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Suggest Treatment For Obstructive Hydrocephalus Causing Loss Of Memory And Awareness
Question:
Cause: Loss of memory and awareness, Possible infection in the brain. Patient is currently in ICU.
Expectation: Various diagnosis and solution from your end, please help with supporting facts.
History:
My Dad is 62 years old. He is a retired government employee. From past 2 years, he is at home and has been leading sedentary lifestyle. He is diabetic since 26 years and He has blood pressure since 10 years. He is using insulin injections since 15 years. We started seeing kidney anomalies since 5-6 years. The creatinine, urea levels started rising above normal range since 1 year. We started the dialysis since October 13, 2014 because his legs swollen, vomiting and he had severe itching almost all over the body. At first it was 3 times a week and now it is 2 times a week. The AV fistula is set on his left hand. There was no significant decrease in urea level even after the dialysis process. His urea level had always been around 65-80.
After the dialysis was started, for 1.5 months, though he lost 15 kgs, he was fine. He was on high protein diet and occasionally used to vomit. He used to mention that he does not have much strength in his legs, it is difficult for him to get up from chair or walk for long distance. He did not mention about imbalance but only mentioned of lack of strength.
Recent symptoms:(past 15 - 20 days)
-> He has got herpes on his left leg since 7th December and it has spread a little to his left buttock and to the right ankle. It is quite doubtful that it is on his buttock because it is difficult to differentiate between itching marks and blisters.
-> Since 20 days month there were few times when we wakes from the nap/sleep and he had no idea where he is and he used to forget where is the kitchen, bathroom and he was able to recall once we explain. This memory loss condition lasted only for few minutes and it was intermittent. He has fallen down couple of times while getting out of the bed or the chair. During the past few days , this may have happened because of imbalance rather than lack of strength in his legs.
-> On 13th December the memory loss got way to severe he used to forget every 5 minutes. This time the condition lasted for more than 8 hours and his sugar levels were high so We took him to the doctor.
-> Sugar levels 400 on 11th December and 554 on 13th December. Blood pressure 160, Urea 110, Creatinine 6.5.
-> There has been no fever recently
-> There has been no frequent vomiting recently.
-> He has never wet the bed and always knew whenever he wants to urinate and went to the bath room.
Initial treatment:
The doctor said the memory Loss condition might have happened because of high sugar level (500). We got him admitted and his sugar levels were brought down but there was no improvement on the memory part and it was getting worse. On 14th December My doctor recommended a different hospital and adviced to consult a neuro surgeon as his condition was deteriorating. On 14th December evening my was admitted to MICU with ventilator as he closed his eyes and he was not responding to our words. He was reacting to the pain, move his hands but he was not self aware.
Current treatment in micu:
First day: (14th December)
He was put on ventilator because he was not opening his eyes and was not responding to our words. He responded to pain and was able to move his hands. An MRI was done and when he brought out of MRI, I was that he was bleeding . Doctors said that they were able to do MRI and his BP is very high around 200 and they started treating for the same.
Doctor said the herpes/chicken pox migh have also caused the infection in the brain. Hence he was put on antibiotics and sedation.
His urea level is 33.
Second day:(15th December)
Medication for antibiotics continued. Sedation levels decreased. Dialysis was done today.
the MRI results have shown no stroke, no injury but the fluid content in the brain dilated. Doctor said the dilation could have happened because of aging also.
There was also a FITS(seizure) attack in the morning and evening.
His urea level is normal
Third day:(16 th December )
LP lambak aperture tests were done. I think it involves taking fluid from the spine. During the test his BP fluctuated. It was 200 once and later it was below 100. However, after few minutes, his BP was in normal range the results indicated that everything was normal except that results indicated that he got chicken pox in his leg. The doctor said both herpes and chicken pox are same.
Culture tests are being conducted expecting results in 2 days. Till the results are obtained, antibiotics are continued.
Culture test:
1. PAN CNS
2. HSv142 Real time PCR - 1
3. Blood culture
4. HSv142 Real time PCR - 2
Fourth day: (17th December till 3 pm)
The culture test results are yet to come back. My Dad is still not responding to our words and doctor tried to wake him up after removing sedation . He did not wake up. Creatinine level is 7.6, the neurosurgeon said the drowsiness, seizure could be happening cuz of renal effects. This also need to come down to proceed with other actions. Dialysis was done today.
