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Background Interest has mounted into the use of objective clinical biomarkers for traumatic brain injury (TBI). This systematic review and meta-analysis aimed to synthesise the existing evidence investigating the use of serum & plasma biomarkers to exclude significant intracranial injuries seen on CT head scans in patients that present to ED with TBI. Methods The primary outcome was to review the diagnostic accuracy (sensitivity & specificity) of S100B, GFAP and UCH-L1 to exclude significant intracranial pathology on CT head scan in adults presenting with TBI. Secondary outcomes investigated biomarker performance at different time points, in isolated TBI and multi-trauma and with pre-specified cut offs. Systematic searches were conducted on MEDLINE ® (via PubMed), Cochrane electronic databases and EMBASE from 1st January 2000 until June 2020. Bias was assessed using QUADAS 2 tool. A narrative synthesis and meta-analysis were performed. PROSPERO registration number CRD42020212206. Results After screening, 22 papers were included. The total number of patients with TBI was 9,416. There was significant variation regarding study design, population selection and the clinical threshold/decision rule for CT head request. The diagnostic accuracy of S100B as measured by the range of individual sensitivities and specificities were 63-100% and 5-58%, respectively. Individual sensitivities and specificities for GFAP were 67-100% and 0-89% and for UCH-L1 were 61-100% and 21-63.7% respectively. When measured within 3 hours individual sensitivities & specificities for S100B were 98-100% & 20-58% respectively. The quality of evidence for the primary outcome overall was low. The quality of evidence was low for all secondary outcomes apart from studies that used a pre-specified cut off for S100B which had a moderate strength of evidence. Conclusion The overall quality of evidence regarding the diagnostic accuracy of single biomarkers as a rule out for significant intracranial injury seen on CT head scans in ED patients with TBI is low. Based on current evidence, S100B is the only single biomarker with a validated clinical platform, pre-determined cut off threshold and moderate quality evidence; at this stage making it the biomarker of choice. More robust clinical outcome and economic impact data is required to support its incorporation into clinical decision tools.

Transcranial ultrasound has been described as a tool to identify intracranial pathology, however, it is seldom used in the adult patient population due to poor imaging windows and rapid availability of more advanced imaging such as CT and MRI. We report a unique population in which transcranial ultrasound may be beneficial: those with a history of hemicraniectomy. We present a case of a 65-year-old male with a history of hemicraniectomy who suffered head trauma after a fall from his wheelchair. An initial non-contrast head CT scan identified an intracranial hemorrhage. Point-of-care bedside transcranial ultrasound was able to identify the progression of intracranial hemorrhage, which was confirmed by interval head CT. This prompted repeat CT imaging followed by neurosurgical intervention with the placement of an external ventricular drain in the right lateral ventricle. While ultrasound is unlikely to replace the need for more advanced imaging in these patients, point-of-care transcranial ultrasound may be a useful tool that can be employed rapidly at the bedside for interval screening in patients with hemicraniectomy and concern for new or worsening intracranial hemorrhage. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40477-021-00588-6.

Background Sport-related structural brain injury (SRSBI) is intracranial pathology incurred during sport. Management mirrors that of non-sport-related brain injury. An empirical vacuum exists regarding return to play (RTP) following SRSBI. Objective To provide key insight for operative management and RTP following SRSBI using a (1) focused systematic review and (2) survey of expert opinions. Methods A systematic literature review of SRSBI from 2012 to present in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was conducted. Results Of 27 included articles out of 241 systematically reviewed, 9 (33.0%) case reports provided RTP information for 12 athletes. To assess expert opinion, 31 of 32 neurosurgeons (96.9%) provided survey responses. For acute, asymptomatic SRSBI, 12 (38.7%) would not operate. Of the 19 (61.3%) who would operate, midline shift (63.2%) and hemorrhage size > 10 mm (52.6%) were the most common indications. Following SRSBI with resolved hemorrhage, with or without burr holes, the majority of experts (>75%) allowed RTP to high-contact/collision sports at 6 to 12 mo. Approximately 80% of experts did not endorse RTP to high-contact/collision sports for athletes with persistent hemorrhage. Following craniotomy for SRSBI, 40% to 50% of experts considered RTP at 6 to 12 mo. Linear regression revealed that experts allowed earlier RTP at higher levels of play (β = -0.58, 95% CI -0.111, -0.005, P = .033). Conclusion RTP decisions following structural brain injury in athletes are markedly heterogeneous. While individualized RTP decisions are critical, aggregated expert opinions from 31 international sports neurosurgeons provide key insight. Level of play was found to be an important consideration in RTP determinations.

