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Computerized tomography in the diagnosis of intracranial bleeding
Volume 92 Number 2
conditions and lowering the secretion of the various hormones influencing carbohydrate and fat metabolism, such as catecholamines, growth hormone, cortisol, and glucagon--all of which are "stress hormones." There seems to be increasing acknowledgment o f the fact that good control prevents many of the late vascular complications?. G. We have recently summarized the findings in 262 juvenile diabetic patients (13l boys and 131 girls) treated on an ambulatory basis by our multidisciplinary team for many years, and have found that good control led to fewer and less severe complications, s As an example we found only nine patients with retinopathy (six BDR and three PDR). After 15 years of diabetes the prevalence was 22% as compared to the 40 to 73% mentioned in the literature. ~ Comparison of the effect of the treatment by the multidisciplinary team (which includes a psychologist and social worker in addition to the medical team) with the conventional treatment (by physician alone or with nurse) we found the following positive influences: the degree of control attained was both higher and sustained with greater regularity; there were fewer complications with no episodes of coma, brittle diabetes, or severe ketoacidosis and almost no need for hospitalization; the attitude of the affected child, his parents, and his teachers was found to be considerably improved; there was better understanding of the nature of the disease and its requirements; the child'.s motivation to maintain the diabetic regimen was greater and conflicts within the family circle were markedly reduced; the patient's self-concept was much higher and both scholastic achievement and social adjustment were greater. It thus became evident that psychologic stability is a basic factor in the control of diabetes.
Zvi Laron, M.D. Professor of Pediatric Endocrinology Director, Institute of Pediatric and Adolescent Endocrinology Beilinson Medical Center Petah Tikva, Israel REFERENCES 1. Malone JI, Hellrung JM, Malphus EW, Rosenbloom AL, Grgic A, and Weber FT: Good diabetic control--a study in mass delusion, J PEDIATR 88:943, 1976. 2. Drash A: The control of diabetes mellitus: is it achievable? Is it desirable? J PEDIATR 88:1074, 1976. 3. Dorchy H, and Loeb H: More on "diabetic control" What is it?--J PEDIATR 90:502, 1977 (letter). 4. Laron Z, editor: Medical aspects of balance of diabetes in juveniles, in Pediatric and adolescent endocrinology, vol 2, Basel, 1977, S. Karger. 5. Laron Z, editor: Opening remarks, in Psychological and social aspects of balance of diabetes in juveniles, Pediatric and adolescent endocrinology, vol 3, Basel, 1977, S. Karger. 6. Cahill GF Jr, Etzwiler DD, and Freinkel N: "Control" and diabetes, N Engl J Med 294:1004, 1976. 7. Ellenberg M: Diabetic retinopathy--editorial, Metab Ophthalmol 1:69, 1977. 8. Laron Z, Amir S, Galatzer A, Gil R, Blum I, and Mimouni M: The advantages of an ambulatory multidisciplinary
Editorial correspondence
9.
34 1
treatment program for diabetic children, Klinische P~idiatrie (in press). Larsson Y, Sterky G, and Christianson G: Long-term prognosis in juvenile diabetes mellitus, Acta Paediat Scand 51(Suppt 130):29, 1962.