Culture test whose results are yet to come, Doctor has mentioned this would help in pin pointing the problem and the last resort they would need to drain the brain fluid this might bring him to conscious level.
PLEASE NOTE : I can get you interim medical summary if you want.
Please and let us know if you have other solutions in mind.
Cause: Loss of memory and awareness, Possible infection in the brain. Patient is currently in ICU.
Expectation: Various diagnosis and solution from your end, please help with supporting facts.
History:
My Dad is 62 years old. He is a retired government employee. From past 2 years, he is at home and has been leading sedentary lifestyle. He is diabetic since 26 years and He has blood pressure since 10 years. He is using insulin injections since 15 years. We started seeing kidney anomalies since 5-6 years. The creatinine, urea levels started rising above normal range since 1 year. We started the dialysis since October 13, 2014 because his legs swollen, vomiting and he had severe itching almost all over the body. At first it was 3 times a week and now it is 2 times a week. The AV fistula is set on his left hand. There was no significant decrease in urea level even after the dialysis process. His urea level had always been around 65-80.
After the dialysis was started, for 1.5 months, though he lost 15 kgs, he was fine. He was on high protein diet and occasionally used to vomit. He used to mention that he does not have much strength in his legs, it is difficult for him to get up from chair or walk for long distance. He did not mention about imbalance but only mentioned of lack of strength.
Recent symptoms:(past 15 - 20 days)
-> He has got herpes on his left leg since 7th December and it has spread a little to his left buttock and to the right ankle. It is quite doubtful that it is on his buttock because it is difficult to differentiate between itching marks and blisters.
-> Since 20 days month there were few times when we wakes from the nap/sleep and he had no idea where he is and he used to forget where is the kitchen, bathroom and he was able to recall once we explain. This memory loss condition lasted only for few minutes and it was intermittent. He has fallen down couple of times while getting out of the bed or the chair. During the past few days , this may have happened because of imbalance rather than lack of strength in his legs.
-> On 13th December the memory loss got way to severe he used to forget every 5 minutes. This time the condition lasted for more than 8 hours and his sugar levels were high so We took him to the doctor.
-> Sugar levels 400 on 11th December and 554 on 13th December. Blood pressure 160, Urea 110, Creatinine 6.5.
-> There has been no fever recently
-> There has been no frequent vomiting recently.
-> He has never wet the bed and always knew whenever he wants to urinate and went to the bath room.
Initial treatment:
The doctor said the memory Loss condition might have happened because of high sugar level (500). We got him admitted and his sugar levels were brought down but there was no improvement on the memory part and it was getting worse. On 14th December My doctor recommended a different hospital and adviced to consult a neuro surgeon as his condition was deteriorating. On 14th December evening my was admitted to MICU with ventilator as he closed his eyes and he was not responding to our words. He was reacting to the pain, move his hands but he was not self aware.
Current treatment in micu:
First day: (14th December)
He was put on ventilator because he was not opening his eyes and was not responding to our words. He responded to pain and was able to move his hands. An MRI was done and when he brought out of MRI, I was that he was bleeding . Doctors said that they were able to do MRI and his BP is very high around 200 and they started treating for the same.
Doctor said the herpes/chicken pox migh have also caused the infection in the brain. Hence he was put on antibiotics and sedation.
His urea level is 33.
Second day:(15th December)
Medication for antibiotics continued. Sedation levels decreased. Dialysis was done today.
the MRI results have shown no stroke, no injury but the fluid content in the brain dilated. Doctor said the dilation could have happened because of aging also.
There was also a FITS(seizure) attack in the morning and evening.
His urea level is normal
Third day:(16 th December )
LP lambak aperture tests were done. I think it involves taking fluid from the spine. During the test his BP fluctuated. It was 200 once and later it was below 100. However, after few minutes, his BP was in normal range the results indicated that everything was normal except that results indicated that he got chicken pox in his leg. The doctor said both herpes and chicken pox are same.
Culture tests are being conducted expecting results in 2 days. Till the results are obtained, antibiotics are continued.
