scholarly journals Conditions associated with giant pituitary tumors at the time of surgery effecting outcome morbidity and mortality

2019 ◽  
Vol 10 ◽  
pp. 92
Author(s):  
Marc Billings ◽  
Robert Dahlin ◽  
Bailey Zampella ◽  
Raed Sweiss ◽  
Shokry Lawandy ◽  
...  
Keyword(s):  
Mental Status ◽  
Expectant Management ◽  
Pituitary Tumors ◽  
Mass Effect ◽  
Brain Structures ◽  
Altered Mental Status ◽  
Time Of Surgery ◽  
Presenting Symptoms ◽  
Imaging Characteristics ◽  
Brainstem Compression

Background: Surgical outcome prediction has assisted physicians in discussing surgical intervention or expectant management. While increasing pituitary tumor size would seem to be associated with increasing challenge of removal and associated complications, that relationship has not been borne in the literature. Methods: We performed a retrospective review of a consecutive cohort of pituitary surgeries completed at our institution. Data included age at the time of surgery, presenting symptoms and Glasgow Coma scale (GCS), GCS at discharge or 7 days postoperatively, GCS at 6 months, adenoma size, imaging characteristics of the tumor and brain before resection, postoperative complications, the presence of preoperative hydrocephalus, brainstem compression, and patient mortality. Results: Patients with giant adenomas were more likely to present with a cranial nerve palsy (P = 0.019), altered mental status (P = 0.0001), hydrocephalus (P = 0.002), and mass effect on the brainstem (P = 0.020). Patients who experienced a postoperative decline in mental status were more likely to present with altered mental (P = 0.006), had an increased prevalence of mass effect on the brainstem (P = 0.005), and were more likely to have either an ischemic stroke (P = 0.0001) and vasospasms or new intraparenchymal hemorrhage (P = 0.013). Conclusion: The results of this study demonstrate that postoperative mental status declines after pituitary adenoma resection can be directly related to brainstem compression and further surgical irritation of the surrounding vasculature. The intraoperative irritation can be multifactorial and may result as the decompressed brain structures assume their anatomical position.

scholarly journals Clinical Characteristics of Coronavirus Disease 2019 (COVID-19) among Patients at a Movement Disorders Center

Geriatrics ◽  
2020 ◽  
Vol 5 (3) ◽  
pp. 54
Author(s):  
Joy Antonelle de Marcaida ◽  
Jeffrey Lahrmann ◽  
Duarte Machado ◽  
Lawrence Bluth ◽  
Michelle Dagostine ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Mental Status ◽  
Movement Disorders ◽  
Clinical Characteristics ◽  
Altered Mental Status ◽  
Atypical Parkinsonism ◽  
Health Records ◽  
Telephone Interviews ◽  
Presenting Symptoms ◽  
Idiopathic Parkinson Disease

It is not established whether SARS-CoV-2 (COVID-19) patients with movement disorders, are at greater risk for more serious outcomes than the larger COVID-19 population beyond the susceptibility associated with greater age. We reviewed electronic health records and conducted telephone interviews to collect the demographics and clinical outcomes of patients seen at our Movement Disorders Center who tested positive for COVID-19 from 8 March 2020 through 6 June 2020. Thirty-six patients were identified, 23 men and 13 women, median age of 74.5 years. They primarily carried diagnoses of idiopathic Parkinson disease (n = 22; 61%) and atypical parkinsonism (n = 7; 19%) with the balance having other diagnoses. Twenty-seven patients (75%) exhibited alteration in mental status and fifteen (42%) had abnormalities of movement as common manifestations of COVID-19; in 61% and 31%, respectively, these were the presenting symptoms of the disease. Sixty-seven percent of patients in our cohort required hospitalization, and the mortality rate was 36%. These data demonstrate that in patients with movement disorders, the likelihood of hospitalization and death after contracting COVID-19 was greater than in the general population. Patients with movement disorders frequently presented with altered mental status, generalized weakness, or worsening mobility but not anosmia.

scholarly journals Hyponatremia as the Initial Presentation of Evolving Pituitary Apoplexy

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A586-A586
Author(s):  
Jovan Milosavljevic ◽  
Asha Mary Thomas
Keyword(s):  
Mental Status ◽  
Pituitary Apoplexy ◽  
Pituitary Tumors ◽  
Altered Mental Status ◽  
Clinical Syndrome ◽  
Medical Emergency ◽  
Fluid Restriction ◽  
Free T4 ◽  
Acute Hemorrhage ◽  
Initial Testing

