Ciro Ramos-Estebanez

A systematic review on the role of adjunctive corticosteroids in herpes simplex virus encephalitis: is timing critical for safety and efficacy?

BACKGROUND Most herpes simplex virus encephalitis (HSVE) patients become disabled despite antiviral therapy. Adjunctive corticosteroid therapy may improve outcomes. METHODS This was a systematic review of the literature addressing the use of corticosteroids in HSVE. RESULTS Data suggesting that steroids decrease the immunological response and enhance viral replication originated from non-neural microenvironments. Early steroid administration might be harmful because initial damage in HSVE is mediated by viral replication. Steroid treatment improves outcomes in animal models by inhibiting the subsequent inflammatory response. Clinical observations support a similar benefit in symptomatic HSVE patients. Cerebrospinal fluid inflammatory markers might guide appropriate timing in future clinical practice. CONCLUSIONS Experimental and clinical observations suggest a benefit from adjunctive steroid therapy in HSVE. Nevertheless, current evidence is not yet sufficient to endorse this approach as a standard of practice.

Are Steroids a Beneficial Adjunctive Therapy in the Immunosuppressed Patient with Herpes Simplex Virus Encephalitis

Few reports describe the reactivation of latent herpes simplex virus causing encephalitis (HSVE) in patients undergoing brain radiation therapy and a concomitant steroid regimen. The role for steroid use in the treatment of patients with HSVE has not been fully elucidated. We report the case of a female patient immunosuppressed by steroids and brain radiation who developed HSVE and responded to acyclovir and dexamethasone.

Heroin inhalation complicated by refractory hydrocephalus: A novel presentation

CNS manifestations of heroin include toxic leukoencephalopathy, strokes, seizures, and movement disorders.1 Oral2,3 and IV4 opiate intoxications may trigger obstructive hydrocephalus. We describe refractory hydrocephalus with a communicating element as a new complication of heroin inhalation while “chasing the dragon.” We discuss the putative mechanisms for communicating hydrocephalus, and its successful management with a ventriculo-peritoneal shunt (VPS).

Clinical and ethical judgment A profound dilemma

After 16 years of postgraduate medical education, which included a PhD and postdoctoral research, 3 residencies, and a clinical fellowship, I felt thoroughly prepared for the challenges of the neurocritical care unit. Then I met Ms. G.

Prolonged Intracisternal Papaverine Toxicity: Index Case Description and Proposed Mechanism of Action

BACKGROUND Intracisternal papaverine (iPPV) is a vasodilator used for prophylaxis of intraoperative vasospasm during aneurysmal clipping. Postoperative side effects of iPPV include transient cranial nerve palsies, most commonly mydriasis owing to oculomotor nerve involvement, with rapid resolution. METHODS We critically reviewed current literature on the adverse effects of iPPV in aneurysmal surgery with a focus on oculomotor nerve involvement. We also present the index case of prolonged bilateral mydriasis secondary to iPPV irrigation toxicity and its putative underlying mechanism. RESULTS Papaverine toxicity occurs in the setting of its antimuscarinic action and blood-cerebrospinal fluid and blood-brain barrier compromise owing to acute subarachnoid hemorrhage and direct effect of papaverine. Our patient also experienced severe vasospasm and a minor stroke, both contributing to further blood-brain barrier disruption, and relatively acidic pH of the subarachnoid hemorrhage milieu. CONCLUSIONS We propose that these factors perpetuate phase dynamics of papaverine crystals and facilitate a sustained slow release of papaverine within the cisternal system. Were it indicated, 0.3% iPPV would reasonably diminish the risk for neurotoxicity.

Fast magnetic resonance fingerprinting for dynamic contrast-enhanced studies in mice

The goal of this study was to develop a fast MR fingerprinting (MRF) method for simultaneous T1 and T2 mapping in DCE‐MRI studies in mice.

High-resolution dynamic oxygen-17 MR imaging of mouse brain with golden-ratio–based radial sampling and k-space–weighted image reconstruction

The current study aimed to develop a three‐dimensional (3D) dynamic oxygen‐17 (17O) MR imaging method with high temporal and spatial resolution to delineate the kinetics of 17O water uptake and washout in the brains of mice with glioblastoma (GBM).

Bedside optical coherence tomography for Terson’s syndrome screening in acute subarachnoid hemorrhage: a pilot study

In BriefThis study was performed to address the possibility of screening for ocular bleeds (Tersons syndrome [TS]) in critically ill patients with a brain bleed (acute subarachnoid hemorrhage) through an advanced eye imaging technique, i.e., optical coherence tomography (OCT). TS can damage the retina and cause legal blindness. An early diagnosis of TS using OCT may guide the patients need for surgery, improve quality of life, and decrease associated health care costs.

The Emerging Role of Inhaled Heroin in the Opioid Epidemic: A Review

Importance Opioid addiction affects approximately 2.4 million Americans. Nearly 1 million individuals, including a growing subset of 21 000 minors, abuse heroin. Its annual cost within the United States amounts to

Acute Ischemic Pediatric Stroke Management: An Extended Window for Mechanical Thrombectomy?

51 billion. Inhaled heroin use represents a global phenomenon and is approaching epidemic levels east of the Mississippi River as well as among urban youth. Chasing the dragon (CTD) by heating heroin and inhaling its fumes is particularly concerning, because this method of heroin usage has greater availability, greater ease of administration, and impressive intensity of subjective experience (high) compared with sniffing or snorting, although it also has a safer infectious profile compared with heroin injection. This is relevant owing to peculiar and often catastrophic brain complications. Following the American Medical Association Opioid Task Force mandate, we contribute a description of the pharmacology, pathophysiology, clinical spectrum, neuroimaging, and neuropathology of CTD leukoencephalopathy, as distinct from other heroin abuse modalities. Observations The unique spectrum of CTD-associated health outcomes includes an aggressive toxic leukoencephalopathy with pathognomonic neuropathologic features, along with sporadic instances of movement disorders and hydrocephalus. Clinical CTD severity is predominantly moderate at admission, frequently unmodified at discharge, and largely improved in the long term. Mild cases survive with minor sequelae, while moderate to severe presentations might deteriorate and progress to death. Other methods of heroin use may complicate with stroke, seizure, obstructive hydrocephalus, and (uncharacteristically) leukoencephalopathy. Conclusions and Relevance The distinct pharmacology of CTD correlates with its specific clinical and radiological features and prompts grave concern for potential morbidity and long-term disability costs. Proposed diagnostic criteria and standardized reporting would ameliorate the limitations of CTD literature and facilitate patient selection for a coenzyme Q10 therapeutic trial.