Culture test:
1. PAN CNS
2. HSv142 Real time PCR - 1
3. Blood culture
4. HSv142 Real time PCR - 2
Fourth day: (17th December till 3 pm)
The culture test results are yet to come back. My Dad is still not responding to our words and doctor tried to wake him up after removing sedation . He did not wake up. Creatinine level is 7.6, the neurosurgeon said the drowsiness, seizure could be happening cuz of renal effects. This also need to come down to proceed with other actions. Dialysis was done today.
Culture test whose results are yet to come, Doctor has mentioned this would help in pin pointing the problem and the last resort they would need to drain the brain fluid this might bring him to conscious level.
PLEASE NOTE : I can get you interim medical summary if you want.
Please and let us know if you have other solutions in mind.
Brief Answer:
Metabolic encephalopathy or viral encephalitis-I.V. antivirals to be tried
Detailed Answer:
Hi XXXX,
I am Dr.Ajay Panwar, a neurologist and I feel deeply concerned about your father. I'd like to help you at my best.
I read your father's history as told by you and I think the possible causes of his altered sensorium can be-
1)Hyperglycemic encephalopathy- High levels of blood sugar can cause brain damage, which may persist even after correction of blood sugar(if it is of severe degree, although normal MRI rules out a very severe brain damage). At this point, I would like to ask you that what was his 'urinary ketones' result-positive or negative, at the time when his blood sugar was high as you have mentioned it is normal at present(I'm sure urinary ketones must have been done).
2)Uremic encephalopathy- He in a state of chronic kidney disease and his serum creatinine even now is 7.6, and this can be very lethal to brain causing brain damage, which should recover with dialysis but may persist for some time or more(if it has caused severe brain damage). Though, normal MRI(make sure that it is normal) essentially rules out a very severe brain damage.
Uremia can be a cause of his increased bleeding tendencies as it causes impaired coagulation. You did not mention what was the site from where he bled-nose? or hand or mouth? I mean where did he bled after coming out of MRI?
3)Acute viral encephalitis- It is one strong possibility, in the immunosuppressed state caused by chronic kidney disease and the setting of herpes infection already present in the body. But again, there should be some abnormality in MRI.
Please follow up with the following details-
1) His cerebrospinal fluid(csf) reports- number of cells, sugar and protein
2) His current medicine details in ICU(Is he on antivirals?)
3) Please upload his MRI images and the report(and not only report)
4) His current blood sugar levels and urinary ketones report.
I don't think dilated ventricles is causing all this and draining the fluid will help as they are normally dilated in more than 60 percent of the persons after 60 years of age.
If it is hyperglycemic or uremic, it should improve with control of blood sugar and dialysis, respectively, atleast partially if not fully.
Please revert back with the details, I asked and I'll feel happy to help you and I pray to God for his good health.
Bottom line - Intravenous antivirals like acyclovir should be started in the slightest doubt of viral brain infection.(Please consult the treating doctor regarding this).
Dr.Ajay Panwar
MD,DM(Neurology)
Metabolic encephalopathy or viral encephalitis-I.V. antivirals to be tried
Detailed Answer:
Hi XXXX,
I am Dr.Ajay Panwar, a neurologist and I feel deeply concerned about your father. I'd like to help you at my best.
I read your father's history as told by you and I think the possible causes of his altered sensorium can be-
1)Hyperglycemic encephalopathy- High levels of blood sugar can cause brain damage, which may persist even after correction of blood sugar(if it is of severe degree, although normal MRI rules out a very severe brain damage). At this point, I would like to ask you that what was his 'urinary ketones' result-positive or negative, at the time when his blood sugar was high as you have mentioned it is normal at present(I'm sure urinary ketones must have been done).
2)Uremic encephalopathy- He in a state of chronic kidney disease and his serum creatinine even now is 7.6, and this can be very lethal to brain causing brain damage, which should recover with dialysis but may persist for some time or more(if it has caused severe brain damage). Though, normal MRI(make sure that it is normal) essentially rules out a very severe brain damage.
Uremia can be a cause of his increased bleeding tendencies as it causes impaired coagulation. You did not mention what was the site from where he bled-nose? or hand or mouth? I mean where did he bled after coming out of MRI?
3)Acute viral encephalitis- It is one strong possibility, in the immunosuppressed state caused by chronic kidney disease and the setting of herpes infection already present in the body. But again, there should be some abnormality in MRI.