Abstract Pituitary apoplexy (PA) is a known, often under-recognized medical emergency and is characterized by ischemic or hemorrhagic necrosis of the pituitary gland. It is a rare clinical syndrome that occurs in 2-12% of pituitary tumors. Hyponatremia can occur secondary to hypocortisolism (12-40%) or, rarely, to the syndrome inappropriate antidiuretic hormone (ADH) secretion. We present the case of a 69-year-old man who presented with altered mental status on post-operative day 3 from total knee replacement surgery. Initial testing revealed hyponatremia of 124 mmol/L, low serum osmolality of 266 mOsm/kg, and high urine osmolality of 664 mOsm/kg with urine sodium of 179 mmol/L. Head computerized tomography revealed a sellar mass of 1.8 x 2.4 cm. Initial testing revealed low prolactin (0.7 ng/mL), normal TSH (0.458 mcIU/mL) with borderline low free T4 of 0.72 ng/dL. Morning cortisol was 12.7 mcg/dL with ACTH of 8.5 pg/mL. Cosyntropin stimulation test was done revealing baseline cortisol of 5.8 mcg/dL (at midnight), increasing to 25.8 mcg/dL after 30 minutes and to 30.9 mcg/dL 60 minutes after cosyntropin administration. His sodium and mental status initially improved with fluid restriction and salt tablets, for the assumed syndrome of inappropriate ADH secretion. The patient remained hemodynamically stable. On the fourth day, however, his mental status deteriorated. Magnetic resonance imaging revealed expansion of sella with hyperintense mass 2.2 x 2.0 x 2.8 cm with compression of the optic chiasm. He was given stress dose hydrocortisone and levothyroxine and underwent emergency transsphenoidal resection. Biopsy revealed acute hemorrhage within infarcted adenoma. Postoperatively, both the patient’s sodium and mental status improved significantly and he was discharged to home on hydrocortisone and levothyroxine. The main clinical concern in the management of PA remains under-diagnosis at presentation. Prognosis is dependent on management during the acute phase. PA can present as hyponatremia even in the absence of overt hypocortisolism, presumably due to inappropriate ADH secretion. Therefore, PA should be considered as one of the differential diagnoses in hemodynamically stable patients with altered mental status and hyponatremia.

scholarly journals 275. Clinical and Laboratory Predictors of Stroke Associated with COVID-19 Disease

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S243-S243
Author(s):  
Valerie R Bromberg ◽  
Leigh Cressman ◽  
Pam C Tolomeo ◽  
Hatem Abdallah ◽  
Alexis Holmes ◽  
...  
Keyword(s):  
Mental Status ◽  
Inflammatory Markers ◽  
Chart Review ◽  
Stroke Risk ◽  
Vascular Complications ◽  
Credible Interval ◽  
Altered Mental Status ◽  
Reactive Protein ◽  
Presenting Symptoms ◽  
Binomial Regression

Abstract Background Although SARS-CoV-2 predominantly targets the respiratory system, it has also been associated with vascular complications including stroke. Identifying COVID-19 patients at elevated risk for stroke can help inform target anticoagulation strategies. We sought to understand how symptoms and laboratory markers at presentation with COVID-19 relate to stroke risk. Methods We enrolled a cohort of 1324 subjects who were hospitalized with COVID-19 across six PennMedicine hospitals between April and August 2020 and performed retrospective, manual chart review to measure exposures including presenting symptoms and admission inflammatory markers. Data were organized with a REDCap database, and analyses were performed using R statistical software, with Bayesian binomial regression models fit using Stan Hamiltonian Monte Carlo via the “brms” package. Results Among 1324 subjects, 19 stroke events were observed within 30 days of COVID-19 diagnosis. Admission inflammatory markers, including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), ferritin, and D-dimer, were poor predictors of stroke risk. Among presenting symptoms, including respiratory, gastrointestinal, dermatologic, and neurologic features of COVID-19 disease, only altered mental status documented on presentation (in 529 subjects) was significantly associated with stroke risk (odds ratio 6.06, 95% credible interval 2.16 - 18.7). Conclusion Inflammatory markers associated with COVID-19 disease severity did not discriminate patients at high versus low risk of stroke in this cohort. Altered mental status documented on presentation was significantly associated with incident stroke during COVID-19 disease. Disclosures Ebbing Lautenbach, MD, MPH, MSCE, Merck (Other Financial or Material Support, Member of Data and Safety Monitoring Board (DSMB)) Michael Z. David, MD PhD, GSK (Board Member)

scholarly journals Clinical characteristics, risk factors and antiviral treatments of influenza in immunosuppressed inpatients in Beijing during the 2015–2020 influenza seasons

