Severe Pediatric Traumatic Brain Injury Treatment Approaches of Pediatric Intensivists in Turkey PICUs: National Survey Results

Objectives: Guidelines for the pediatric severe traumatic brain injury were published in 2003, 2012, 2019 in order to establish a common treatment approach. In this study, our aim is to evaluate the approaches of the pediatric intensive care specialists in Turkey, towards the follow-up and treatment of severe traumatic brain injury through a survey that was prepared in the light of the guidelines for the pediatric severe traumatic brain injury, which was updated by Kochanek et al. Methods: The survey of forty-five questions on the SurveyMonkey was sent by e-mail to the centers, which were members of the Turkish Society of Pediatric Emergency and Intensive Care Medicine. Results: A total of 45 centers participated in the survey. In all centers, first choice imaging method in the traumatic brain injury was the cranial brain tomography. Regarding the follow-up of the increased intracranial pressure, all centers reported that they used cranial brain tomography. In addition, 20 (44.44%) centers mentioned using magnetic resonance imaging of the brain, 19 (42.22%) centers mentioned using Near-Infrared Spectroscopy, 12 (26.67%) centers mentioned using ultrasonographic optic nerve sheath diameter measurement, and 7 (15.56%) centers mentioned using the transcranial Doppler ultrasonography. As the hyperosmolar therapy, 30 (65.22%) centers reported using 3% hypertonic saline and 16 (37.78%) reported using 3% hypertonic saline + mannitol. In rapid sequence intubation, the most common sedative drug used by the centers was midazolam. In addition, 40 (86.96%) centers stated that they did not use prophylactic hyperventilation in the first 48 hours. In the first 7 days, prophylactic antiepileptic drugs were administered in 44 centers (97.78%), and the most preferred antiepileptic drug was levetiracetam. Conclusion: The results of our survey supported that the pediatric intensive care specialists in our country planned a large percentage of the treatment for pediatric patients with severe traumatic brain injury in line with the guidelines, which were updated in 2019. In patients with severe traumatic brain injury, it is possible to obtain the good long-term prognosis, prevent the secondary injury, and decrease the morbidity and mortality with the administration of appropriate treatments in the acute period.

Generalized choreoathetosis secondary to non-ketotic hyperglycemic disorder

Introduction: Type 2 diabetes mellitus is one of the diseases that is most associated with chorea, and although it is a rare complication, it is necessary tobe aware of it so that the correct diagnosis and early treatment can be made. Case report: Male patient, 78 years old, diabetic and uncontrolled hypertension. Began uncontrolled glycemic 7 days before admission. Evolves with imbalance when walking and with involuntary movements in the left upper limb. At admission, dextro 682 mg/dl and at neurological exam the presence of asymmetric choreoathetotic movements, more evident in the left dimidium. Investigation with neuroimaging, brain tomography showed the presence of hyperdensity in bilateral basal nuclei, confirmed by brain MRI. Other differential diagnoses were ruled out, such as hyperthyroidism, liver failure and rheumatic fever. The most likely diagnosis was generalized choreoathetosis secondary to a non-ketotic hyperglycemic disorder. During hospitalization, adequate glycemic control was performed and clonazepam was introduced as an aid, with significant improvement of movements and absence of the same at discharge. Conclusions: Cases of non-ketotic hyperglycemia are associated with the onset of chorea, and although it is a rare complication, it is not uncommon given the high incidence of diabetes mellitus in the Brazilian population, and clinical improvement may take weeks to months, even after adequate glycemic control.

A developing brain abscess as acute stroke mimic: presentation of case and review of literature

Whether brain abscess is a cause, or a complication of stroke has been a question that elicited differing opinions. We report a case of a child who initially presented with hemiparesis and seizures. Initial brain tomography did not show hemorrhage or infarction. He was managed as a case of childhood stroke. The neurologic manifestations gradually improved until the 17th day of hospitalization when regression of the motor strength and anisocoria occurred. A repeat brain tomography showed multiple masses and vasogenic edema consistent with brain abscess.

EFFICIENCY OF COMPUTED BRAIN TOMOGRAPHY AND MINIMAL PARA-NASAL SINUS SCANNING IN PATIENTS WITH HEADACHE

Background: Headache is the most common human condition and affects a wide range of populations with a number of etiologies. The majority of headaches are accounted for by main headache disorders that involve migraine, cluster and tension-type headaches, whereas secondary headaches are much less common than those with underlying disease (e.g. tumour). Aims & objectives: To assess the Utility of computed tomography of brain and limited para-nasal sinuses scanning in patients with headache. Methodology: This prospective research included 400 cases of primary headache symptoms undergoing computed brain tomography and minimal para-nasal sinus CT scans. For the diagnostic yield from imaging, findings were tabulated and analysed. Results: Isolated headache, accompanied by headache with vomiting, was the most common symptom of referral to CT brain. In 44 subjects, 26 due to intracranial pathology and 18 due to para-nasal sinus disease, a severe abnormality was found. Of the 44 positive cases, 12 were lesions occupying room, 4 vaccine infarctions, 2 subarachnoid haemorrhages, 8 cortical vein thrombosis, and 18 had sinusitis. Conclusion: Computed tomography is a useful screening tool in the assessment of headache patients. Keywords: Headache, Computed Tomography, Migraine, Para Nasal Sinus.

Pneumocephalus Associated with Aggressive Pneumococcal Meningitis

A 44-year-old woman presented with headache and delirium. Brain tomography indicated pneumocephalus, while blood and cerebrospinal fluid cultures revealed Streptococcus pneumoniae. Despite antibiotic treatment and admission to the intensive care unit, the patient died 3 days later. Pneumocephalus in association with meningitis is very rare and may be caused by gas produced by microorganisms.

Silent Brain Infarction: A Missed Opportunity for Prevention (Preprint)

BACKGROUND : Silent brain infarction (SBI) is prevalent in 10%-30% of the elderly, predicting future stroke and cryptogenic dementia. SBI may also be "administrative" due to communication errors between radiologists and caregivers. OBJECTIVE To study the documentation gap between a brain infarction in a computerized brain tomography (brain-CT) report and diagnosis in the Electronic medical record (EHR). METHODS This is a multicenter retrospective observational study, using Clalit's HMO integrated data. We studied 1,339 brain-CT unstructured data from brain-CT reports and EHRs of patients aged 50-80. Patients were categorized by the presence or absence of brain infarction in the brain CT report and then compared to the presence of stroke diagnoses in the corresponding patient EHR. We divided the patient cohort into four groups: with/without Brain infarction in the brain-CT report and with/without stroke diagnoses in the EHR. RESULTS Among the brain-CT reports with Brain infarction, there was a missing EHR documentation in 38.1% of cases. Missing documentation was more likely associated with the identification of lacunar infarctions (P<0.01), with inadequate documentation of other cardiovascular comorbidities and risk factors as well as lower rates of secondary prevention medication (P<0.01). Factors showing significant association with missing documentation in the EHR were a non-stroke neurological indication (P<0.001), a Brain infarction that was mentioned only in the brain-CT report text (and not in summary) (P<0.001), and lacunar infarction (P<0.009). CONCLUSIONS Brain infarction can be silent both clinically and administratively. The main informational barrier is most likely due to interdisciplinary miscommunication. Unstructured computerized report processing can help in closing this gap and potentially improve care. CLINICALTRIAL non