Please follow up with the following details-
1) His cerebrospinal fluid(csf) reports- number of cells, sugar and protein
2) His current medicine details in ICU(Is he on antivirals?)
3) Please upload his MRI images and the report(and not only report)
4) His current blood sugar levels and urinary ketones report.
I don't think dilated ventricles is causing all this and draining the fluid will help as they are normally dilated in more than 60 percent of the persons after 60 years of age.
If it is hyperglycemic or uremic, it should improve with control of blood sugar and dialysis, respectively, atleast partially if not fully.
Please revert back with the details, I asked and I'll feel happy to help you and I pray to God for his good health.
Bottom line - Intravenous antivirals like acyclovir should be started in the slightest doubt of viral brain infection.(Please consult the treating doctor regarding this).
Dr.Ajay Panwar
MD,DM(Neurology)
Above answer was peer-reviewed by :
Dr. Ashwin Bhandari
Hello Sir,
Thanks for the quick response and for the suggestions.
Let me answer few of your questions first.
1) Urinary Ketones report is 1+ . So i guess this is normal.
2) Creatine is dropped to 3.6 and urea is dropped to 12.
3) Blood Sugar is normal, fluctuates between 100 to 120.
4) BP is high. Fluctuates between 140 to 210.
5) When my dad got out of MRI, he bled from his nose.(not profusely)
I have collected all the reports including clinical summary, test results, CSF reports, MRI report and film etc.
Steps to access the reports:
1) The reports are available at the link https://drive.google.com/file/d/0B9UwHj2KKh0gVEJhQjJrVTFjZWs/view?usp=sharing
2) Before opening the "All in one" folder, please download it first by clicking the "down arrow" button at the top.
3) After downloading, extract using winzip and winrar
4) To access MRI film, please open "MRI CD" folder and open "Autorun.exe"
5) CSF report is normal.
I have only attached clinical summary in the attachments, rest everything is available in the above provided link.
Important questions needs to be answered:
1) Doctors are planning to drain the liquid from brain. Will therapeutic lumbar puncture / EVD help my dad to wake up and open his eyes? What is the life risk involved in this procedure ?
2) Please let me know if you know any other procedures.
Please respond ASAP and thanks in advance.
Brief Answer:
EVD should be done. No risk. Neurosurgeon's view on hydrocephalus
Detailed Answer:
Hi XXXX,
Thanks for being in follow-up and I am extremely sorry for replying late as I was on an overnight journey with no way to assess your MRI CD.
I went through all the clinical details,investigations and viewed all sections of MRI Brain on CD.
MRI sections indicate that-yes; there is a definite evidence of non-communicating or obstructive hydrocephalus with no apparent cause like tumor or exudates in the Brain. Along with there are patchy areas of parietotemporal diffusion restriction and blooming on GRE images (diffusion restriction suggests ischemia or poor blood perfusion in those areas and blooming on GRE means 'blood or hemorrhage' in those areas).There is nothing convincing of viral encephalitis which is further supported by normal CSF analysis.
The amount of obstructive hydrocephalus he has, is sufficient to cause a person's comatose state and his low Glassgow coma scale (GCS){as he has no eye opening and limb movements only on painful stimuli) is well explained by it. Also, his generalized seizures for which EEG was not able to localize any focus in brain, are also explained by obstructive hydrocephalus.
However one important thing that remains unexplained is the cause of 'Obstructive hydrocephalus'. However there are certain postulations that can be made-
1) As you said that his BP fluctuates between 140 to 210,such a presentation may be caused by accelerated hypertension and is termed as hypertensive encephalopathy. If hypertensive encephalopathy affects cerebellum and posterior fossa brain parts, then edema in posterior fossa can compress 4th ventricle and cause obstructive hydrocephalus (as when the pressure in the posterior fossa increases, due to the small size of posterior fossa, there is no room for the pressure to disperse and it then mounts tremendously on 4th ventricle causing compression-this is the most likely explanation here as other MRI finding correlate with hypertensive encephalopathy).
2) Such a presentation can be seen in uremic encephalopathy (however microhemorrhages or bloom on GRE is unusual).
