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      A Case of Carbon Monoxide-Induced Delayed Neurological Sequelae Successfully Treated with Hyperbaric Oxygen Therapy, N-Acetylcysteine, and Glucocorticoids: Clinical and Neuroimaging Follow-Up

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          Abstract

          Carbon monoxide (CO) poisoning is a leading cause of intentional and unintentional poisoning worldwide, associated with mortality and severe morbidity. Some survivors of CO poisoning develop, after a lucid interval, a potentially permanent encephalopathy in the form of cognitive impairment and movement disorders, such as Parkinsonism. One of the most frequent neuroimaging findings is a cerebral white matter damage, but so far its precise cause and specific therapy are still debated. We here report the case of a 33-year-old woman with severe carbon monoxide poisoning who, after a period of lucid interval, presented symptoms of declining motor and cognitive functions. She was treated with 40 sessions of Hyperbaric Oxygen Therapy (HBOT). The therapeutic use of oxygen at supraphysiological pressures might either increase systemic oxidative stress or cause an overproduction of oxygen free radicals as drawbacks. Concurrent use of antioxidants and anti-inflammatory drugs may prevent the side effects of oxygen therapy at supraphysiological pressure due to oxidative stress. For this reason, the patient was also treated with high-dose N-Acetylcysteine and glucocorticoids. Here, we describe the longitudinal monitoring of patient's cognitive abilities and leukoencephalopathy associated with her positive clinical outcome.

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          Most cited references31

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          Immunosuppression by Glucocorticoids: Inhibition of NF-kappaB Activity Through Induction of IkappaB Sy nthesis

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            Disability rating scale for severe head trauma: coma to community.

            The objective of this study was to develop one instrument for assessing quantitatively the disability of severe head trauma patients so their rehabilitative progress could be followed from coma through different levels of awareness and functioning to their return to the community. This disability rating (DR) instrument was designed to be easily learned, quickly completed, valid, predictive of outcome and to have a high inter-rater reliability. The DR Scale consists of 8 items divided into 4 categories; 1. Arousal and awareness; 2. Cognitive ability to handle self-care functions; 3. Physical dependence upon others; 4. Psychosocial adaptability for work, housework, or school. Completed independently by several raters for more than 88 serious head injury patients, inter-rater correlations were highly significant. The admission DR was significantly related to clinical outcome at 1 year after injury and was significantly related to electrophysiologic measures of brain dysfunction as reflected in degree of abnormality of evoked brain potential patterns. The DR Scale is more sensitive than the Glasgow Outcome Scale in detecting and measuring clinical changes in individuals who have sustained severe head trauma. Also it can be used to help identify patients most likely to benefit from intensive rehabilitation care within a hospital setting. It provides a shorthand global description of a head injury patient's condition that facilitates understanding and communication.
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              Delayed neurologic sequelae in carbon monoxide intoxication.

              Of 2,360 victims of acute carbon monoxide intoxication examined between 1976 and 1981, delayed neurologic sequelae were diagnosed in 65 (2.75% of the total group, 11.8% of those admitted). There were 25 men and 40 women. Ages ranged from 34 to 80 years (mean, 56.1 years), with the peak incidence in the sixth and seventh decades. The lucid interval before appearance of neurologic sequelae varied from two to 40 days (mean, 22.4 days). The most frequent symptoms were mental deterioration, urinary or fecal incontinence, gait disturbance, and mutism; the most frequent signs were masked face, glabella sign, grasp reflex, increased muscle tone, short-step gait, and retropulsion. There were no important contributory factors except age and the severity of anoxia. Previous associated disease did not hasten the development of sequelae. Of 36 patients followed up for two years, 27 (75%) recovered within one year.
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                Author and article information

                Contributors
                Journal
                Case Rep Neurol Med
                Case Rep Neurol Med
                CRINM
                Case Reports in Neurological Medicine
                Hindawi
                2090-6668
                2090-6676
                2019
                15 May 2019
                : 2019
                : 9360542
                Affiliations
                1Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
                2Auxilium Vitae, Volterra (Pisa), Italy
                3Neurology Department, ASLAL, San Giacomo Hospital, Novi Ligure (Alessandria), Italy
                4Molecular Mind Lab, IMT School for Advanced Studies Lucca, Lucca, Italy
                Author notes

                Academic Editor: Jacqueline A. Pettersen

                Author information
                http://orcid.org/0000-0002-3779-046X
                http://orcid.org/0000-0001-5097-1014
                Article
                10.1155/2019/9360542
                6541979
                02cc2878-33ce-4053-b626-3aeeec416b4d
                Copyright © 2019 Vincenzo Spina et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 1 February 2019
                : 30 March 2019
                : 24 April 2019
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