Hepatic encephalopathy represents a continuum of neuropsychiatric symptoms among patients with end-stage liver disease. When a patient with cirrhosis presents with altered mental status (AMS), routine neurologic imaging is not typically recommended, due to low diagnostic yield. Guidance from the American Association for the Study of Liver Disease states that, on initial presentation, brain imaging is not required unless there are other signs of intracranial pathology, including focal neurologic deficits. We present a case of a 61-year-old female with cirrhosis presenting with AMS without focal deficits, in whom neurological imaging revealed a meningioma and subsequent resection led to symptom improvement.

Cocaine consumption is associated with a variety of clinical manifestations. Though cocaine intranasal inhalation always determines nasal mucosal damages, extensive septum perforations, and midline destructions-known as cocaine-induced midline destructive lesions (CIMDL)-affect only a limited fraction of patients. CIMDL is viewed as a cocaine-associated autoimmune phenomenon in which the presence of atypical anti-neutrophil cytoplasmic antibody (ANCA) promotes and/or defines the disease phenotype. A 51-year-old man presented with an intracranial tumor-like lesion by its space-occupying effect. CT also revealed the destruction of the nasal septum and skull base. A diagnosis of CIMDL was made in light of the patient's history as well as findings of the physical and endoscopic examinations, imaging studies, and laboratory testing. There was no evidence of other pathologies. Histopathological results from cerebral biopsy led us to consider the intracranial pathology as an extension of the CIMDL. CIMDL is the result of a necrotizing inflammatory tissue response triggered by cocaine abuse in a subset of predisposed patients. The reported case is the first CIMDL consistent with brain extension mimicking a tumor-like lesion. While the presence of atypical ANCA seems to promote and/or define the disease phenotype, the specific role of these and other circulating autoantibodies needs further investigation.

Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic state often characterized by altered mental state and is seen in various clinical settings. Although it is often reversible, it may result in long term sequelae. The typical and atypical neuroimaging findings seen in PRES have been previously well-described in the literature. However, the presence of other co-existing intracranial lesions along with PRES can occasionally confound the imaging findings and poses a diagnostic challenge. Herein, the authors report four cases of PRES with etiologically different co-existing intracranial lesions confounding the clinical and imaging manifestations. When presented with atypical imaging findings in PRES, the possibility of a co-existing intracranial pathology with superimposed imaging findings should be considered.

A brief introduction is provided of the different imaging modalities encountered in the intensive care unit (ICU). The spectrum of intracranial pathology as well as potential postsurgical complications is reviewed, with a focus on pearls and pitfalls. A brief overview also is provided of imaging of the spine in an ICU patient.

Extradural hematoma (EDH) is a common intracranial pathology following motor vehicle accidents, comprising approximately 0.2 to 6% of all head injuries. The association of EDH with subperiosteal intraorbital hematomas is rarely reported. We report a case of a traumatic subfrontal EDH with subperiosteal hematoma (orbital EDH) successfully treated with needle aspiration, demonstrating that in appropriate patients, needle aspiration can result in the resolution of symptoms without an invasive procedure.

Although various changes in electrocardiogram (ECG) were reported with normal serum potassium levels in acute intracranial pathology, giant asymmetrical T-wave change has not been reported. We report a case of a previously healthy male child who presented with acute febrile illness and features of raised intracranial pressure. Full standardized ECG shows normal sinus rhythm and tall, broad, and giant asymmetrically peaked T-wave. Serum potassium, echocardiography, and cardiac injury marker were normal. The child managed with supportive care and antimicrobials and showed recovery in 7 days.

