The Impact of Hyponatremia on the Severity of Childhood Tuberculous Meningitis

Introduction: Hyponatremia and/or hypoglycorrhachia are commonly encountered biochemical derangements during the acute stage of childhood tuberculous meningitis (TBM). Few studies have explored the correlation between these derangements and the staging of TBM disease (severity), or explored their role as biomarkers for vascular ischemic events, hydrocephalus, or seizures.Methods: We aimed to identify the prevalence and the correlation between serum hyponatremia (mild, moderate and severe) and/or hypoglycorrhachia in relation to clinical TBM features such as stage of disease, seizures and stroke in children diagnosed with definite and probable TBM, between 1985 and 2015, at Tygerberg Hospital, Cape town, South Africa.Results: The prevalence of hyponatremia was 344 out of 481 (71.5%) patients; 169 (49.1%) had mild hyponatremia, 146 (42.4%) moderate hyponatremia and 29 (8.4%) severe hyponatremia. Children with severe hyponatremia had higher frequency of stroke [odds ratio (OR) 4.36, 95% confidence interval (CI) 1.24–15.35; p = 0.01], brainstem dysfunction (OR 7.37, 95% CI 2.92–18.61; p < 0.01), cranial nerve palsies (OR 2.48, 95% CI 1.04–5.91; p = 0.04) and non-communicating hydrocephalus (OR 2.66, 95% CI 1.09–6.44; p = 0.03). Children with moderate hyponatremia and mild hyponatremia compared to those without hyponatremia similarly were more likely to exhibit signs of brainstem dysfunction (OR 1.91, 95% CI 1.11–3.28; p = 0.02) and hydrocephalus (OR 3.18, 95% CI 1.25–8.09; p = 0.01), respectively. On multivariable analysis only brainstem dysfunction was significantly associated with severe hyponatremia [adjusted odds ratio (aOR) 4.46, 95% CI 1.62–12.30; p < 0.01]. Children with hypoglycorrhachia compared to normoglycorrhachia were more likely to have had longer symptom duration prior to admission (OR 1.87, 95% CI 1.09–3.20; p = 0.02), non-communicating hydrocephalus (OR 1.64, 95% CI 0.99–2.71; p = 0.05), higher cerebrospinal white cell counts (OR 3.00, 95% CI 1.47–6.12; p < 0.01) and higher CSF protein concentrations (OR 2.51, 95% CI 1.49–4.20; p < 0.01). On multivariable analysis raised CSF protein concentration >1 g/L was significantly associated with hypoglycorrhachia (aOR 2.52, 95% CI 1.44–4.40; p < 0.01). Death rates did not differ by sodium level category or presence of hypoglycorrachia, however an increasing trend of children that had demised was noted the more severe the sodium category.Conclusion: Hyponatremia and/or hypoglycorrhachia occur in more than two-thirds of children with TBM. Severe TBM disease complications such as brainstem dysfunction was associated with moderate hyponatremia, while severe hyponatremia was associated with brainstem dysfunction, stroke, cranial nerve palsies and non-communicating hydrocephalus. Cerebrospinal fluid (CSF) glucose depletion correlated with non-communicating hydrocephalus and increased CSF inflammation.

Fourth ventricle roof angle as a measure of fourth ventricle bowing and a radiographic predictor of brainstem dysfunction in Chiari malformation type I

OBJECTIVE Chiari malformation type I (CM-I) is a congenital and developmental abnormality that results in tonsillar descent 5 mm below the foramen magnum. However, this cutoff value has poor specificity as a predictor of clinical severity. Therefore, the authors sought to identify a novel radiographic marker predictive of clinical severity to assist in the management of patients with CM-I. METHODS The authors retrospectively reviewed 102 symptomatic CM-I (sCM-I) patients and compared them to 60 age-matched normal healthy controls and 30 asymptomatic CM-I (aCM-I) patients. The authors used the fourth ventricle roof angle (FVRA) to identify fourth ventricle “bowing,” a configuration change suggestive of fourth ventricle outlet obstruction, and compared these results across all three cohorts. A receiver operating characteristic (ROC) curve was used to identify a predictive cutoff for brainstem dysfunction. Binary logistic regression was used to determine whether bowing of the fourth ventricle was more predictive of brainstem dysfunction than tonsillar descent, clival canal angle, or obex position in aCM-I and sCM-I patients. RESULTS The FVRA had excellent interrater reliability (intraclass correlation 0.930, 95% CI 0.905–0.949, Spearman r2 = 0.766, p < 0.0001). The FVRA was significantly greater in the sCM-I group than the aCM-I and healthy control groups (59.3° vs 41.8° vs 45.2°, p < 0.0001). No difference was observed between aCM-I patients and healthy controls (p = 0.347). ROC analysis indicated that an FVRA of 65° had a specificity of 93% and a sensitivity of 50%, with a positive predictive value of 76% for brainstem dysfunction. FVRA > 65° was more predictive of brainstem dysfunction (OR 5.058, 95% CI 1.845–13.865, p = 0.002) than tonsillar herniation > 10 mm (OR 2.564, 95% CI 1.050–6.258, p = 0.039), although increasing age was also associated with brainstem dysfunction (OR 1.045, 95% CI 1.011–1.080, p = 0.009). A clival canal angle < 140° (p = 0.793) and obex below the foramen magnum (p = 0.563) had no association with brainstem dysfunction. CONCLUSIONS The authors identified a novel radiographic measure, the FVRA, that can be used to assess fourth ventricular bowing in CM-I and is more predictive of brainstem dysfunction than tonsillar herniation. The FVRA is easy to measure, has excellent interrater variability, and can be a reliable universal radiographic measure. The FVRA will be useful in further describing CM-I radiographically and clinically by identifying patients more likely to be symptomatic as a result of brainstem dysfunction.