Computerized tomography in the diagnosis of intracranial bleeding To the Editor: Kinney and associates 1 report the value of computerized tomography in the management of intracranial bleeding in hemophilia. It is important, however, that physicians recognize the possibility of false negative results. A recent case at Johns Hopkins Hospital (JHH) illustrates this point. CASE REPORT A 7-year-old child with a factor VII deficiency was transferred to JHH from an outlying hospital for evaluation of increasing obtundation. History revealed several episodes of head trauma within the preceding two weeks. Initial evaluation demonstrated no focal findings, and a CT scan showed lucent areas in both posterior medial occipital lobes, but no shift of the ventricular system or subdural hematoma. Despite appropriate factor replacement, the patient's neurologic condition rapidly deteriorated. A cerebral angiogram was performed and demonstrated a 1 to 11/2cm right extracerebral collection with a 3 to 4 mm shift of the internal cerebral vein. At surgery, 100 to 125 ml of brown subdural fluid was drained with transient improvement in the clinical findings. DISCUSSION The value of the CT scan in the diagnosis of intracranial hemorrhage is well-documented. A fresh hemorrhage appears as a circumscribed area of increased absorption that diminishes in density as the hematoma ages. ~ As the absorption coefficient decreases, a stage will be reached when the lesion density equals that of the surrounding brain tissue. In subdural hematomas it is estimated that this isodense phase occurs two to six weeks postbleed? During this period, angiography may, therefore, continue to be o f value in the diagnosis of hemorrhagic lesions. Although quite helpful when positive, false negative computerized tomography may be misleading in hemophilia or other hemorrhagic conditions.
Harvey S. Singer, M.D. Assistant Professor of Pediatrics and Neurology Johns Hopkins University School of Medicine Baltimore, MD 21205 REFERENCES 1. Kinney TR, Zimmerman RA, Butler RB, and Jill SM: Computerized tomography in the management of intracranial bleeding in hemophilia, J PEDIATR 91:31, 1977.
342
Editorial correspondence
2.
Messina AV, and Chernik NL: ComPuted tomography: The "resolving" intracerebral hemorrhage, Radiology 118:609, 1975. 3. French PN, and Dublin AB: The value of computerized tomography in the management of 1,000 consecutive head injuries, Surg Neurol 7:171, 1977.
Rep y To the Editor: Dr. Singer's report, illustrating an example of a "false negative" computed tomogram (CT) in a child with factor VII deficiency, correctly points out that the CT may fail to diagnose some cases of subdural hematoma, and that angiography may be required. We feel that a CT in patients with bleeding disorders should be done as soon as the history or physical examination suggests intracranial bleeding. ~This is necessary because the difference in density (attenuation coefficient) between the hematoma and the brain is greatest immediately. The attenuation coefficient of blood is a function, of the hemoglobin concentration? Thus, the hematoma formed acutely in an anemic patient is less dense than that in the normal patient. As Dr. Singer points out, the attenuation coefficient of the hematoma decreases with time as the hemoglobin molecule is reabsorbed? Thus, an anemic patient starts with a less dense hematoma, and the clot reaches a stage of isodensity with the brain more rapidly than normal. Both of these factors should be considered in Dr. Singer's case. A subdural hematoma that is relatively small, but high over the convexity, may be difficult to detect with the standard transverse sections because of partial volume averaging with the adjacent bone. Tilting the head to one side can be used to obviate this problem? as can coronal sectioning. In 109 patients with extradural hematomas evaluated at the Hospital of the University of Pennsylvania, only one extradural hematoma was missed on CT scanning using the above techniques. This child had a small, high-convexity subdural hematoma. The diagnosis was established by angiography performed when the child's clinical condition worsened. Further experience with CT scanning is needed to determine its specificity and sensitivity. CT scanning, like other diagnostic procedures, should never replace a careful history and physical examination. Further investigations, including angiography and radionucleotide scans, should be performed despite a negative CT scan when indicated by the patient's condition. Thomas R. Kinney, M.D. Robert A. Zimmerman, M.D. Regina B. Butler, R.N. Frances M. Gill, M.D. The Children's Hospital of Philadelphia and The University of Pennsylvania School of Medicine Philadelphia, PA 19104
The Journal of Pediatrics February 1978
REFERENCES
1. Kinney TR, Zimmerman RA, Butler RB, and Gill FM: Computerized tomography in the management of intracranial bleeding in hemophilia, J PEmAT~ 91:31, 1977. 2. Norman D, Price D, Boyd D, Biianiuk Fishman R, and Newton T: Quantitative aspects of computed tomography of the blood and cerebrospinal fluid, Radiology 123:335, 1977. 3. Dolinskas C, Bilaniuk LT, Zimmerman RA, and Kuhl D: Computed tomography of intracerebral hematomas: Part I. Transmission CT Observations on hematoma resolution, Am J Roentgenol 129:681, 1977. 4. Svendsen P: Computer tomography of traumatic extracerebral lesions, Br J Radiol 49:1004, 1976.