Stereotactic radiosurgery is a modern discipline that emerged after World War II. It represents a synthesis of an approach to patient care that was not immediately embraced by either neurosurgeons or radiation oncologists, but which has been shown, time and again, to be advantageous for the treatment of intracranial pathology. Indeed, stereotactic radiosurgical techniques are now being rapidly adapted and adopted for the treatment of extracranial malignant and benign disease. Any examination of the individuals, devices, and technological advances that permitted stereotactic radiosurgery to become a preferred approach for patient care cannot be absolutely comprehensive but can provide insights into the evolution of the specialty and potential future prospects for further improvements in patient care. As Shakespeare wrote in The Tempest, "What's past is prologue."

*Sert, Ekrem Taha ( Aksaray, Yazar ), Background: Currently, a large burden of hospital admissions is related to minor head trauma and its related imaging studies. One of the challenging issues for emergency physicians is head computed tomography scan. Objective: The aim of this study was to determine whether there are clinical risk factors that may reveal the intracranial pathology occurring after discharge in adult patients who underwent computerized tomography because of mild/minor head traumas. We aimed to evaluate the prevalence of abnormal computerized tomography in these patients. Methods: Between January 2013 and December 2017 medical records and imaging findings of patients over 18 years of age who had undergone computerized tomography examination in the emergency department of our hospital were evaluated retrospectively. Patients were divided into groups according to age, sex, symptoms and physical examination findings. The relationship between these findings and abnormal computerized tomography findings was evaluated statistically. Results: A total of 619 patients who were admitted to the emergency department for the second time because of the same head trauma and underwent control head computerized tomography were included in the study. Abnormal head computerized tomography findings were found in 7.6% (47) of the patients. Clinical risk factors; Glasgow Coma Scale score, vomiting, loss of consciousness, dangerous trauma mechanism and anticoagulant drug use were significantly correlated with the presence of pathology on head CT(p

In recent decades, diagnostic imaging became an important generator of large increases in medical spending. Inappropriate head CT referrals also increase population irradiation and unnecessarily burden and frighten patients. To validate previously proposed clinical criteria for referral to head imaging (age > 55 years, focal neurological deficit, changed mental state, nausea or vomiting, coagulation disorder, cancer) in a setting of emergency neurological service. We retrospectively analyzed electronic records of 500 consecutive referrals to neurological emergency and 500 referrals to emergency head imaging. In patients with several referrals, only results of the first evaluation were further analyzed. We calculated relations between clinical predictors, referrals, and findings of head imaging. Of 486 first referrals of consecutive patients, 216 (44%) were referred to the emergency, and 100 (21%) to non-emergency head imaging. Remaining 170 (35%) were not referred to head imaging. Clinical predictors of pathologic head imaging fulfilled 77%, 41%, and 43% of patients, respectively. Pathologic head imaging had 153 of 490 (31%) referred patients. Referral criteria fulfilled 146 (sensitivity 95%) of them. Intracranial pathology was found in 7 of 125 patients not fulfilling referral criteria (negative predictive value 94%): 3 reported transient neurological symptoms, 2 sudden headache, and 2 headache with nausea and vomiting. We confirmed utility of previously proposed clinical criteria for referral to head CT in emergency neurological setting. In addition, we found transient neurological symptoms, sudden severe headache, and headache with nausea or vomiting as additional independent indications for emergency head imaging.

The aim of this study was to evaluate the utility of neuroimaging in children who present to the pediatric emergency department with acute-/subacute-onset ataxia. Neuroimaging is performed in many children with ataxia to rule out serious intracranial pathology. There is, however, limited evidence to support such practice.This was a retrospective review of electronic medical records of children who presented to the emergency department with ataxia between 2007 and 2013. Patient demographics, historical features, physical examination findings, laboratory results, and neuroimaging results were collected. Neuroimaging studies that were classified as abnormal by a neuroradiologist were further reviewed and classified by the study neurologist as clinically significant or not.The records of 141 subjects were analyzed. The most common causes of ataxia were infectious/postinfectious (36.2%) and ingestion (15.6%). Neuroimaging was performed in 104 children (73.8%). Neuroimaging was abnormal in 63 children (60.6%). However, these abnormalities were clinically significant in only 14 children (13.5%). Focal neurological findings were noted in 12 of 14 children (85.7%) with clinically significant neuroimaging.Clinically significant neuroimaging was noted in a minority of children who presented with acute/subacute ataxia. The majority of patients with clinically significant neuroimaging had focal neurological findings on examination. Neuroimaging may not be required in all children presenting to the ED with acute ataxia, but further large-scale studies are needed to validate these findings and identify a subset of patients with ataxia in whom imaging can be deferred.

