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Post traumatic cerebral oedema in severe head injury is related to intracranial pressure and cerebral perfusion pressure but not to cerebral compliance

Nujaimin U, Saufi A, Rahman AG, Badrisyah I, Sani S, Zamzuri I, et al.

Asian J Surg, 2009 Jul;32(3):157-62.
PMID: 19656755

This was a prospective cohort study, carried out in the Neuro Intensive Care Unit, Department of Neurosciences, Hospital Universiti Sains Malaysia, Kubang Kerian Kelantan. The study was approved by the local ethics committee and was conducted between November 2005 and September 2007 with a total of 30 patients included in the study. In our study, univariate analysis showed a statistically significant relationship between mean intracranial pressure (ICP) as well as cerebral perfusion pressure (CPP) with both states of basal cistern and the degree of diffuse injury and oedema based on the Marshall classification system. The ICP was higher while CPP and compliance were lower whenever the basal cisterns were effaced in cases of cerebral oedema with Marshall III and IV. In comparison, the study revealed lower ICP, higher mean CPP and better mean cerebral compliance if the basal cisterns were opened or the post operative CT brain scan showed Marshall I and II. These findings suggested the surgical evacuation of clots to reduce the mass volume and restoration of brain anatomy may reduce vascular engorgement and cerebral oedema, therefore preventing intracranial hypertension, and improving cerebral perfusion pressure and cerebral compliance. Nevertheless the study did not find any significant relationship between midline shifts and mean ICP, CPP or cerebral compliance even though lower ICP, higher CPP and compliance were frequently observed when the midline shift was less than 0.5 cm. As the majority of our patients had multiple and diffuse brain injuries, the absence of midline shift did not necessarily mean lower ICP as the pathology was bilateral and even when after excluding the multiple lesions, the result remained insignificant. We assumed that the CT brain scan obtained after evacuation of the mass lesion to assess the state basal cistern and classify the diffuse oedema may prognosticate the intracranial pressure and cerebral perfusion pressure thus assisting in the acute post operative management of severely head injured patients. Hence post operative CT brain scans may be done to verify the ICP and CPP readings postoperatively. Subsequently, withdrawal of sedation for neurological assessment after surgery could be done if the CT brain scan showed an opened basal cistern and Marshall I and II coupled with ICP of less than 20 mmHg.

Matched MeSH terms: Brain Edema/etiology; Brain Edema/physiopathology; Brain Edema/surgery*
The study of the function of AQP4 in cerebral ischaemia-reperfusion injury using poroelastic theory

Mokhtarudin MJ, Payne SJ

Int J Numer Method Biomed Eng, 2017 01;33(1).
PMID: 26991256 DOI: 10.1002/cnm.2784

Brain oedema is thought to form and to clear through the use of water-protein channels, aquaporin-4 (AQP4), which are found in the astrocyte endfeet. The model developed here is used to study the function of AQP4 in the formation and elimination of oedema fluid in ischaemia-reperfusion injury. The cerebral space is assumed to be made of four fluid compartments: astrocyte, neuron, ECS and blood microvessels, and a solid matrix for the tissue, and this is modelled using multiple-network poroelastic theory. AQP4 allows the movement of water between astrocyte and the ECS and the microvessels. It is found that the presence of AQP4 may help in reducing vasogenic oedema shown by a decrease in brain tissue extracellular pressure. However, the astrocyte pressure will increase to compensate for this decrease, which may lead to cytotoxic oedema. In addition, the swelling will also depend on the ionic concentrations in the astrocyte and extracellular space, which may change after ischaemic stroke. Understanding the role of AQP4 in oedema may thus help the development of a treatment plan in reducing brain swelling after ischaemia-reperfusion.

Matched MeSH terms: Brain Edema/metabolism*; Brain Edema/pathology
Lightning fatality with blast, flame, heat and current effects: a macroscopic and microscopic view

Murty OP

J Forensic Leg Med, 2009 Apr;16(3):162-7.
PMID: 19239970 DOI: 10.1016/j.jflm.2008.07.009

A case is presented of a fatal environmental accidental injuries of lightning. A pedestrian was struck by lightning. The macroscopic and microscopic lightning injuries are reviewed.

