A 21-year-old Chinese gentleman with no known medical illness, presented with a history of right painless blurring of vision with central scotoma of two weeks duration. He also had a history of multiple episodes of seizures prior to presentation. Visual acuity was 1/60 with unremarkable anterior segment findings and no relative afferent pupillary defect. Fundus examination of the right eye revealed dilated and tortuous retinal veins with multiple retinal capillary hemangiomas and sub retinal hard exudates at the macula with edema. A diagnosis of Von Hippel Lindau disease was made when a posterior fossa mass suggestive of hemangioblastoma with obstructive hydrocephalus was seen on computed tomography of the brain. Craniotomy with nodule excision was performed. The retinal capillary hemangiomas were treated with the combination of laser photocoagulation and intravitreal Ranibizumab injections. Visual acuity subsequently improved to 6/36.
The study objective was to determine the diagnostic value of physical examinations for positive computer tomography (CT) scans in children with mild head injuries. Retrospective data of patients evaluated for mild head injuries with loss of consciousness (LOC) or amnesia were reviewed. Estimations of prevalence, sensitivity, specificity and predictive values were calculated. Agreement between the physical examinations and CT brain scans was calculated using the Kappa test. 225 patients were included in the study. Of this group, 19.56% of patients had positive CT scans and 7.56% had normal physical examinations. 15 underwent neurosurgical intervention. For positive CT scans, sensitivity and specificity were 61.36% and 60.22%, respectively. Agreement between physical examinations and CT scans was Kappa = 0.147 (P < 0.05), 95% CI (0.035, 0.259). The present study demonstrated that physical examinations were significantly associated with positive CT scans (P = 0.01). However, the calculated Kappa value showed only slight agreement between these 2 variables and the low sensitivity and specificity of the physical examinations suggest that intracranial pathology in children with mild head injuries and LOC or amnesia cannot be excluded based on physical examinations alone.
Ventriculostomy or external ventricular drain (EVD) placement by free-hand technique has a high malplacement rate. It is a blind procedure that often requires multiple attempts and revisions. To date, no neurological complication due to EVD malplacement has been reported in the literature. In this report, we present the first case of coma induced by a malplaced EVD and the patient regained consciousness after the drain was adjusted. Our discussion focused on various techniques that can improve the accuracy of EVD insertion. EVD insertion under image guidance provides better accuracy with limited disadvantages. We hypothesized that the patient's coma was due to the mass effect and irritation of the malplaced EVD exerted onto the ventral periaqueductal grey matter and the ascending neurons from upper brainstem.