2022 ◽  
Vol 19 (1) ◽  
Author(s):  
Yafen Liu ◽  
Yue Wang ◽  
Huan Mai ◽  
YuanYuan Chen ◽  
Baiyi Liu ◽  
...  
Keyword(s):  
Risk Factors ◽  
Influenza Virus ◽  
Mental Status ◽  
Clinical Characteristics ◽  
Antiviral Treatment ◽  
Altered Mental Status ◽  
Haematopoietic Stem Cell ◽  
Severe Illness ◽  
Presenting Symptoms ◽  
Immunosuppressed Patients

Abstract Background Compared with immunocompetent patients, immunosuppressed patients have higher morbidity and mortality, a longer duration of viral shedding, more frequent complications, and more antiviral resistance during influenza infections. However, few data on this population in China have been reported. We analysed the clinical characteristics, effects of antiviral therapy, and risk factors for admission to the intensive care unit (ICU) and death in this population after influenza infections and explored the influenza vaccination situation for this population. Methods We analysed 111 immunosuppressed inpatients who were infected with influenza virus during the 2015–2020 influenza seasons. Medical data were collected through the electronic medical record system and analysed. Univariate analysis and multivariate logistics analysis were used to identify risk factors. Results The most common cause of immunosuppression was malignancies being treated with chemotherapy (64.0%, 71/111), followed by haematopoietic stem cell transplantation (HSCT) (23.4%, 26/111). The most common presenting symptoms were fever and cough. Dyspnoea, gastrointestinal symptoms and altered mental status were more common in HSCT patients than in patients with immunosuppression due to other causes. Approximately 14.4% (16/111) of patients were admitted to the ICU, and 9.9% (11/111) of patients died. Combined and double doses of neuraminidase inhibitors did not significantly reduce the risk of admission to the ICU or death. Risk factors for admission to the ICU were dyspnoea, coinfection with other pathogens and no antiviral treatment within 48 h. The presence of dyspnoea and altered mental status were independently associated with death. Only 2.7% (3/111) of patients less than 12 months old had received a seasonal influenza vaccine. Conclusion Fever and other classic symptoms of influenza may be absent in immunosuppressed recipients, especially in HSCT patients. Conducting influenza virus detection at the first presentation seems to be a good choice for early diagnosis. Clinicians should pay extra attention to immunosuppressed patients with dyspnoea, altered mental status, coinfection with other pathogens and no antiviral treatment within 48 h because these patients have a high risk of severe illness. Inactivated influenza vaccines are recommended for immunosuppressed patients.

scholarly journals Altered Mental Status and a Not-So-Benign Rash

2011 ◽  
Vol 2011 ◽  
pp. 1-2
Author(s):  
Aakash N. Bodhit ◽  
Latha Ganti Stead
Keyword(s):  
Emergency Department ◽  
Mental Status ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Peripheral Blood Smear ◽  
Altered Mental Status ◽  
Care Hospital ◽  
Case Presentation ◽  
Presenting Symptoms ◽  
Symptoms And Signs

Introduction. The authors are presenting a case of Thrombotic Thrombocytopenic Purpura (TTP) that presented with complaints of altered mental status and found to have petechiae.Case Presentation. An 81-year-old female patient presented to the Emergency Department (ED) of a tertiary care hospital with chief complains of dizziness, slurred speech, and weakness. She was found to have lower extremity petechiae on physical examination. On blood exam, she had thrombocytopenia, and her peripheral blood smear showed schistocytes. Her renal function was also impaired. The CT scan of head was without any abnormality. She was finally diagnosed as having TTP and transferred to ICU but ultimately passed away.Conclusion. TTP is a rare syndrome with preventable mortality if diagnosed early and managed appropriately with plasmapheresis. The Emergency Department physicians should be aware of the presenting symptoms and signs of TTP.

scholarly journals Clinical Characteristics of Coronavirus disease 2019 (COVID-19) Among Patients at a Movement Disorders Center