Matched MeSH terms: Brain Edema/pathology
Acute liver failure--current approach to treatment

Ganesalam K

Med J Malaysia, 2005 Jul;60 Suppl B:127-32.
PMID: 16108193
Matched MeSH terms: Brain Edema/etiology
Fulltext Dialysis disequilibrium syndrome: A preventable fatal acute complication

Mah DY, Yia HJ, Cheong WS

Med J Malaysia, 2016 04;71(2):91-2.
PMID: 27326954 MyJurnal

Dialysis disequilibrium syndrome (DDS) is a neurological disorder with varying severity that is postulated to be associated with cerebral oedema. We described a case of DDS resulting in irreversible brain injury and death following acute haemodialysis. A 13-year-old male with no past medical history and weighing 30kg, presented to hospital with severe urosepsis complicated by acute kidney injury (Creatinine 1422mmol/L; Urea 74.2mmol/L, Potassium 6.3mmol/L, Sodium 137mmol/L) and severe metabolic acidosis (pH 6.99, HC03 1.7mmol/L). Chest radiograph was normal. Elective intubation was done for respiratory distress. Acute haemodialysis performed due to refractory metabolic acidosis. Following haemodialysis, he became hypotensive which required inotropes. His Riker's score was low with absence of brainstem reflexes after withholding sedation. CT Brain showed generalised cerebral oedema consistent with global hypoxic changes involving the brainstem. The symptoms of DDS are caused by water movement into the brain causing cerebral oedema. Two theories have been proposed: reverse osmotic shift induced by urea removal and a fall in cerebral intracellular pH. Prevention is the key to the management of DDS. It is important to identify high risk patients and haemodialysis with reduced dialysis efficacy and gradual urea reduction is recommended. Patients who are vulnerable to DDS should be monitored closely. Low efficiency haemodialysis is recommended. Acute peritoneal dialysis might be an alternative option, but further studies are needed.

Matched MeSH terms: Brain Edema/etiology*
Outcome prediction in early management of severe head injury: an experience in Malaysia

Selladurai BM, Jayakumar R, Tan YY, Low HC

Br J Neurosurg, 1992;6(6):549-57.
PMID: 1472321

The outcome of 109 patients with severe head injury was studied in relation to clinical and computed tomographic (CT) criteria on admission, after resuscitation. Age, Glasgow Coma Score (GCS) and state of pupils strongly correlated with outcome. The presence of hypothalamic disturbances, hypoxia and hypotension were associated with an adverse outcome. The CT indicators associated with poor outcome were perimesencephalic cistern (PMC) obliteration, subarachnoid haemorrhage, diffuse axonal injury and acute subdural haematoma. The prognostic value of midline shift and mass effect were influenced by concomitant presence of diffuse brain injury. For the subset of patients aged < 20 years, with GCS 6-8 and patent PMC (n = 21), 71.4% correct predictions were made for a good outcome. For the subset of patients aged > 20 years, with GCS 3-5 and partial or complete obliteration of PMC (n = 28), 89.3% correct predictions were made for a poor outcome.

Matched MeSH terms: Brain Edema/etiology
Salvaging "hopeless" post head injury patients

Delikan AE, Namazie M

Med J Malaysia, 1979 Sep;34(1):42-5.
PMID: 542150
Matched MeSH terms: Brain Edema/therapy
Fulltext Computed tomography findings in maple syrup urine disease

Ong LC, Khoo TB, Zulfiqar A, Zarida H, Ruzana A

Singapore Med J, 1998 Aug;39(8):370-2.
PMID: 9844500

Maple syrup urine disease (MSUD) is an inherited metabolic disorder characterised by a severe, usually lethal, neonatal course unless dietary intake of branched chain amino acids is restricted. We describe a patient with MSUD who had computed tomography (CT) changes of diffuse white matter hypodensity, particularly in the deep white cerebellar matter, brain stem, cerebral peduncles, thalamus and posterior limb of the internal capsule. With dietary treatment, there was neurological improvement with simultaneous disappearance of the oedema. These CT changes are typical of MSUD, hence are relevant findings in the neuroradiologic differential diagnosis of a possible metabolic disorder.