Thyroid function in premature infants with RDS To the Editor: The report by Klein and co-workers' confirms previous observations~-~ of temporarily depressed thyroid hormone concentrations in premature infants with respiratory distress syndrome (RDS). The authors suggest that these newborn infants are euthyroid because they had normal somatic growth during convalescence and did not have elevated concentrations of thyroid-stimulating hormone (TSH). Based on that assumption, they further state that replacement therapy is unwarranted and ullnecessary. Klein and associates' observations do not justify the conclusion that these patients are euthyroid. Normal somatic growth is usually present in patients with congenital hypothyroidism? and clinical assessment is a poor indicator of thyroid status early in infancy. To require elevation of the TSH concentration as an indication of hypothyroidism in premature infants with RDS can be misleading. The TSH elevation in response to hypothyroidism occurs if the hypothalamo-pituitary-thyroid axis is functioning normally. There is no evidence that this system functions normally in premature infants with RDS. On the contrary, we have reported 4 that the early postnatal rise in TSH is abnormally blunted in premature newborn infants with RDS. Lukas and associates3 have also reported abnormally low TSH levels in such infants for several days or weeks after birth. Finally, unpublished observations by myself show that the TSH response to thyroidreleasing hormone is lower than expected in premature infants recovering from RDS. Although the mechanism leading to these phenomena is unknown, it appears that in premature infants with RDS, TSH secretion does not follow the usual pattern. Thus, conclusions based on TSH concentrations in this population should be postpostponed until these mechanisms are better understood. The question of whether premature newborn infants with RDS should or should not receive thyroxine supplementation must not be discarded on the basis of Klein and associates' observations.
conditions and lowering the secretion of the various hormones influencing carbohydrate and fat metabolism, such as catecholamines, growth hormone, cortisol, and glucagon--all of which are "stress hormones." There seems to be increasing acknowledgment o f the fact that good control prevents many of the late vascular complications?. G. We have recently summarized the findings in 262 juvenile diabetic patients (13l boys and 131 girls) treated on an ambulatory basis by our multidisciplinary team for many years, and have found that good control led to fewer and less severe complications, s As an example we found only nine patients with retinopathy (six BDR and three PDR). After 15 years of diabetes the prevalence was 22% as compared to the 40 to 73% mentioned in the literature. ~ Comparison of the effect of the treatment by the multidisciplinary team (which includes a psychologist and social worker in addition to the medical team) with the conventional treatment (by physician alone or with nurse) we found the following positive influences: the degree of control attained was both higher and sustained with greater regularity; there were fewer complications with no episodes of coma, brittle diabetes, or severe ketoacidosis and almost no need for hospitalization; the attitude of the affected child, his parents, and his teachers was found to be considerably improved; there was better understanding of the nature of the disease and its requirements; the child'.s motivation to maintain the diabetic regimen was greater and conflicts within the family circle were markedly reduced; the patient's self-concept was much higher and both scholastic achievement and social adjustment were greater. It thus became evident that psychologic stability is a basic factor in the control of diabetes.
