Safety of lumbar puncture in comatose children with clinical features of cerebral malaria.

OBJECTIVE: We assessed the independent association of lumbar puncture (LP) and death in Malawian children admitted to the hospital with the clinical features of cerebral malaria (CM). METHODS: This was a retrospective cohort study in Malawian children with clinical features of CM. Allocation to LP was nonrandom and was associated with severity of illness. Propensity score-based analyses were used to adjust for this bias and assess the independent association between LP and mortality. RESULTS: Data were available for 1,075 children: 866 (80.6%) underwent LP and 209 (19.4%) did not. Unadjusted mortality rates were lower in children who underwent LP (15.3% vs 26.7% in the no-LP group) but differences in covariates between the 2 groups suggested bias in LP allocation. After propensity score matching, all covariates were balanced. Propensity score-based analyses showed no change in mortality rate associated with LP: by inverse probability weighting, the average risk reduction was 2.0% at 12 hours (95% confidence interval -1.5% to 5.5%, p = 0.27) and 1.7% during hospital admission (95% confidence interval -4.5% to 7.9%, p = 0.60). Undergoing LP did not change the risk of mortality in subanalyses of children with severe brain swelling on MRI or in those with papilledema. CONCLUSION: In comatose children with suspected CM who were clinically stable, we found no evidence that LP increases mortality, even in children with objective signs of raised intracranial pressure.

[Incidence of ophthalmologic complications in acute intracranial hypertension]. / Inzidenz ophthalmologischer Komplikationen bei akuter intrakranieller Drucksteigerung.

Although Terson's syndrome has been diagnosed more frequently since the early 1960s because of improved intensive-care facilities, these reports are single case reports or retrospective studies. Therefore, we examined prospectively 20 patients (11 male, 9 female), aged between 23 and 77 years, with subarachnoid hemorrhages or rapid increase in intracranial pressure (ICP) of other origin (tumor-associated, post-traumatic) to evaluate ocular changes. In all patients the increase in ICP was confirmed by computed tomography. Additionally, in 16 patients permanent monitoring of ICP was performed. Twelve patients presented with subarachnoid hemorrhage, 6 had a post-traumatic increase in ICP, and 2 more presented with a tumor-associated intracranial hemorrhage. A total of 8 patients (40%) presented with intraocular changes; 6 presented with uni- or bilateral intraretinal hemorrhage, 1 patient had a bilateral papilledema and 1 more patient had bilateral vitreal hemorrhage. When ocular hemorrhage occurred, the mortality was 2.5 times as high as in patients without ocular hemorrhage. For this prognostic feature of the ophthalmological status all patients with rapid increase in ICP should be monitored early for intraocular hemorrhage. The possibility of intraocular hemorrhage is elevated in high-degree subarachnoid hemorrhage, whereas a rapid increase in ICP also found when the pressure has other causes (tumor-associated, posttraumatic).

Retinal changes in malignant hypertension.

To assess the diagnostic and prognostic importance of papilloedema in malignant hypertension a two part study was undertaken. Four observers reviewed 56 photographs of fundi from patients with grade 3 or 4 hypertensive retinopathy. Complete agreement on the presence or absence of haemorrhages was recorded in 52 cases and on exudates in 53 cases. Opinion on papilloedema, however, was divided, all four observers agreeing in only 34 cases. In the second part of the study survival in 139 consecutive hypertensive patients with bilateral retinal haemorrhages and exudates was examined by life tables. Ten year survival was 46% in patients with bilateral haemorrhages and exudates alone (n = 43) and 48% when papilloedema was also present (n = 96). Multivariate analysis confirmed that papilloedema was not related to survival. These results suggest that papilloedema is an unreliable physical sign and does not adversely influence prognosis in hypertensive patients who already have bilateral retinal haemorrhages and exudates when effective treatment is available. Papilloedema should no longer be regarded as a necessary feature of malignant hypertension.

Lack of difference between malignant and accelerated hypertension.

The clinical features and survival rates of 200 consecutive patients with malignant and accelerated hypertension admitted to a district hospital were investigated. Ninety five patients had bilateral haemorrhages and exudates and papilloedema (grade IV retinopathy) and 31 had bilateral haemorrhages and exudates with no papilloedema (grade III). A further 74 patients had bilateral retinopathy but failed to meet the criteria for grade IV or III and were investigated separately. No overall differences were found in survival when comparing the various grades of retinopathy. Cigarette smoking was significantly commoner only in grade IV patients compared with those with non-malignant hypertension matched for age, sex, and race. In patients with grade III retinopathy excess smoking was not statistically significant. In conclusion, the clinical features and survival rate showed that malignant and accelerated hypertension are one and the same disease.