Matched MeSH terms: Brain Edema/prevention & control; Brain Edema/radiography
The prognostic value of the Glasgow Coma Scale, hypoxia and computerised tomography in outcome prediction of pediatric head injury

Ong L, Selladurai BM, Dhillon MK, Atan M, Lye MS

Pediatr Neurosurg, 1996 Jun;24(6):285-91.
PMID: 8988493

The outcome of 151 children less than 15 years of age and admitted within 24 h of head injury was studied in relation to clinical and computed tomography (CT) scan features. Thirty one (20.5%) had a poor outcome (24 died, 6 were severely disabled at 6 months after injury and 1 was in a persistent vegetative state) while 120 (79.5%) had a good outcome (89 recovered well and 31 were moderately disabled). Factors associated with a poor outcome were Glasgow Coma Scale (GCS) score 24 h following injury, presence of hypoxia on admission and CT scan features of subarachnoid haemorrhage, diffuse axonal injury and brain swelling. GCS scores alone, in the absence of other factors, had limited predictive value. The prognostic value of GCS scores < 8 was enhanced two-to fourfold by the presence of hypoxia. The additional presence of the CT scan features mentioned above markedly increased the probability of a poor outcome to > 0.8, modified only by the presence of GCS scores > 12. Correct predictions were made in 90.1% of patients, indicating that it is possible to estimate the severity of a patient's injury based on a small subset of clinical and radiological criteria that are readily available.

Matched MeSH terms: Brain Edema/diagnosis; Brain Edema/mortality
Gamma knife thalamotomy for disabling tremor: a blinded evaluation

Lim SY, Hodaie M, Fallis M, Poon YY, Mazzella F, Moro E

Arch. Neurol., 2010 May;67(5):584-8.
PMID: 20457958 DOI: 10.1001/archneurol.2010.69

Gamma knife thalamotomy (GKT) has been used as a therapeutic option for patients with disabling tremor refractory to medications. Impressive improvement of tremor has been reported in the neurosurgical literature, but the reliability of such data has been questioned.

Matched MeSH terms: Brain Edema/etiology; Brain Edema/pathology; Brain Edema/physiopathology
Fulltext Risk of acute kidney injury and hyponatremia in long-distance runners

Abdullah R., Wan Md Adnan W.A.H.

JUMMEC, 2018;21(2):4-9.
MyJurnal

Long-distance running has gathered some momentum among health-conscious participants. However, some
studies have revealed association between long-distance running and development of acute kidney injury.
Although the impact usually lasts only for a few days after the event, some participants have been admitted for
severe acute kidney injury, the minority of which require dialysis treatment. The mechanisms underlying the
injury may include dehydration, development of rhabdomyolysis, heat stroke and concomitant use of NSAIDS.
Unfortunately, there is no long-term follow-up study to determine the long-term effect on kidney function.
Acute hyponatremia may develop in a significant proportion of long-distance runners. Majority of them were
asymptomatic but a few fatal cases which were supposedly due to cerebral oedema have been reported.
Excessive intake of hypotonic drinks, excessive sweating and secretion of non-osmotic antidiuretic hormone
have been postulated to be the causes of hyponatremia. This mini review will discuss the pathophysiology of
the development of acute kidney injury and hyponatremia. It will also discuss the prevention and treatment
of both conditions.

Matched MeSH terms: Brain Edema
Patient-Specific Reconstruction Utilizing Computer Assisted 3D Modelling for Partial Bone Flap Defect in Hybrid Cranioplasty