Today, stereotactic radiosurgery is an effective therapy for a variety of intracranial pathology that were treated solely with open neurosurgery in the past. The technique was developed from the combination of therapeutic radiation and stereotactic devices for the precise localization of intracranial targets. Although stereotactic radiosurgery was originally performed as a partnership between neurosurgeons and radiation oncologists, this partnership has weakened in recent years, with some procedures being performed without neurosurgeons. At the same time, neurosurgeons across the United States and Canada have found their stereotactic radiosurgery training during residency inadequate. Although neurosurgeons, residency directors, and department chairs agree that stereotactic radiosurgery education and exposure during neurosurgery training could be improved, a limited number of resources exist for this kind of education. This review describes the history of stereotactic radiosurgery, assesses the state of its use and education today, and provides recommendations for the improvement of neurosurgical education in stereotactic radiosurgery for the future.

Introduction: We sought to validate a handheld, near-infrared spectroscopy (NIRS) device for detecting intracranial hematomas in children with head injury. Methods: Eligible patients were those 3.5 milliliters in volume and 0.2 on three successive scans. We calculated diagnostic performance measures with corresponding exact two-sided 95% Clopper-Pearson confidence intervals (CI). Hypothesis test evaluated whether predictive performance exceeded chance agreement (predictive Youden’s index > 0). Results: A total of 464 patients were enrolled and 344 met inclusion for primary data analysis: 10.5% (36/344) had evidence of a hematoma on HCT, and 4.7% (16/344) had qualifying hematomas. The handheld brain scanner demonstrated a sensitivity of 58.3% (21/36) and specificity of 67.9% (209/308) for hematomas of any size. For qualifying hematomas the scanner was designed to detect, sensitivity was 81% (13/16) and specificity was 67.4% (221/328). Predictive performance exceeded chance agreement with a predictive Youden’s index of 0.11 (95% CI, 0.10 – 0.15; P < 0.001) for all hematomas, and 0.09 (95% CI, 0.08 – 0.12; P < 0.001) for qualifying hematomas. Conclusion: The handheld brain scanner can non-invasively detect a subset of intracranial hematomas in children and may serve an adjunctive role to head-injury neuroimaging decision rules that predict the risk of clinically significant intracranial pathology after head trauma.

Pulmonary arteriovenous malformations (PAVMs) are caused by abnormal connections between arteries and veins, which lead to right-to-left shunting of deoxygenated blood. Here, we report an 11-year-old male who presented with signs suggestive of intracranial pathology. The patient displayed signs of a chronic illness, possibly congenital malformation that was complicated by PAVM and multiple brain abscesses. This case illustrates the importance of doing a detailed examination and investigations, especially if the history alone is not helpful in making a diagnosis.

Aim To test the two prevailing hypotheses regarding the aetiology of infant retinal haemorrhage: (a) traction forces exerted by the lens and/or corpus vitreum on the retina during infant shaking or (b) retinal vessel leakage secondary to intracranial pathology and raised intracranial pressure. Methods Comparison of medical findings and reported type of trauma in infants investigated for suspected physical abuse with presence (n = 29) or non-presence of retinal haemorrhage (RH) (n = 119). Results Intracranial pathology was recorded in 15 (13%) of the non-RH cases and in 27 (97%) of the RH cases (p < 0.0001). All 18 infants with bilateral RH had intracranial pathology. Of 27 infants subjected to witnessed or admitted shaking, two were in the group with RH. One had a single unilateral RH and no intracranial pathology. The other had bilateral RH and intracranial pathology with non-specific white matter changes, acute subdural and subarachnoid haemorrhages, and suspected cortical venous thrombosis. In 15 RH cases, there was no trauma reported and no findings other than RH and intracranial pathology. Accidental blunt head trauma was reported in 7 RH cases. Conclusion The present study indicates that RH in infants is secondary to intracranial pathology of non-specific aetiology. publishedVersion

Orbital pathology requiring surgery can be planned based on the nature of the disease and the position of this relative to the globe and optic nerve complex. Multidisciplinary treatment is now common, and this sometimes includes multiple surgical corridors employed for approach. The orbit is also now frequently used as a corridor to intracranial pathology, and these same processes may be applied. Combined surgical approaches, whether at the same time or staged, allow for minimization of manipulation of critical neurovascular structures in complex skull base pathology.

