Innovations In Clinical Neuroscience

JAN-FEB 2018

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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14 ICNS Innovations in Clinical Neuroscience • January–February 2018 • Volume 15 • Number 1–2 L E T T E R S T O T H E E D I T O R and those patients who are diagnosed with acute schizophrenia-like psychotic disorder should be closely monitored because their symptoms could represent a schizophrenia spectrum disorder in the early stage. Therefore, it would seem justified in these cases to perform evidence-based interventions similar to those performed on patients with first-episode schizophrenia, including interventions in terms of duration of the antipsychotic treatment as well as adjunctive psychosocial therapies with psychoeducational components to improve medication adherence and relapse prevention. REFERENCES 1. Castagnini A, Galeazzi GM. Acute and transient psychoses: clinical and nosological issues. B J Psychiatr Adv. 2016; 22(5):292–300. 2. World Health Organization. The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. 1993. 3. Marneros, A. Beyond the Kraepelinian dichotomy: acute and transient psychotic disorders and the necessity for clinical differentiation. Br J Psychiatry. 2006;189,1–2. 4. Castagnini A, Bertelsen A, Berrios GE. Incidence and diagnostic stability of ICD-10 acute and transient psychotic disorders. Compr Psychiatry. 2008;49(3):255–261. 5. Farooq S. Is acute and transient psychotic disorder (ATPD) mini schizophrenia? The evidence from phenomenology and epidemiology. Psychiatr Danub. 2012;24(3):311–315. 6. Fusar-Poli P, Cappucciati M, Rutigliano G, et al. Diagnostic stability of ICD/DSM first episode psychosis diagnoses: meta-analysis. Schizophr Bull. 2016;42(6):1395–1406. 7. Salvatore P, Baldessarini RJ, Tohen M, et al. McLean- Harvard International First-Episode Project: two-year stability of ICD-10 diagnoses in 500 first-episode psychotic disorder patients. J Clin Psychiatry. 2011;72(2):183. 8. Gaebel W. Status of psychotic disorders in ICD-11. Schizophr Bull. 2012;38(5):895–898. 9. Bobes J. A Spanish validation study of the mini international neuropsychiatric interview. Eur Psychiatry. 1998;13:198s–199s. With regard, Álvaro López-Díaz, MD; Ignacio Lara, MD; and José Luis Fernández-González, MD Drs. López-Díaz and Lara are with the UGC Salud Mental, Hospital Universitario Virgen Macarena in Seville, Spain, and Dr. Fernández-González is with the UGC Salud Mental, Hospital San Juan de la Cruz in Úbeda (Jaén), Spain. Correspondence: Álvaro López-Díaz, MD; Email: Funding/financial disclosures: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors report no conflicts of interest relevant to the content of this letter. PNEUMOCEPHALUS: IS THE NEEDLE SIZE SIGNIFICANT? Dear Editor: Pneumocephalus was first described in 1866, and the term was coined in 1914. 1 It is also known as a pneumatocele or intracerebral aerocele and may be classified as simple or tension pneumocephalus. The most common causes are craniofacial trauma, neoplasm, infection, surgical intervention, and barotrauma. Pneumocephalus has been documented most often following lumbar punctures (LPs). 1–5 It also can occur following spinal or epidural anesthesia. One article reported an instance of pneumocephalus in a 48-year-old man after several diagnostic LPs. 2 A second case was observed in a 72-year-old woman with normal pressure hydrocephalus who developed a pneumocephalus following an LP. 3 A 50-year- old woman with disequilibrium experienced an LP complicated by tension pneumocephalus, 4 and another reported case was in a 35-year- old woman evidencing a pneumocephalus after having an LP performed for spontaneous intracranial hypotension. 5 Vignette. A 74-year-old, right-handed, Caucasian man with history of alcohol abuse, hypertension, and insulin-dependent diabetes mellitus presented with receptive aphasia, acalculia, and agitation. New-onset atrial flutter was observed. Magnetic resonance imaging (MRI) revealed a left middle cerebral artery stroke with hemorrhagic conversion. During hospitalization, the patient evidenced severe alcohol withdrawal, including delirium tremens. His alcohol withdrawal was treated without much clinical benefit. Fentanyl was then administered to calm agitation and facilitate an LP in order to rule out encephalitis. An 18-gauge needle was utilized, and the procedure completed in the decubitus position. Following some clinical deterioration, a computerized tomography (CT) scan of the head without contrast one hour after the procedure revealed pneumocephaly in the middle cranial fossae, likely induced by the LP (Figure 1). Discussion. Pneumocephalus is defined by two mechanisms: a ball-valve and an inverted bottle concept. 1 The ball-valve type implies positive pressure events, such as coughing or valsalva maneuvers, that prevent air escape. Tension pneumocephalus is included in this mechanism, causing a parenchymal mass effect. The inverted bottle theory includes a negative intracranial pressure gradient following cerebrospinal fluid drainage, relieved by air influx. A small pneumocephalus is usually sealed by blood clots or granulation, allowing spontaneous reabsorption and resolution. 1 Otherwise, the lateral positioning of a patient during spinal tap might create a lower intrathecal pressure with air being allowed into the subarachnoid space. Pneumocephalus also can develop when a stylet is reinserted into the needle before needle retraction, usually performed to minimize post-dural-puncture headache. 6 Pneumocephalus can be avoided by performing the LP in a sitting position, monitoring the amount of fluid drainage, carefully replacing the stylet to make sure the needle does not contain air, and instructing patients to briefly hold their breath and prevent making sudden movements during the procedure. 3 It is also important to consider needle size during a spinal tap. A smaller gauge makes a smaller dural perforation, causing less damage compared to larger ones; that also prevents cerebrospinal fluid leakage. 7,8 There is an inverse correlation between the needle gauge and post-dural-puncture headache. 8,9 The incidence of headache decreases by 1.4 percent per unit increase in the gauge. 8 Additionally, it is necessary to consider the longer time required for the procedure while using smaller needles (e.g., 25 gauge). It takes more time because introducers are needed, smaller needles require aspiration of cerebrospinal fluid, and it takes longer to collect the required fluid volume. Research documents

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