Low PH, Abdullah JY, Abdullah AM, Yahya S, Idris Z, Mohamad D

J Craniofac Surg, 2019 Jun 28.
PMID: 31261343 DOI: 10.1097/SCS.0000000000005713

PURPOSE: Decompressive craniectomy is a life-saving procedure in the setting of malignant brain swelling. Patients who survive require cranioplasty for anatomical reconstruction and cerebral protection. Autologous cranioplasty remains the commonest practice nowadays, but partial bone flap defects are frequently encountered. The authors, therefore, seek to develop a new technique of reconstruction for cranioplasty candidate with partial bone flap defect utilizing computer-assisted 3D modeling and printing.
METHODS: A prospective study was conducted to evaluate the outcome of a new reconstruction technique that produces patient-specific hybrid polymethyl methacrylate-autologous cranial implant. Computer-assisted 3D modeling and printing was utilized to produce patient-specific molds, which allowed real-time reconstruction of bone flap with partial defect intra-operatively.
RESULTS: Outcome assessment for 11 patients at 6 weeks and 3 months post-operatively revealed satisfactory implant alignment with favorable cosmesis. The mean visual analog scale for cosmesis was 91. Mean implant size was 50cm, and the mean duration of intra-operative reconstruction was 30 minutes. All of them revealed improvement in quality of life following surgery as measured by the SF-36 score. Cost analysis revealed that this technique is more cost-effective compared to customized cranial prosthesis.
CONCLUSION: This new technique and approach produce hybrid autologous-alloplastic bone flap that resulted in satisfactory implant alignment and favorable cosmetic outcome with relatively low costs.

Matched MeSH terms: Brain Edema
Severe head injury management in a general surgical department

Visvanathan R

Aust N Z J Surg, 1994 Aug;64(8):527-9.
PMID: 8048888

Sixty-nine severely head-injured patients treated by general surgeons over a 28 month period with admission Glasgow Coma Scale motor scores of 3 to 8 were reviewed retrospectively. Fifty-one patients were comatose on admission with periods from injury to admission exceeding 4 h in 34 patients who were referred from peripheral hospitals. Forty patients with acute intracranial bleeding underwent emergency decompressive surgery with 13 good recoveries and 18 deaths; good recoveries were observed in 11 of 20 patients with extradural haemorrhages, one out of eight patients with subdural haemorrhages, and one of 12 patients with intracerebral and/or combined haemorrhages. Twenty-nine patients with no evidence of acute mass lesions were treated medically with sedation, mechanical ventilation and mannitol infusion for cerebral decompression with seven good recoveries and 16 deaths. There were 15 good outcomes in 40 patients with admission motor scores of 6, 7 or 8 and five good outcomes in 29 patients with scores of 3, 4 or 5. A good outcome of 29% in the study may be improved by (i) better neurosurgical training of surgical and nursing staff; (ii) provision of technologically advanced diagnostic and treatment modalities; (iii) an efficient referral system; and (iv) provision of effective long-term rehabilitation.

Matched MeSH terms: Brain Edema/prevention & control
Light-Emitting Diode (LED) Therapy Attenuates Neurotoxicity of Methanol-Induced Memory Impairment and Apoptosis in The Hippocampus

Ghanbari A, Zibara K, Salari S, Ghareghani M, Rad P, Mohamed W, et al.

CNS Neurol Disord Drug Targets, 2018;17(7):528-538.
PMID: 29968547 DOI: 10.2174/1871527317666180703111643

BACKGROUND & OBJECTIVE: The adolescent brain has a higher vulnerability to alcoholinduced neurotoxicity, compared to adult's brain. Most studies have investigated the effect of ethanol consumption on the body, however, methanol consumption, which peaked in the last years, is still poorly explored.
METHOD: In this study, we investigated the effects of methanol neurotoxicity on memory function and pathological outcomes in the hippocampus of adolescent rats and examined the efficacy of Light- Emitting Diode (LED) therapy. Methanol induced neurotoxic rats showed a significant decrease in the latency period, in comparison to controls, which was significantly improved in LED treated rats at 7, 14 and 28 days, indicating recovery of memory function. In addition, methanol neurotoxicity in hippocampus caused a significant increase in cell death (caspase3+ cells) and cell edema at 7 and 28 days, which were significantly decreased by LED therapy. Furthermore, the number of glial fibrillary acid protein astrocytes was significantly lower in methanol rats, compared to controls, whereas LED treatment caused their significant increase. Finally, methanol neurotoxicity caused a significant decrease in the number of brain-derived neurotrophic factor (BDNF+) cells, but also circulating serum BDNF, at 7 and 28 days, compared to controls, which were significantly increased by LED therapy. Importantly, LED significantly increased the number of Ki-67+ cells and BDNF levels in the serum and hypothalamus in control-LED rats, compared to controls without LED therapy.
CONCLUSION: In conclusion, chronic methanol administration caused severe memory impairments and several pathological outcomes in the hippocampus of adolescent rats which were improved by LED therapy.

