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Hector E. James

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Mohammadali M. Shoja and Joshua J. Chern

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Samir Sarda, Mike K. Moore and Joshua J. Chern

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Andrew Reisner, Matthew F. Gary, Joshua J. Chern and J. Damien Grattan-Smith

Spinal cord infarctions following seemingly innocuous trauma in children are rare, devastating events. In the majority of these cases, the pathophysiology is enigmatic. The authors present 3 cases of pediatric spinal cord infarction that followed minor trauma. An analysis of the clinical, radiographic, and laboratory features of these cases suggests that thromboembolism of the nucleus pulposus into the spinal cord microcirculation is the likely mechanism. A review of the human and veterinary literature supports this notion. To the authors' knowledge, this is the largest pediatric series of myelopathy due to thromboembolism of the nucleus pulposus reported to date, and it is the first report of this condition occurring in an infant.

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Joshua J. Chern, Andrew J. Tsung, William Humphries, Raymond Sawaya and Frederick F. Lang

Object

Intracranial hemorrhage (ICH) is a frequent complication found in leukemia patients with thrombocytopenia. At the University of Texas MD Anderson Cancer Center, when a leukemia patient is found to have ICH, a platelet transfusion is generally recommended until 50,000/μl is reached. The authors examine the feasibility and outcome of their intervention strategy in this study.

Methods

Records were reviewed from 76 consecutive leukemia patients with newly diagnosed ICH at the University of Texas MD Anderson Cancer Center from January 1, 2007, to December 31, 2009. Variables of interest included age, platelet count at presentation, leukemia subtype, history of trauma, Glasgow Coma Scale score at presentation, whether the 50,000/μl goal was reached after transfusion, and whether the patient was a transfusion responder (platelet count increase > 2000/μl/unit transfused). Outcome parameters were mortality rates at 72 hours and 30 days and imaging-documented hemorrhage progression.

Results

Thrombocytopenia was prevalent at the time of presentation (68 of 76 patients had platelet levels < 50,000/μl at presentation). Despite an aggressive transfusion protocol, only 24 patients reached the 50,000/μl target after an average of 16 units of transfusion. Death due to ICH occurred in 15 patients within the first 72 hours (mortality rate 19.7%). Death correlated with the presenting Glasgow Coma Scale score (p = 0.0075) but not with other transfusion-related parameters. A significant mortality rate was again observed after 30 days (32.7%). The 30-day mortality rate, however, was largely attributable to non-ICH related causes and correlated with patient age (p = 0.032) and whether the patient was a transfusion responder (p = 0.022). Reaching and maintaining a platelet count > 50,000/μl did not positively correlate with the 30-day mortality rate (p = 0.392 and 0.475, respectively).

Conclusions

Platelet transfusion in the setting of ICH in leukemia patients is undoubtedly necessary, but whether the transfusion threshold should be 50,000/μl remains unclear. Factors other than thrombocytopenia likely contribute to the overall poor prognosis.

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Andrew B. Boucher and Joshua J. Chern

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Hyunmi Kim, Ahyuda Oh, Larry Olson and Joshua J. Chern

OBJECTIVE

The objective of this study was to evaluate mesial temporal electroencephalographic (EEG) monitoring, using an intraventricular strip electrode (IVSE) along the ventricular surface of the hippocampus, in children with medically intractable epilepsy.

METHODS

The authors reviewed 10 consecutive cases in which subdural electrode placements and mesial temporal monitoring were recommended. The median age of the patients was 12.7 years (range 4.5–19.3 years). Both grids and IVSE were placed in all patients. The 4-contact IVSE was used in 5 cases, and the 6-contact IVSE in the other 5 cases. The median number of contacts, including IVSE contacts, was 122 (range 66–181). A total of 182 seizures were analyzed.

RESULTS

The IVSE localized seizure-onset zones in 8 patients. The seizure-onset zone was identified exclusively by IVSE in 3 patients and was simultaneous in IVSE and subdural electrodes in 5 patients. Among the 5 patients with simultaneous onset on both IVSE and subdural electrodes, 4 had basal temporal onset and one had orbitofrontal and lateral midtemporal onset. In the remaining 2 patients, the absence of IVSE seizure onset permitted sparing of mesial temporal structures. An Engel Class Ia outcome was achieved in 9 of 10 cases. No complication was associated with IVSE placement.

CONCLUSIONS

Intracranial monitoring using IVSE offers an alternative in terms of quality of EEG recording. IVSE was useful in children who already required open craniotomy for intracranial monitoring over an extensive network of hyper-excitability.

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Rohini Komarla, Bruno P. Soares, Joshua J. Chern and Sarah S. Milla

Spontaneous epidural hematoma (EDH) is a rare occurrence in patients with sickle cell disease, with a small number of cases reported. Appropriate diagnosis is critical, because rapid neurosurgical intervention may be required. This unique case illustrates clinical and MRI features of an 18-year-old woman presenting with a headache and subsequent progression to severe focal neurological symptoms. Imaging demonstrated a large EDH of mixed signal characteristics and underlying calvarial infarction, requiring emergency decompression and evacuation. A second companion case is also presented. The authors discuss proposed pathophysiology of the formation of EDHs in sickle cell anemia.