Zvi Laron, M.D. Professor of Pediatric Endocrinology Director, Institute of Pediatric and Adolescent Endocrinology Beilinson Medical Center Petah Tikva, Israel REFERENCES 1. Malone JI, Hellrung JM, Malphus EW, Rosenbloom AL, Grgic A, and Weber FT: Good diabetic control--a study in mass delusion, J PEDIATR 88:943, 1976. 2. Drash A: The control of diabetes mellitus: is it achievable? Is it desirable? J PEDIATR 88:1074, 1976. 3. Dorchy H, and Loeb H: More on "diabetic control" What is it?--J PEDIATR 90:502, 1977 (letter). 4. Laron Z, editor: Medical aspects of balance of diabetes in juveniles, in Pediatric and adolescent endocrinology, vol 2, Basel, 1977, S. Karger. 5. Laron Z, editor: Opening remarks, in Psychological and social aspects of balance of diabetes in juveniles, Pediatric and adolescent endocrinology, vol 3, Basel, 1977, S. Karger. 6. Cahill GF Jr, Etzwiler DD, and Freinkel N: "Control" and diabetes, N Engl J Med 294:1004, 1976. 7. Ellenberg M: Diabetic retinopathy--editorial, Metab Ophthalmol 1:69, 1977. 8. Laron Z, Amir S, Galatzer A, Gil R, Blum I, and Mimouni M: The advantages of an ambulatory multidisciplinary
Editorial correspondence
9.
34 1
treatment program for diabetic children, Klinische P~idiatrie (in press). Larsson Y, Sterky G, and Christianson G: Long-term prognosis in juvenile diabetes mellitus, Acta Paediat Scand 51(Suppt 130):29, 1962.
Computerized tomography in the diagnosis of intracranial bleeding To the Editor: Kinney and associates 1 report the value of computerized tomography in the management of intracranial bleeding in hemophilia. It is important, however, that physicians recognize the possibility of false negative results. A recent case at Johns Hopkins Hospital (JHH) illustrates this point. CASE REPORT A 7-year-old child with a factor VII deficiency was transferred to JHH from an outlying hospital for evaluation of increasing obtundation. History revealed several episodes of head trauma within the preceding two weeks. Initial evaluation demonstrated no focal findings, and a CT scan showed lucent areas in both posterior medial occipital lobes, but no shift of the ventricular system or subdural hematoma. Despite appropriate factor replacement, the patient's neurologic condition rapidly deteriorated. A cerebral angiogram was performed and demonstrated a 1 to 11/2cm right extracerebral collection with a 3 to 4 mm shift of the internal cerebral vein. At surgery, 100 to 125 ml of brown subdural fluid was drained with transient improvement in the clinical findings. DISCUSSION The value of the CT scan in the diagnosis of intracranial hemorrhage is well-documented. A fresh hemorrhage appears as a circumscribed area of increased absorption that diminishes in density as the hematoma ages. ~ As the absorption coefficient decreases, a stage will be reached when the lesion density equals that of the surrounding brain tissue. In subdural hematomas it is estimated that this isodense phase occurs two to six weeks postbleed? During this period, angiography may, therefore, continue to be o f value in the diagnosis of hemorrhagic lesions. Although quite helpful when positive, false negative computerized tomography may be misleading in hemophilia or other hemorrhagic conditions.
Harvey S. Singer, M.D. Assistant Professor of Pediatrics and Neurology Johns Hopkins University School of Medicine Baltimore, MD 21205 REFERENCES 1. Kinney TR, Zimmerman RA, Butler RB, and Jill SM: Computerized tomography in the management of intracranial bleeding in hemophilia, J PEDIATR 91:31, 1977.
342
Editorial correspondence
2.
Messina AV, and Chernik NL: ComPuted tomography: The "resolving" intracerebral hemorrhage, Radiology 118:609, 1975. 3. French PN, and Dublin AB: The value of computerized tomography in the management of 1,000 consecutive head injuries, Surg Neurol 7:171, 1977.
