathy ; Humans ; Intensive Care Units ; Intracranial Hemorrhages ; Liver Transplantation* ; Liver* ; Middle Aged ; Nervous System Diseases ; Peripheral Nervous System Diseases* ; Pupil ; Reflex* ; Reflex, Pupillary ; Thromboembolism

PURPOSE: To report a case of rhino-orbital mucormycosis successfully treated by posaconazole salvage therapy after a surgical intervention combined with amphotericin B treatment. CASE SUMMARY: A 57-year-old female with uncontrolled diabetes mellitus presented to our department with left periorbital swelling and pain for 3 days. At initial presentation, complete ptosis, complete external ophthalmoplegia, and exophthalmos of 6 mm were observed in the left eye. Pupillary reflex was absent in the left eye. Orbital magnetic resonance imaging showed left focal maxillary sinusitis and left posterior orbital inflammatory infiltration with left optic nerve involvement. Nasal endoscopic examination showed black eschar in both nasal cavities. Histopathological examination of the involved nasal cavities showed non-septated fungal hyphae with blunt-angle branching, thus rhino-orbital mucormycosis was diagnosed. The patient underwent a lid-sparing subtotal exenteration, wide endonasal debridement of the nasal necrotic tissues, and intravenous injections of amphotericin B for 7 weeks. The patient continued to receive oral posaconazole salvage therapy for 6 months and was successfully treated. At the 44-month follow-up, recurrence was not observed, and the patient is wearing a new type of silicone oculofacial prosthesis. CONCLUSIONS: Rhino-orbital mucormycosis is an aggressive, opportunistic fungal infection that is life-threatening despite exenteration and amphotericin B treatment. Sequential use of oral posaconazole as salvage therapy may be helpful for a successful treatment.
Amphotericin B* ; Debridement ; Diabetes Mellitus ; Exophthalmos ; Female ; Follow-Up Studies ; Humans ; Hyphae ; Injections, Intravenous ; Magnetic Resonance Imaging ; Maxillary Sinus ; Maxillary Sinusitis ; Middle Aged ; Mucormycosis* ; Nasal Cavity ; Ophthalmoplegia ; Optic Nerve ; Orbit ; Prostheses and Implants ; Recurrence ; Reflex, Pupillary ; Salvage Therapy ; Silicones

A 46-year-old female patient was admitted to the intensive care unit (ICU) after liver transplantation. About an hour later after the ICU admission, she had no pupillary light reflex. Both pupils were also fixed at 5 mm. Patients who undergo liver transplantation are susceptible to neurologic disorders including hepatic encephalopathy, thromboembolism and intracranial hemorrhage. Abnormal pupillary light reflex usually indicates a serious neurologic emergency in these patients; however, benign neurologic disorders such as peripheral autonomic neuropathy or Holmes-Adie syndrome should also be considered. We experienced a case of fixed pupillary light reflex after liver transplantation diagnosed as peripheral autonomic neuropathy.
Adie Syndrome ; Emergencies ; Female ; Hepatic Encephalopathy ; Humans ; Intensive Care Units ; Intracranial Hemorrhages ; Liver Transplantation ; Liver ; Middle Aged ; Nervous System Diseases ; Peripheral Nervous System Diseases ; Pupil ; Reflex ; Reflex, Pupillary ; Thromboembolism