Ocular motility refers to the movement of the eyes as they track from side to side and up and down as a person follows an object through space. When the eyes are aligned, all is well. However, when the eyes deviate and point in different directions, an abnormal condition known as strabismus occurs. Additionally, nystagmus, a rhythmic oscillation of the eyes can occur and be a sign of systemic or intracranial pathology. The following chapter provides a guide to examining children with motility issues, including clinical pearls for the clinician in the emergency room.

The use of ultrasound in children with neurological disease is perhaps more diverse than in adults. This multifaceted tool can be used as a diagnostic, navigation, or intraoperative guidance adjunct. Common pediatric conditions where ultrasound diagnosis can be used include, hydrocephalus, congenital malformations, infection, tumors, vascular malformations and other causes of raised intracranial pressure (ICP). Children are quite a heterogenous group, ranging from neonates with open anterior fontanelles to adolescents where the skull is a closed cavity, making the spectrum of ultrasound applications in children quite diverse. Increasingly though, the appeal of a non-invasive, radiation-free, portable and relatively cost-effective imaging modality in children is receiving more widespread appreciation and attention. This chapter provides an overview of the most relevant applications of ultrasound imaging in children with intracranial pathology.

Severe traumatic brain injury (TBI) is a leading cause of death and disability worldwide, especially in low- and middle-income countries, and in austere, rural, and remote settings. The purpose of this Perspective is to challenge the notion that accurate and actionable diagnosis of the most severe brain injuries should be limited to physicians and other highly-trained specialists located at hospitals. Further, we aim to demonstrate that the great opportunity to improve severe TBI care is in the prehospital setting. Here, we discuss potential applications of prehospital diagnostics, including ultrasound and near-infrared spectroscopy (NIRS) for detection of life-threatening subdural and epidural hemorrhage, as well as monitoring of cerebral hemodynamics following severe TBI. Ultrasound-based methods for assessment of cerebrovascular hemodynamics, vasospasm, and intracranial pressure have substantial promise, but have been mainly used in hospital settings; substantial development will be required for prehospital optimization. Compared to ultrasound, NIRS is better suited to assess certain aspects of intracranial pathology and has a smaller form factor. Thus, NIRS is potentially closer to becoming a reliable method for non-invasive intracranial assessment and cerebral monitoring in the prehospital setting. While one current continuous wave NIRS-based device has been FDA-approved for detection of subdural and epidural hemorrhage, NIRS methods using frequency domain technology have greater potential to improve diagnosis and monitoring in the prehospital setting. In addition to better technology, advances in large animal models, provider training, and implementation science represent opportunities to accelerate progress in prehospital care for severe TBI in austere, rural, and remote areas.

The sphenoid sinus is an uncommon location for protrusion of a meningocele. When this does occur, it nearly always presents with leakage of cerebrospinal fluid through the nasal cavity. We present a case of a 38-year-old female found to have a meningocele protruding into the left sphenoid sinus, who presented with intractable headache but no CSF rhinorrhea. The lesion was discovered on computed tomography angiography, which was performed in order to rule out intracranial pathology as the etiology of her headache. Prior imaging, including pre- and post-contrast MRI, demonstrated the fluid within the sphenoid sinus, but did not reveal the communication through a defect in the base of the skull. Thus, it was assumed to be strictly related to sinus disease in the past. Our case represents a phenomenon whereby meningoceles protruding through the basilar skull into the sphenoid sinus or any other location are potentially misdiagnosed due to poor visualization of the osseous defect and lack of awareness of this entity.

The goal of our research was to assess the possibility of reliable investigation of brain tissue stiffness using ultrasonographic brain parenchyma elastography with an intact temporal bone. We enrolled 108 patients after exclusion of intracranial pathology or healthy volunteers. All patients were subdivided by age into groups: 20–40, 40–60 and >60 y. For statistical analysis, the χ 2 test and t -test were used. The mean values, regardless of age and other parameters, were 3.34 kPa (SD = 0.59) on the left side and 3.33 kPa (SD = 0.58) on the right side. We found no correlation between the values, body mass index (r = 0.07, p = 0.48) and sex (t = −0.11, p = 0.91), but we observed a highly significant correlation between the values and age (r = 0.43, p 0.0001). We found ultrasonographic brain parenchyma elastography to be a valid, reproducible and investigator-independent method that reliably determines brain parenchyma stiffness. Normal values should serve as a reference for studies on various intracranial lesions.

