Dabigatran etexilate was the first direct-acting oral anticoagulant approved in the United States. The prevalence of intracranial hemorrhage after blunt head trauma in patients on dabigatran is currently unknown, complicating adequate ability to accurately compare the risks and benefits of dabigatran to alternative anticoagulants. We aimed to determine the prevalence of intracranial hemorrhage for patients on dabigatran presenting to a Level I trauma center.
Introduction: On March 18, 2009, actress Natasha Richardson died after a head injury. It is possible that the rate of patients presenting with mild head injury and receiving computed tomographies (CTs) may have been influenced by the Richardson event. We hypothesized that there was a statistically significant increase in the rate of census-adjusted head CTs performed for mild trauma after March 16, 2009, compared to prior to this date.
Conclusion: The percentage of all ED patients seen with mild trauma tested with head CT almost doubled when comparing the pre-Richardson accident vs. post time periods. There was an increase in media reports of the accident that occurred rapidly after the event and peaked on day 3.
The following is a case of Charles Bonnet syndrome in an 86-year-old woman who presented with visual hallucinations. The differential diagnosis of visual hallucinations is broad and emergency physicians should be knowledgeable of the possible etiologies.
A 33-year-old woman with no past medical history presented to the emergency department with asymmetric pupils. At 7:30am while putting on makeup, she noted her pupils were equal in size. One hour later, she developed light sensitivity in her right eye, and soon after noticed her right pupil was significantly enlarged. She denied headache, facial or extremity weakness, dysarthria, or ataxia. On exam…
Cysticercosis is an emerging disease in the United States. Neurocysticercosis may rarely cause disease within the spinal cord, but the occurrence of such pathology can produce debilitating symptoms for patients. We present the second report in the literature of intramedullary spinal neurocysticercosis presenting with a Brown-Sequard syndrome.
Acute prevertebral calcific tendonitis (APCT) is a rare condition, the exact incidence of which is unknown. It is of particular interest to the emergency physician owing to the other potentially devastating conditions in the differential diagnosis of neck stiffness and/or odynophagia (including retropharyngeal abscess, infectious spondylitis, and meningitis.) In contrast, APCT has a benign clinical course and can be easily managed in the emergency department. We will present a case of APCT, followed by a brief discussion of the disease and current literature.
Subdural hematoma (SDH) is a rare, but life-threatening complication of spinal anesthesia. Subdural hematoma resulting from this procedure could present with vague symptoms such as chronic headache and could easily be missed.
We present the case of a 31-year-old trauma patient with computed tomography concerning significant C3–C4 subluxation. The abnormality is due to an artifact with which emergency physicians should be aware.
The presentation of vertebrobasilar artery occlusion varies with the cause of occlusion and location of ischemia. This often results in delay in diagnosis. Areas of the brain supplied by the posterior circulation are difficult to visualize and usually require angiography or magnetic resonance imaging. Intravenous thrombolysis and local-intra arterial thrombolysis are the most common treatment approaches used. Recanalization of the occluded vessel significantly improves morbidity and mortality. Here we present a review of the literature and a case of a patient with altered mental status caused by vertebrobasilar artery occlusion.
In cerebral regions affected by ischemia, intrinsic vascular autoregulation is often lost. Blood flow delivery depends upon cardiac function and may be influenced by neuro-endocrine mediated myocardial suppression. Our objective is to evaluate the relation between ejection fraction (EF) and transcranial doppler (TCD) peak systolic velocities (PSV) in patients with cerebral ischemic events.
We present an unusual neurologic emergency in an elderly male patient. Given his presentation and risk factors, we presumed the initial symptoms to be secondary to a cerebrovascular accident. As the case evolved, however, it became apparent that a more unusual pathology was present. This case report showcases a rare condition masquerading as a common neurologic emergency.
A 65-year-old woman presented to the emergency department after a seizure. An unexplained bradycardia and heart murmur were detected and an emergency bedside echocardiography was performed. This revealed a mass in the left atrium. The provisional diagnosis of left atrial tumor was later confirmed by formal echocardiography and ultimately by histology. The first presentation of primary cardiac tumors can be misleading and sometimes presents with neurological manifestations. An early echocardiography can be diagnostic and could lead to early surgical intervention with better prognosis.
Excited (or agitated) delirium is characterized by agitation, aggression, acute distress and sudden death, often in the pre-hospital care setting. It is typically associated with the use of drugs that alter dopamine processing, hyperthermia, and, most notably, sometimes with death of the affected person in the custody of law enforcement. Subjects typically die from cardiopulmonary arrest, although the cause is debated. Unfortunately an adequate treatment plan has yet to be established, in part due to the fact that most patients die before hospital arrival. While there is still much to be discovered about the pathophysiology and treatment, it is hoped that this extensive review will provide both police and medical personnel with the information necessary to recognize and respond appropriately to excited delirium.
Imaging in the acute setting of suspected stroke is an important topic to all emergency physicians, neurologists, neurosurgeons and neuroradiologist. When it comes to imaging, the American College of Radiology (ACR) continually updates its guidelines for imaging pathways through the ACR Appropriateness Criteria.1,2 This article is a general review of the imaging modalities currently used to assess and help guide the treatment of strokes.
Determining the presence or absence of red blood cells (RBC) or their breakdown products in cerebrospinal fluid (CSF) is essential for the evaluation of subarachnoid hemorrhage (SAH) in headache patients. Current methodology for finding blood in the CSF is either spectrophotometric detection of pigment, which is time consuming and labor intensive, or visual assesment of samples for color change (xanthochromia), which is inaccurate. Bayer Multistix® urine test strips are designed to test urine for RBC by detecting the presence of hemoglobin. The aim of this pilot study was to evaluate the perfomance of urine reagent test strips for ruling out the presence of RBC in CSF.
We present a case of catatonia, which occurred shortly after starting a new antipsychotic, paliperidone, an active metabolite of risperidone. Catatonia may be caused by a variety of conditions, including metabolic, neurologic, psychiatric and toxic processes. Interestingly, risperidone, which has been thought to cause several cases of catatonia, has also been recommended as a potential treatment. We discuss potential mechanisms for causes of drug-induced catatonia as well as potential treatment options.
Pneumocephalus typically implies a traumatic breach in the meningeal layer or an intracranial gas-producing infection. Unexplained pneumocephalus on a head computed tomography (CT) in an emergency setting often compels emergency physicians to undertake aggressive evaluation and consultation.
Author Affiliation Troy E. Madsen, MD University of Utah, Division of Emergency Medicine, Salt Lake City, UT Anne Bennett, MD University of Utah, Division of Emergency Medicine, Salt Lake City, UT Steven Groke, BSN University of Utah, Division of Emergency Medicine, Salt Lake City, UT Anne Zink, MD University of Utah, Division of Emergency […]
This article summarizes the emergency department approach to diagnosing cerebellar infarction in the patient presenting with vertigo. Vertigo is defined and identification of a vertigo syndrome is discussed. The differentiation of common vertigo syndromes such as benign paroxysmal positional vertigo, Meniere’s disease, migrainous vertigo, and vestibular neuritis is summarized. Confirmation of a peripheral vertigo syndrome substantially lowers the likelihood of cerebellar infarction, as do indicators of a peripheral disorder such as an abnormal head impulse test. Approximately 10% of patients with cerebellar infarction present with vertigo and no localizing neurologic deficits. The majority of these may have other signs of central vertigo, specifically direction-changing nystagmus and severe ataxia.