OBJECTIVE: Stroke is the most prevalent disease involving the central nervous system. Since medical modalities are sometimes ineffective for the acute edema following massive infarction, surgical decompression may be an effective option when medical treatments fail. The present study was undertaken to assess the outcome and prognostic factors of decompressive surgery in life threatening acute, severe, brain infarction. METHODS: We retrospectively analyzed twenty-six patients (17 males and 9 females; average age, 49.7yrs) who underwent decompressive surgery for severe cerebral or cerebellar infarction from January 2003 to December 2006. Surgical indication was based on the clinical signs such as neurological deterioration, pupillary reflex, and radiological findings. Clinical outcome was assessed by Glasgow Outcome Scale (GOS). RESULTS: Of the 26 patients, 5 (19.2%) showed good recovery, 5 (19.2%) showed moderate disability, 2 (7.7%) severe disability, 6 (23.1%) persistent experienced vegetative state, and 8 (30.8%) death. In this study, the surgical decompression improved outcome for cerebellar infarction, but decompressive surgery did not show a good result for MCA infarction (30.8% overall mortality vs 100% mortality). The dominant-hemisphere infarcts showed worse prognosis, compared with nondominant-hemisphere infarcts (54.5% vs 70%). Poor prognostic factors were diabetes mellitus, dominant-hemisphere infarcts and low preoperative Glasgow Coma Scale (GCS) score. CONCLUSION: The patients who exhibit clinical deterioration despite aggressive medical management following severe cerebral infarction should be considered for decompressive surgery. For better outcome, prompt surgical treatment is mandatory. We recommend that patients with severe cerebral infarction should be referred to neurosurgical department primarily in emergency setting or as early as possible for such prompt surgical treatment.
Brain Edema ; Brain Infarction* ; Brain* ; Central Nervous System ; Cerebral Infarction ; Decompression ; Decompression, Surgical ; Diabetes Mellitus ; Edema ; Emergencies ; Female ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Humans ; Infarction ; Infarction, Middle Cerebral Artery ; Male ; Mortality ; Persistent Vegetative State ; Prognosis ; Reflex, Pupillary ; Retrospective Studies ; Stroke

PURPOSE: Pupillary examination is an important objective method to diagnose lesions of the anterior visual pathways. However, errors and faults may easily alter the interpretation and value of the test as it is highly dependent on the examiner's skills. Therefore, we tried to develop a pupillography which is independent of the examiner. METHODS: Hardware composed of a binocularly measuring instrument adapted for an infrared charge coupled device (CCD) was developed. Two arrays of infrared light emitting diodes (LED) were supplied in front of each of the subject's eyes. A microcontroller to modulate these LED was developed, as was software to save and analyze the pupil images. The hardware was able to deliver a light to either eye or to both eyes, and to change the time, frequency, and intensity of the stimulus. The software automatically analyzed the pupil size and location by image processing. Pupil size was calculated continuously. After artifact elimination, the response amplitudes of the pupils were determined for the right and left pupils. RESULTS: Pupillary images of size 320 x 240, at 30 frames/second, were saved and processed to evaluate the change of the actual pupil size and the velocity of pupillary response. CONCLUSIONS: A pupillography to measure, save and analyze the pupillary response using image processing was developed. Further detailed clinical studies with a large number of patients will be required to validate this new method.
Diagnostic Techniques, Ophthalmological/*instrumentation ; Equipment Design ; Humans ; *Image Processing, Computer-Assisted ; *Reflex, Pupillary

OBJECTIVES: Massive cerebral infarction could be accompanied by severe brain swelling and death secondary to transtentorial herniation. Approximately 10% to 15% of middle cerebral artery infarctions are associated with this phenomenon. However, the effectiveness and timing of decompressive surgery are still controversial. In this study, we present our results on the effect of decompressive craniectomy in life threatening cerebral infarction. METHOD: We retrospectively analyzed 15 patients who underwent decompressive craniectomy for massive cerebral infarction from January 1997 to April 1999. Surgical indication was based on the clinical signs such as neurological deterioration, pupillary reflex, and radiological findings. Clinical outcome was assessed by Glasgow Outcome Scale (GOS). RESULTS: All 15 patients(five men, ten women; mean age, 52.3 years; right 11, left 4) were treated with wide craniectomy and duroplasty. The average time interval between onset of symptom and surgical decompression was 2.9 days. Clinical signs of uncal herniation(anisocoria, or fixed and dilated pupils) were presented in 13 of 15 patients. Mean Glasgow coma scale(GCS) was 12.4 points on admission, 8.1 points on preoperative state and 11.8 points postoperatively. Overall outcomes were favorable in 5 cases(Glasgow outcome scale: GOS I, II), unfavorable in 6 cases(Glasgow outcome scale:GOS III, IV) and dead in 4 cases. CONCLUSION: Early decompressive craniectomy before brain stem compression is considered as an effective lifesaving procedure for massive cerebral infarction unresponsive to aggressive medical therapy.
Brain Edema ; Brain Stem ; Cerebral Infarction* ; Coma ; Decompression, Surgical ; Decompressive Craniectomy* ; Female ; Glasgow Outcome Scale ; Humans ; Infarction ; Male ; Middle Cerebral Artery ; Reflex, Pupillary ; Retrospective Studies