Rep y To the Editor: Dr. Singer's report, illustrating an example of a "false negative" computed tomogram (CT) in a child with factor VII deficiency, correctly points out that the CT may fail to diagnose some cases of subdural hematoma, and that angiography may be required. We feel that a CT in patients with bleeding disorders should be done as soon as the history or physical examination suggests intracranial bleeding. ~This is necessary because the difference in density (attenuation coefficient) between the hematoma and the brain is greatest immediately. The attenuation coefficient of blood is a function, of the hemoglobin concentration? Thus, the hematoma formed acutely in an anemic patient is less dense than that in the normal patient. As Dr. Singer points out, the attenuation coefficient of the hematoma decreases with time as the hemoglobin molecule is reabsorbed? Thus, an anemic patient starts with a less dense hematoma, and the clot reaches a stage of isodensity with the brain more rapidly than normal. Both of these factors should be considered in Dr. Singer's case. A subdural hematoma that is relatively small, but high over the convexity, may be difficult to detect with the standard transverse sections because of partial volume averaging with the adjacent bone. Tilting the head to one side can be used to obviate this problem? as can coronal sectioning. In 109 patients with extradural hematomas evaluated at the Hospital of the University of Pennsylvania, only one extradural hematoma was missed on CT scanning using the above techniques. This child had a small, high-convexity subdural hematoma. The diagnosis was established by angiography performed when the child's clinical condition worsened. Further experience with CT scanning is needed to determine its specificity and sensitivity. CT scanning, like other diagnostic procedures, should never replace a careful history and physical examination. Further investigations, including angiography and radionucleotide scans, should be performed despite a negative CT scan when indicated by the patient's condition. Thomas R. Kinney, M.D. Robert A. Zimmerman, M.D. Regina B. Butler, R.N. Frances M. Gill, M.D. The Children's Hospital of Philadelphia and The University of Pennsylvania School of Medicine Philadelphia, PA 19104
The Journal of Pediatrics February 1978
REFERENCES
1. Kinney TR, Zimmerman RA, Butler RB, and Gill FM: Computerized tomography in the management of intracranial bleeding in hemophilia, J PEmAT~ 91:31, 1977. 2. Norman D, Price D, Boyd D, Biianiuk Fishman R, and Newton T: Quantitative aspects of computed tomography of the blood and cerebrospinal fluid, Radiology 123:335, 1977. 3. Dolinskas C, Bilaniuk LT, Zimmerman RA, and Kuhl D: Computed tomography of intracerebral hematomas: Part I. Transmission CT Observations on hematoma resolution, Am J Roentgenol 129:681, 1977. 4. Svendsen P: Computer tomography of traumatic extracerebral lesions, Br J Radiol 49:1004, 1976.
Thyroid function in premature infants with RDS To the Editor: The report by Klein and co-workers' confirms previous observations~-~ of temporarily depressed thyroid hormone concentrations in premature infants with respiratory distress syndrome (RDS). The authors suggest that these newborn infants are euthyroid because they had normal somatic growth during convalescence and did not have elevated concentrations of thyroid-stimulating hormone (TSH). Based on that assumption, they further state that replacement therapy is unwarranted and ullnecessary. Klein and associates' observations do not justify the conclusion that these patients are euthyroid. Normal somatic growth is usually present in patients with congenital hypothyroidism? and clinical assessment is a poor indicator of thyroid status early in infancy. To require elevation of the TSH concentration as an indication of hypothyroidism in premature infants with RDS can be misleading. The TSH elevation in response to hypothyroidism occurs if the hypothalamo-pituitary-thyroid axis is functioning normally. There is no evidence that this system functions normally in premature infants with RDS. On the contrary, we have reported 4 that the early postnatal rise in TSH is abnormally blunted in premature newborn infants with RDS. Lukas and associates3 have also reported abnormally low TSH levels in such infants for several days or weeks after birth. Finally, unpublished observations by myself show that the TSH response to thyroidreleasing hormone is lower than expected in premature infants recovering from RDS. Although the mechanism leading to these phenomena is unknown, it appears that in premature infants with RDS, TSH secretion does not follow the usual pattern. Thus, conclusions based on TSH concentrations in this population should be postpostponed until these mechanisms are better understood. The question of whether premature newborn infants with RDS should or should not receive thyroxine supplementation must not be discarded on the basis of Klein and associates' observations.