Matched MeSH terms: Brain Edema/chemically induced; Brain Edema/therapy
Changes in blood-brain barrier permeability and ultrastructure, and protein expression in a rat model of cerebral hypoperfusion

Sekaran H, Gan CY, A Latiff A, Harvey TM, Mohd Nazri L, Hanapi NA, et al.

Brain Res Bull, 2019 10;152:63-73.
PMID: 31301381 DOI: 10.1016/j.brainresbull.2019.07.010

Cerebral hypoperfusion involved a reduction in cerebral blood flow, leading to neuronal dysfunction, microglial activation and white matter degeneration. The effects on the blood-brain barrier (BBB) however, have not been well-documented. Here, two-vessel occlusion model was adopted to mimic the condition of cerebral hypoperfusion in Sprague-Dawley rats. The BBB permeability to high and low molecular weight exogenous tracers i.e. Evans blue dye and sodium fluorescein respectively, showed marked extravasation of the Evans blue dye in the frontal cortex, posterior cortex and thalamus-midbrain at day 1 following induction of cerebral hypoperfusion. Transmission electron microscopy revealed brain endothelial cell and astrocyte damages including increased pinocytotic vesicles and formation of membrane invaginations in the endothelial cells, and swelling of the astrocytes' end-feet. Investigation on brain microvessel protein expressions using two-dimensional (2D) gel electrophoresis coupled with LC-MS/MS showed that proteins involved in mitochondrial energy metabolism, transcription regulation, cytoskeleton maintenance and signaling pathways were differently expressed. The expression of aconitate hydratase, heterogeneous nuclear ribonucleoprotein, enoyl Co-A hydratase and beta-synuclein were downregulated, while the opposite observed for calreticulin and enhancer of rudimentary homolog. These findings provide insights into the BBB molecular responses to cerebral hypoperfusion, which may assist development of future therapeutic strategies.

Matched MeSH terms: Brain Edema/metabolism
Fulltext Central scotoma at near top of Mount Everest – a case report of bilateral high altitude retinopathy

Nazrina Hassan, Yong Meng Hsien, Wan Haslina Wan Abdul Halim, Norshamsiah Md Din

Malaysian Journal of Medicine and Health Sciences, 2019;15(106):94-94.
MyJurnal

Introduction: High altitude retinopathy (HAR) is part of high altitude illness (HAI) which includes acute mountain sickness, high altitude cerebral oedema and pulmonary oedema. We present a case of bilateral HAR with right eye central scotoma during Mount Everest expedition. Case description: A 37-year-old lady presented with decreased right eye (OD) vision and central scotoma during ascending to the top of Mount Everest at 5100m. She developed respiratory symptoms with shortness of breath at the same time and warranted her a rapid descend on day eight of her excursion. Ocular examination revealed visual acuity of 6/36 OD and 6/6 left eye (OS). Both pupils were normal without relative afferent pupillary defect. Anterior segment and intraocular pressure were unremarkable. Fundus examination revealed bilateral multiple retinal haemorrhages along vascular arcades, with macula involvement in the right eye only. Otherwise there was no sign of optic disc swelling, vascular sheathing or choroidal involvement. Optical coherence tomography (OCT) of the macula showed hyperreflectivity changes on the right fovea at the level of superficial nerve fiber layer. Diagnosis of bilateral HAR was made and treated conservatively. She was also diag-nosed with HAI with acute pulmonary oedema and pneumonia by the treating physician. The retinal haemorrhages started to resolve after two weeks with full recovery of vision in ten weeks. Conclusion: With increasing popularity of mountaineering, ophthalmologists should be prepared to recognise HAR as part of HAI. Visual impairment depends on the location and extent of the lesions. HAR is self-limiting with good prognosis but can be associated with poten-tially fatal conditions of HAI e.g. pulmonary oedema in our case.