Objectives: For patients with intracranial hemorrhage (ICH), routine follow-up computed tomography (CT) scans are typically required to monitor the progression of intracranial pathology. Remarkable levels of radiation exposure are accumulated during repeated CT scan. However, the effects and associated risks have still remained elusive. This study presented an effective approach to quantify organ-specific radiation dose of repeated CT scans of head for patients with ICH. We also indicated whether a low-dose CT scan may reduce radiation exposure and keep the image quality highly acceptable for diagnosis. Methods: Herein, 72 patients with a history of ICH were recruited. The patients were divided into 4 groups and underwent CT scan of head with different tube current–time products (250, 200, 150, and 100 mAs). Two experienced radiologists visually rated scores of quality of images according to objective image noise, sharpness, diagnostic acceptability, and artifacts due to physiological noise on the same workstation. Organ-/tissue-specific radiation doses were analyzed using Radimetrics. Results: In conventional CT scan group, signal to noise ratio (SNR) and contrast to noise ratio (CNR) of ICH images were significantly higher than those in normal brain structures. Reducing the tube current–time product may decrease the image quality. However, the predilection sites for ICH could be clearly identified. The SNR and CNR in the predilection sites for ICH were notably higher than other areas. The brain, eye lenses, and salivary glands received the highest radiation dose. Reducing tube current–time product from 250 to 100 mA can significantly reduce the radiation dose. Discussion: We demonstrated that low-dose CT scan of head can still provide reasonable images for diagnosing ICH. The radiation dose can be reduced to ∼45% of the conventional CT scan group.

Background. Imaging sequences for detection of meningeal and parenchymal lesions are critical in intracranial pathology. Our study analysed FLAIR MRI sequence for evaluating postcontrast enhancement. Objectives. FLAIR imaging sequences have been used in evaluation of enhancement in the brain. We conducted a study of FLAIR imaging sequences to better delineate postcontrast enhancement. Materials and Methods. In this prospective hospital-based observational study, postcontrast T1 MTC and delayed postcontrast T2 FLAIR and T1 FLAIR images of 66 patients with intracranial pathology were assessed by experienced radiologists from November 2017 to November 2019. Results. 28 cases of meningeal enhancement were identified in delayed postcontrast T2 FLAIR images. Low-grade gliomas included in the study showed postcontrast enhancement on postcontrast T1 MTC images. Multiple sclerosis lesions were better seen on postcontrast T1 FLAIR. In extraaxial lesions of 11 cases of meningioma, brighter enhancement was seen on delayed postcontrast T2 FLAIR images. Conclusion. We found that delayed postcontrast T2 FLAIR was better in detection of meningeal enhancement in infectious meningitis and in meningitis carcinomatosis than T1 MTC images. In delayed postcontrast T2 FLAIR images, intra-axial parenchyma lesions appeared more conspicuous or similar to T1 MTC images. Delayed postcontrast T1 FLAIR images provided better anatomic delineation of intra-axial lesions.

Critically ill pregnant women with neurosurgical crises or those requiring brain surgery are infrequently encountered. Thus, evidence-based recommendations for neuroanesthesia or intensive care management of this patient population are lacking. Considerations include maternal physiological changes related to pregnancy and specific obstetric considerations. Multidisciplinary management with input from obstetricians, neurosurgeons, anesthesiologists, critical care physicians, and neonatologists is essential for optimal maternal and neonatal outcomes. This chapter presents the approach to and the investigation of intracranial pathology, anesthesia, surgery, and delivery for such cases based on the existing literature where available and on expert opinion when evidence is not available.

Hyponatremia is a common electrolyte disturbance usually observed in neurosurgical patients undergoing surgical management of traumatic, as well as, nontraumatic intracranial pathology. The spinal cord trauma is also associated with occasional development of such hyponatremia; it usually occurs within the first two-weeks of the injury. Hyponatremia can lead to alterations of consciousness, convulsions, coma, cardiac arrhythmias and on rare occasions, death. Authors present a practical oriented review of the literature.