The Underappreciated But Potentially Lethal Role of Brainstem Dysfunction in Epilepsy

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Biopsychosocial Aspect of Pregnant Women Suspected Brainstem Death

Objectives: Diagnosis of brainstem death and the vital organ function support in the pregnant woman to prolong gestation to attain fetal viability is still controversial. The decision is influenced by ethical and legal issue in the country. Another consideration is the hospital cost and health insurance coverage. This article purpose is to report a case and discuss the biopsychosocial aspect of this issue, so the doctors know how to decide a similar case.Methods: We reported a suspected brainstem death in pregnant women and discussed the holistic approach.Case: This case is a-38-year-old women, third pregnancy, 22 weeks of gestation, referred from the secondary hospital in a comatose condition. She was diagnosed with brainstem dysfunction due to intracranial mass and cerebral oedema. She wasn't diagnosed with brainstem death due to the electrolyte imbalance that can cause this condition. We did the multidisciplinary management approach. We decided the termination of pregnancy would only be performed if the fetus reaches 28 weeks of gestational age (with survival rate on perinatology is 31%). From the husband point of view, since the attending doctors have not declared the mother to be dead, then the husband still want to keep the mother in full life support. The patient and the fetus died on the 8th day of hospitalization. The patient was fully paid for by Indonesian Health Insurance.Conclusion: Maternal brainstem dysfunction and brainstem death during pregnancy are rare. In Indonesia, ethical and legal consideration to keep both mother and fetus are appropriate with the general social, cultural, and religious values. However, we recommend managing every single case individually with an intensive multidisciplinary approach due to the possibility of the different personal value of the patient.Keywords: brainstem dysfunction, brain death, pregnancy, fetal, ethic, legal. Abstrak Tujuan: Diagnosis kematian batang otak dan dukungan fungsi organ vital pada perempuan hamil untuk melanjutkan kehamilannya sampai janin dapat hidup jika dilahirkan masih kontrovesi. Keputusan ini dipengaruhi oleh etik dan hukum di suatu negara. Pertimbangan lainnya adalah biaya perawatan rumah sakit dan cakupan asuransi kesehatan. Artikel ini bertujuan melaporkan sebuah kasus dan mendiskusikan aspek biopsikososialnya, sehingga para dokter dapat mengambil keputusan pada kasus lain yang serupa.Metode: Kami melaporkan kasus perempuan hamil dengan kecurgaan kematian batang otak dan mendiskusikan pendekatan holistiknya.Hasil: Kasus perempuan usia 38 tahun, kehamilan ketiga, 22 minggu, dirujuk dari rumah sakit sekunder dalam kondisi koma. Pasien didiagnosis dengan disfungsi batang otak akibat massa intracranial dan edema serebri. Pasien tidak didiagnosis dengan meti batang otak karena kondisi ini masih dapat dikarenakan gangguan keseimbangan elektrolit. Kami melakukan pendekatan multidisiplin. Diputuskan terminasi kehamilan akan dilakukan hanya jika janin mencapai usia kehamilan 28 minggu (dengan harapan hidup dari perinatology 31%). Dikarenakan dokter belum mengatakan pasien sudah meninggal, suami pasien menginginkan pasien dalam topangan alat. Pasien dan janinnya meninggal pada hari ke-8 perawatan. Pembiayaan pasien dengan menggunakan BPJS.Kesimpulan: Disfungsi batang otak dan kematian batang otak selama kehamilan adalah kasus yang jarang. Di Indonesia, etik dan hukum yang berlaku untuk menjaga kehidupan ibu dan janin sesuai dengan nilai sosial, budaya, dan agama. Namun demikian, kami merekomendasikan mlakukan tata laksana setiap kasus secara individu dengan pendekatan multidisiplin dikarenakan perbedaan nilai pribadi pasien dan keluarga.Kata kunci: disfungsi batang otak, etik, hukum, janin, mati batang otak, kehamilan.

Effectiveness of Brainstem Auditory Evoked Potentials Scoring in Evaluating Brainstem Dysfunction and Disability Among Individuals With Multiple Sclerosis

Purpose The brainstem dysfunction in multiple sclerosis (MS) often causes significant functional impairment leading to disability. This study aims to explore modified brainstem auditory evoked potential (BAEP) scores based on the pattern of BAEP abnormalities and relate with brainstem symptoms, brainstem functional system scores (BFSS), brainstem lesions, and disability. Method Forty-five participants with relapsing–remitting MS and 45 age- and gender-matched healthy controls underwent case history assessment, otoscopic examination, pure-tone audiometry, and BAEP testing. Also, neurological examination (Expanded Disability Status Scale, FSS scales) and magnetic resonance imaging were carried out on MS participants. Patterns of BAEP abnormalities were categorized and converted to BAEP scores. Results Out of 45 participants' brainstem symptoms, BFSS > 1, brainstem lesions (magnetic resonance imaging), and BAEP abnormalities were observed in 75.6%, 42.2%, 62.2%, and 55.56% of participants, respectively. Waves V and III abnormalities were more common among MS participants and showed a significant difference from the control group in the Mann–Whitney U test. Chi-square test did not show a significant association of BAEP abnormalities with brainstem symptoms and lesions but showed significant association with BFSS. The mean and standard deviation of BAEP scores in MS participants were 1.73 + 2.37. All healthy controls showed BAEP scores of 0. BAEP scores in MS participants showed significant correlation with BFSS scores and predict Expanded Disability Status Scale scores. Conclusion BAEP scores based on the pattern of BAEP abnormality can be a valid and useful measure in evaluating brainstem functions and predicting disability in MS.