Matched MeSH terms: Brain Edema
Fulltext Intracranial bleeding following induction of anesthesia in a patient undergoing elective surgery for refractory epilepsy

Kandasamy R, Tharakan J, Idris Z, Abdullah JM

Surg Neurol Int, 2013;4:124.
PMID: 24232072 DOI: 10.4103/2152-7806.119006

BACKGROUND: A patient with refractory epilepsy due to underlying mesial temporal sclerosis underwent general anesthesia for an elective anterior temporal lobectomy and amgydalo-hippocampectomy. He was a known hypertensive and his blood pressure was well controlled on medication.
CASE DESCRIPTION: Following induction of general anesthesia and subsequent opening of the craniotomy flap it was noted that the patient had a very swollen brain that herniated out of the dural defect. There was an underlying spontaneous intraparenchymal bleed encountered in the region of the left temporal lobe with associated subarachnoid hemorrhage within the sylvian fissure. The clot was evacuated and subsequently brain swelling reduced allowing us to proceed with the intended surgery. Despite the intracranial findings there was no overt abnormality in the hemodynamic status from the time of induction of anesthesia to the craniotomy opening excepting a mild nonsustained elevation of blood pressure at the outset.
CONCLUSION: This case is of interest due to the fact that spontaneous intraparenchymal bleeding after induction of anesthesia has not been reported before in literature and should be considered in any patient in which brain swelling occurs in a setting of elective neurosurgery in which the primary lesion does not cause elevated intracranial pressure.

Matched MeSH terms: Brain Edema
Prediction of Histological Grade and Completeness of Resection of Intracranial Meningiomas: Role of Peritumoural Brain Edema

Palaniandy K, Haspani MSM, Zain NRM

Malays J Med Sci, 2017 May;24(3):33-43.
PMID: 28814931 MyJurnal DOI: 10.21315/mjms2017.24.3.5

BACKGROUND: Meningioma is the commonest primary intracranial tumour in adults. Excision is curative for low grade meningioma, whereas high-grade meningioma requires adjuvant therapy following surgery. Several studies have examined the association between peritumoural brain Edema - a common feature in meningioma - and histological grading with mixed results. The present study attempted to elucidate this association and if peritumoural brain Edema affects the intra-operative judgement of surgeons on the completeness of resection.
METHODS: An observational study was conducted among those who underwent surgery for meningioma. Eighteen subjects were recruited each for low- and high-grades, respectively. Magnetic resonance imaging (MRI) prior to surgery was employed for interpreting the Edema index and MRI after surgery was used to determine residual tumour.
RESULTS: Median age was 50 years, male to female ratio was 1:3.5, 69.4% had peritumoural brain Edema and 75% had reported gross resection. Among the reported gross total resection cases, 40.7% had residual tumour. Analysis showed statistically significant association between peritumoural brain Edema (P = 0.027) and tumour volume (P = 0.001) with high-grade meningioma, however multivariate analysis did not present any association. No association was noted between judgement of tumour resection by surgeons and peritumoural brain Edema.
CONCLUSION: Odds ratio for peritumoural brain Edema remained high and the tumour volume exhibited marginal P-value marginal significance for prediction of high grade meningioma. These two factors may still contribute to the tumour grade and should be included in further studies on the prognosis of meningioma.

Matched MeSH terms: Brain Edema
Fulltext Delayed traumatic intracranial haemorrhage and progressive traumatic brain injury in a major referral centre based in a developing country