Vasovagal syncope is very common in the general population.1 Studies estimate that by 60 years of age, 42% of women and 32% of men will have had at least 1 vasovagal episode.2 A careful review of the patient’s history and witness account are essential in the diagnosis, as is eliciting the predisposing factors. Vasovagal syncope generally is considered benign, resulting from an exaggerated neurocardiogenic reflex, but rarely it may be associated with pathologic conditions. Colloid cysts are rare congenital neoplasms commonly located in the third ventricle.3 Syncope associated with colloid cysts is extremely rare, although sudden death has been reported.3 We report a case, confirmed with tilt table testing, of vasovagal syncope in the setting of a large colloid cyst in the third ventricle. After successful resection of the colloid cyst, the patient’s symptoms resolved completely and tilt table testing became negative.

Objective To review the complex pathogenesis of the subdural membrane and the link between head trauma, dementia, and dural lymphatics. Methods A thorough literature search of published English-language articles was performed using PubMed, Ovid, and Cochrane databases. Results Chronic subdural hematoma (cSDH) is a common intracranial pathology and a leading cause of reversible dementia. cSDH is projected to affect at least 60,000 new individuals in the United States annually by 2030. This condition can result from mild to moderate head trauma that leads to hemorrhaging in the dura-arachnoid interface. The short-term and long-term effects of cSDH and the subdural membrane on the pathogenesis of dementia and the newly discovered dural lymphatics is a topic of increasing importance. Conclusions Further research into the possible link between traumatic brain injury and cSDH in particular and dural lymphatics and intracranial fluid dynamics is warranted.

Dual-energy computed tomography (CT) has the potential to improve detection of abnormalities and increase diagnostic confidence in the evaluation of a variety of neurologic conditions by using different x-ray energy-dependent absorption behaviors of different materials. This article reviews the virtual monochromatic imaging applications of dual-energy CT, particularly material decomposition algorithms to improve lesion conspicuity, define lesion-normal tissue interface using different reconstruction techniques, and discuss miscellaneous emerging applications of dual-energy CT for neuroimaging, with an emphasis on their potential clinical utility.

Idiopathic intracranial hypertension (IIH) is a neurological condition characterized by increased intracranial pressure without an underlying intracranial pathology. This condition is rarely encountered in men and it predominantly affects obese women of childbearing age. We present an interesting case of IIH in a male patient who presented with acute severe vision loss over 2 weeks and was successfully treated via surgery. Although IIH is less common in men than in women, men are more likely to develop vision loss, which is usually severe and less likely to respond to medical treatment. Therefore, surgical intervention might be considered early in the treatment of men with rapidly progressive visual loss. Further prospective studies are needed to evaluate the role of early surgical intervention in comparison to medical treatment in this group of patients.

BackgroundFollowing high-profile cases, referrals for evaluation of ‘suspicious optic discs’ to eye clinics in the UK have sharply increased, asking ophthalmologists to reliably distinguish between true and pseudopapilloedema. Optic nerve sheath dilatation (ONSD) on ocular ultrasound (US) is considered a reliable sign of true papilloedema, but this test is not widely available. Recently, anterior bowing of Bruch’s membrane (BM) and increased retinal nerve fibre layer thickness on optical coherence tomography (OCT) have emerged as indicators of intracranial hypertension, and OCT is widely available. We aimed to evaluate safety and efficacy of the diagnostic workup in our service, with particular emphasis of diagnostic reliability of US and OCT.MethodsRetrospective service evaluation/cohort study of children and young people younger than 16 years investigated for ‘suspicious discs’ over a 7-month period in 2016 at a single eye care provider in London, UK. 61 children and young people underwent clinical assessment, US scan and OCT.ResultsOf 61 cases, 3 had intracranial pathology. At presentation, only one had ONSD on US and anterior bowing of BM on OCT. Increased nerve fibre layer thickness in at least one of three relevant sectors was observed in two cases. All three cases of intracranial pathology, however, had significant points in their presenting or medical history.ConclusionOphthalmologists and optometrists must not rely on funduscopy and ocular imaging when assessing a child for possible intracranial disease; history and basic neurological assessment are critical in the diagnostic workup.