Maintaining blood pressure under control is absolutely must. It should not be reduced too much, reduction being targeted by not more than 25% of the mean arterial pressure (MAP)[MAP=Diastolic pressure+1/3 of Pulse pressure, that means if BP is 160/100,MAP=100+1/3(160-100)]
It is good that Ketones are almost negative, Creatinine levels are falling down and blood sugar is in control. Serum ammonia being normal rules out another big cause.
I hope Intravenous Mannitol is being given along with antibiotics as mannitol lowers the intracranial pressure.
Therapeutic lumbar puncture, rather external ventricular drainage should be done and is almost safe (considering that he is on antibiotics to prevent infection). Maintaining the patient on EVD may provide crucial time to ease off brain from the increased intracranial pressure meanwhile blood pressure, blood sugar and serum creatinine gets controlled. I think the next 2 or 3 days will be crucial and tell about the prognosis of your father.
Hope I have answered your queries. If you still have follow-up queries, I shall be glad to answer them else, you can close the discussion and rate it.
Once again I say sorry for delay as I can't even realize the mental state you are presently going through because of your father's illness.
Wish him a good health.
Dr.Ajay Panwar
MD,DM(Neurology)
EVD should be done. No risk. Neurosurgeon's view on hydrocephalus
Detailed Answer:
Hi XXXX,
Thanks for being in follow-up and I am extremely sorry for replying late as I was on an overnight journey with no way to assess your MRI CD.
I went through all the clinical details,investigations and viewed all sections of MRI Brain on CD.
MRI sections indicate that-yes; there is a definite evidence of non-communicating or obstructive hydrocephalus with no apparent cause like tumor or exudates in the Brain. Along with there are patchy areas of parietotemporal diffusion restriction and blooming on GRE images (diffusion restriction suggests ischemia or poor blood perfusion in those areas and blooming on GRE means 'blood or hemorrhage' in those areas).There is nothing convincing of viral encephalitis which is further supported by normal CSF analysis.
The amount of obstructive hydrocephalus he has, is sufficient to cause a person's comatose state and his low Glassgow coma scale (GCS){as he has no eye opening and limb movements only on painful stimuli) is well explained by it. Also, his generalized seizures for which EEG was not able to localize any focus in brain, are also explained by obstructive hydrocephalus.
However one important thing that remains unexplained is the cause of 'Obstructive hydrocephalus'. However there are certain postulations that can be made-
1) As you said that his BP fluctuates between 140 to 210,such a presentation may be caused by accelerated hypertension and is termed as hypertensive encephalopathy. If hypertensive encephalopathy affects cerebellum and posterior fossa brain parts, then edema in posterior fossa can compress 4th ventricle and cause obstructive hydrocephalus (as when the pressure in the posterior fossa increases, due to the small size of posterior fossa, there is no room for the pressure to disperse and it then mounts tremendously on 4th ventricle causing compression-this is the most likely explanation here as other MRI finding correlate with hypertensive encephalopathy).
2) Such a presentation can be seen in uremic encephalopathy (however microhemorrhages or bloom on GRE is unusual).
Maintaining blood pressure under control is absolutely must. It should not be reduced too much, reduction being targeted by not more than 25% of the mean arterial pressure (MAP)[MAP=Diastolic pressure+1/3 of Pulse pressure, that means if BP is 160/100,MAP=100+1/3(160-100)]
It is good that Ketones are almost negative, Creatinine levels are falling down and blood sugar is in control. Serum ammonia being normal rules out another big cause.
I hope Intravenous Mannitol is being given along with antibiotics as mannitol lowers the intracranial pressure.
Therapeutic lumbar puncture, rather external ventricular drainage should be done and is almost safe (considering that he is on antibiotics to prevent infection). Maintaining the patient on EVD may provide crucial time to ease off brain from the increased intracranial pressure meanwhile blood pressure, blood sugar and serum creatinine gets controlled. I think the next 2 or 3 days will be crucial and tell about the prognosis of your father.
Hope I have answered your queries. If you still have follow-up queries, I shall be glad to answer them else, you can close the discussion and rate it.
Once again I say sorry for delay as I can't even realize the mental state you are presently going through because of your father's illness.
Wish him a good health.
Dr.Ajay Panwar
MD,DM(Neurology)
Above answer was peer-reviewed by :
Dr. Bhagyalaxmi Nalaparaju
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