2020 ◽  
Author(s):  
J. Antonelle de Marcaida ◽  
Jeffrey Lahrmann ◽  
Duarte Machado ◽  
Lawrence Bluth ◽  
Michelle Dagostine ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Mental Status ◽  
Movement Disorders ◽  
Clinical Characteristics ◽  
Altered Mental Status ◽  
Atypical Parkinsonism ◽  
Health Records ◽  
Telephone Interviews ◽  
Presenting Symptoms ◽  
Idiopathic Parkinson Disease

It is not established whether SARS-CoV-2 (COVID-19) patients with movement disorders, are at greater risk for more serious outcomes than the larger COVID-19 population beyond the susceptibility associated with greater age. We reviewed electronic health records and conducted telephone interviews to collect the demographics and clinical outcomes of patients seen at our Movement Disorders Center who tested positive for COVID-19 from 8 March 2020 through 6 June 2020. Thirty-six patients were identified, 23 men and 13 women, median age of 74.5 years. They primarily carried diagnoses of idiopathic Parkinson disease (n=22; 61%) and atypical parkinsonism (n=7; 19%) with the balance having other diagnoses. Twenty-seven patients (75%) exhibited alteration in mental status and fifteen (42%) had abnormalities of movement as common manifestations of COVID-19; in 61% and 31%, these were the presenting symptoms of the disease. 67% of patients in our cohort required hospitalization, and the mortality rate was 39%.. These data demonstrate that in patients with movement disorders, the likelihood of hospitalization and death after contracting COVID-19 was substantially greater than in the general population. Patients with movement disorders frequently presented with altered mental status, generalized weakness, or worsening mobility but not anosmia.

Transient altered mental status and leptomeningeal enhancement associated with pembrolizumab: a case report

2021 ◽  
Author(s):  
Keng Lam ◽  
Sameer K. Kulkarni ◽  
Manya Khrlobyan ◽  
Pamela K. Cheng ◽  
Caroline L. Fong
Keyword(s):  
Case Report ◽  
Mental Status ◽  
Altered Mental Status ◽  
Leptomeningeal Enhancement

scholarly journals Recurrent noncirrhotic hyperammonemia causing acute metabolic encephalopathy in a patient with a continent ileocecal pouch: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
T. M. Skipina ◽  
S. Macbeth ◽  
E. L. Cummer ◽  
O. L. Wells ◽  
S. Kalathoor
Keyword(s):  
Emergency Department ◽  
Metabolic Acidosis ◽  
Mental Status ◽  
Rare Case ◽  
Liver Function Tests ◽  
Altered Mental Status ◽  
Potassium Citrate ◽  
Metabolic Encephalopathy ◽  
History Of ◽  
Normal Urine

Abstract Introduction Acute encephalopathy, while a common presentation in the emergency department, is typically caused by a variety of metabolic, vascular, infectious, structural, or psychiatric etiologies. Among metabolic causes, hyperammonemia is relatively common and typically occurs in the setting of cirrhosis or liver dysfunction. However, noncirrhotic hyperammonemia is a rare occurrence and poses unique challenges for clinicians. Case presentation Here we report a rare case of a 50-year-old Caucasian female with history of bladder cancer status post chemotherapy, radical cystectomy, and ileocecal diversion who presented to the emergency department with severe altered mental status, combativeness, and a 3-day history of decreased urine output. Her laboratory tests were notable for hyperammonemia up to 289 μmol/L, hypokalemia, and hyperchloremic nonanion gap metabolic acidosis; her liver function tests were normal. Urine cultures were positive for Enterococcus faecium. Computed tomography imaging showed an intact ileoceal urinary diversion with chronic ileolithiasis. Upon administration of appropriate antibiotics, lactulose, and potassium citrate, she experienced rapid resolution of her encephalopathy and a significant reduction in hyperammonemia. Her hyperchloremic metabolic acidosis persisted, but her hypokalemia had resolved. Conclusion This case is an example of one of the unique consequences of urinary diversions. Urothelial tissue is typically impermeable to urinary solutes. However, when bowel segments are used, abnormal absorption of solutes occurs, including exchange of urinary chloride for serum bicarbonate, leading to a persistent hyperchloremic nonanion gap metabolic acidosis. In addition, overproduction of ammonia from urea-producing organisms can lead to abnormal absorption into the blood and subsequent oversaturation of hepatic metabolic capacity with consequent hyperammonemic encephalopathy. Although this is a rare case, prompt identification and treatment of these metabolic abnormalities is critical to prevent severe central nervous system complications such as altered mental status, coma, and even death in patients with urinary diversions.

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