Jeng TC, Haspani MS, Adnan JS, Naing NN

Malays J Med Sci, 2008 Oct;15(4):56-67.
PMID: 22589639

A repeat Computer Tomographic (CT) brain after 24-48 hours from the 1(st) scanning is usually practiced in most hospitals in South East Asia where intracranial pressure monitoring (ICP) is routinely not done. This interval for repeat CT would be shortened if there was a deterioration in Glasgow Coma Scale (GCS). Most of the time the prognosis of any intervention may be too late especially in hospitals with high patient-to-doctor ratio causing high mortality and morbidity. The purpose of this study was to determine the important predictors for early detection of Delayed Traumatic Intracranial Haemorrhage (DTICH) and Progressive Traumatic Brain Injury (PTBI) before deterioration of GCS occurred, as well as the most ideal timing of repeated CT brain for patients admitted in Malaysian hospitals. A total of 81 patients were included in this study over a period of six months. The CT scan brain was studied by comparing the first and second CT brain to diagnose the presence of DTICH/PTBI. The predictors tested were categorised into patient factors, CT brain findings and laboratory investigations. The mean age was 33.1 ± 15.7 years with a male preponderance of 6.36:1. Among them, 81.5% were patients from road traffic accidents with Glasgow Coma Scale ranging from 4 - 15 (median of 12) upon admission. The mean time interval delay between trauma and first CT brain was 179.8 ± 121.3 minutes for the PTBI group. The DTICH group, 9.9% of the patients were found to have new intracranial clots. Significant predictors detected were different referral hospitals (p=0.02), total GCS status (p=0.026), motor component of GCS (p=0.043), haemoglobin level (p<0.001), platelet count (p=0.011) and time interval between trauma and first CT brain (p=0.022). In the PTBI group, 42.0% of the patients were found to have new changes (new clot occurrence, old clot expansion and oedema) in the repeat CT brain. Univariate statistical analysis revealed that age (p=0.03), race (p=0.035), types of admission (p=0.024), GCS status (p=0.02), pupillary changes (p=0.014), number of intracranial lesion (p=0.004), haemoglobin level (p=0.038), prothrombin time (p=0.016) as the best predictors of early detection of changes. Multiple logistics regression analysis indicated that age, severity, GCS status (motor component) and GCS during admission were significantly associated with second CT scan with changes. This study showed that 9.9% of the total patients seen in the period of study had DTICH and 42% had PTBI. In the early period after traumatic head injury, the initial CT brain did not reveal the full extent of haemorrhagic injury and associated cerebral oedema. Different referral hospitals of different trauma level, GCS status, motor component of the GCS, haemoglobin level, platelet count and time interval between trauma and the first CT brain were the significant predictors for DTICH. Whereas the key determinants of PTBI were age, race, types of admission, GCS status, pupillary changes, number of intracranial bleed, haemoglobin level, prothrombin time and of course time interval between trauma and first CT brain. Any patients who had traumatic head injury in hospitals with no protocol of repeat CT scan or intracranial pressure monitoring especially in developing countries are advised to have to repeat CT brain at the appropriate quickest time .

Matched MeSH terms: Brain Edema
Fulltext Ischaemic haemorrhagic stroke in a child with new onset type 1 diabetes mellitus

Mohd Nor NS, Fong CY, Rahmat K, Vanessa Lee WM, Zaini AA, Jalaludin MY

Eur Endocrinol, 2018 Apr;14(1):59-61.
PMID: 29922355 DOI: 10.17925/EE.2018.14.1.59

Cerebral oedema is the most common neurological complication of diabetic ketoacidosis (DKA). However, ischaemic and haemorrhagic brain injury has been reported infrequently. A 10-year old girl who was previously well presented with severe DKA. She was tachycardic with poor peripheral perfusion but normotensive. However, two fast boluses totalling 40 ml/kg normal saline were given. She was transferred to another hospital where she was intubated due to drowsiness. Rehydration fluid (maintenance and 48-hour correction for 7.5% dehydration) was started followed by insulin infusion. She was extubated within 24 hours of admission. Her ketosis resolved soon after and subcutaneous insulin was started. However, about 48 hours after admission, her Glasgow Coma Scale score dropped to 11/15 (E4M5V2) with expressive aphasia and upper motor neuron signs. One dose of mannitol was given. Her symptoms improved gradually and at 26-month follow-up she had a near-complete recovery with only minimal left lower limb weakness. Serial magnetic resonance imaging brain scans showed vascular ischaemic injury at the frontal-parietal watershed regions with haemorrhagic transformation. This case reiterates the importance of monitoring the neurological status of patient's with DKA closely for possible neurological complications including an ischaemic and haemorrhagic stroke.

Matched MeSH terms: Brain Edema

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