Intractable/ Persistent Hiccups Due to Acute Subdural Haemorrhage as a Result of Prolonged Inr in a 55 Year Old Man with Rheumatic Mitral Valvular Heart Disease and Atrial Fibrillation: A Case Report

A 58 year old man was brought to hospital in state of deep coma following severe headache for one day. His GCS was 3/15 and had flaccid all 4 limbs with equivocal planter response on both sides on arrival. NECT head showed acute subdural haemorrhage with surrounding cerebral oedema, mid-line shift and corning of brain stem. After giving mannitol and dexamethasone, four hours later, he became fully conscious and orientated; his motor power returned to normal. He was on warfarin 3mg daily for rheumatic mitral valvular heart disease with atrial fibrillation and his INR on arrival was 3.5. He had intractable hiccups once he regained consciousness. Both pharmacological and non-pharmacological measures were tried for distressing hiccups; there was no therapeutic success. His hiccups disappeared completely only after removing the haematoma by burr hole surgery.

Cerebrovascular Accident Complicating Diabetic Ketoacidosis in a Nigerian Adolescent: A Case Report and Review of the Literature

Cerebrovascular accident (CVA) is a rare neurological complication of diabetic ketoacidosis (DKA) in the paediatric population. The risk of developing CVA in DKA patients is often increased due to abnormalities in coagulation factors, platelet activation, blood volume and flow, and vascular reactivity. Cerebral oedema, the most common neurological complication of DKA, may also predispose to CVA. We report the case of a -12-year-old adolescent with DKA complicated by CVA. She developed features of right hemispheric CVA while on admission and had radiological confirmation of an ischaemic CVA. This report highlights that cerebrovascular accidents in DKA can easily be missed or confused with cerebral oedema.

Fluid Management for Critically Unwell Children with Diabetic Ketoacidosis: A Multi-centre Study

Background:Cerebral oedema in paediatric diabetic ketoacidosis (DKA) can be associated with significant mortality and morbidity. These concerns have led to restrictive fluid management in children presenting with DKA and also led to the revision of guidance by the British Society of Paediatric Endocrinology and Diabetes (BSPED) in 2015. Methods:We conducted a multi-centre study of compliance with two BSPED guidelines with liberal (2009) and restrictive fluid management (2015) protocols for children admitted to paediatric critical care units (PCCU) in the UK. We also used univariate and multivariate logistic regressions to study associations with clinical outcomes such as diagnosis of cerebral oedema.Results:96 patients with DKA were admitted to eight PCCUs between January 2013 and December 2017. The median age at presentation was 9 years and weight was 32.4kg. Of all admissions, 25% were invasively ventilated, 4% received vasoactive support, 10% received renal replacement therapy and 98% survived to discharge. 42% were suspected to have cerebral oedema with older children being more likely to be diagnosed with cerebral oedema. There was no significant difference in receiving renal replacement therapy, mechanical ventilation, vasoactive support or a clinical diagnosis of cerebral oedema between the two treatment protocols.Conclusion:Compliance was lower for the guideline with a more restrictive fluid protocol. The study found no evidence to suggest that differing fluid management across BSPED guidance had any significant impact on clinical outcomes. A larger prospective study is needed to study the impact of the revised 2020 guidance.

Lemierre syndrome leading to an ischaemic stroke and malignant cerebral oedema

Lemierre syndrome is an often misdiagnosed disease caused by an anaerobic bacterial infection that produces thrombophlebitis of the internal jugular vein and septic metastasis to distal organs, especially the lungs. Carotid stenosis or thrombosis is a rare complication. We present a patient with Lemierre syndrome who developed malignant cerebral oedema secondary to an ischaemic stroke which required a decompressive craniectomy.

Lethal hyperammonemia in a CAR-T cell recipient due to Ureaplasma pneumonia: a case report of a unique severe complication

We report the first incidence of Ureaplasma infection causing lethal hyperammonemia in a chimeric receptor antigen T cell (CAR-T) recipient. A 53-year-old woman, after receiving CAR-T therapy, suffered sepsis and encephalopathy. She was found to have hyperammonemia up to 643 µmol/L. Imaging revealed lung consolidations and bronchoalveolar lavage PCR was positive for U. parvum. Workup excluded liver failure and metabolic abnormalities. Antibiotics, lactulose, dextrose, arginine, levocarnitine, sodium phenylbutyrate and dialysis were used. Despite these, the patient suffered persistent elevations in ammonia, status epilepticus and cerebral oedema. Early recognition of this rare infection in susceptible populations is needed. CAR-T patients are at risk due to their immunocompromised state and may have amplified harm due to the impact of CAR-T therapy on astrocytes. An early aggressive multimodality approach is needed given the high mortality rates. These include antimicrobials, possibly with double coverage for Ureaplasma. Additionally, concurrent ammonia-suppressing and ammonia-eliminating treatments are necessary.

Peri-operative fluid management during neurosurgical procedures

The management of fluids and electrolytes in neurosurgical patients aims to reduce the risk of cerebral oedema, reduce ICP and at the same time maintain haemodynamic stability and cerebral perfusion. Neurosurgical patients commonly receive diuretics (mannitol and furosemide), developing complications such as bleeding and diabetes insipidus. These patients may require large volumes of intravenous fluids and even blood transfusions for volume resuscitation, treatment of cerebral vasospasm, correction of preoperative dehydration or maintenance of haemodynamic stability. Goal-oriented therapy is recommended in neurological patients, with the aim of maintaining circulating volume and tolerating the changes induced by anaesthesia (vasodilation and myocardial depression).