To determine the correlation between frontal intermittent rhythmic delta activity (FIRDA) and the clinical and radiological correlates in children.

Retrospective review of the EEG and imaging studies of 37 children with documented FIRDA.

FIRDA was associated with multiple neurological conditions and not necessarily with midline lesions. Patients with abnormal neurological exam had a longer FIRDA duration (average 9.5 seconds) compared to children with no reported abnormal examination (average of 6.5 seconds). FIRDA ranged from 2 to 2.5 Hz (n=15), 3 Hz (n=17) and from 1.5 to 3 Hz (n=5) and there was a significant association between the duration of FIRDA and abnormal laboratory tests (p. < 0.05, Student's T test).

FIRDA was not correlated with midline brain lesions in children. FIRDA may be a non specific oscillation of an unhealthy pediatric brain with or without seizures.

Most studies of third nerve palsy (TNP) antedate computerized imaging and focus primarily on chart review of referral outpatients.

To compare a large contrasting population, I reviewed 1400 personally-examined municipal hospital inpatients with TNPs seen over 37 years.

TNPs were bilateral in 11%, complete in 33%, without other neurological signs (isolated) in 36%, and associated with recurrent cranial neuropathies in 7%. Third nerve damage occurred in the subarachnoid space in 32%, the cavernous sinus in 23%, the brainstem in 14%, as a nonlocalized peripheral neuropathy in 18% and at an uncertain location in 13%. Causes were trauma (26%), tumor (12%), diabetes (11%), aneurysm (10%), surgery (10%), stroke (8%), infection (5%), Guillain-Barre and Fisher syndromes (5%), idiopathic cavernous sinusitis (3%), benign self-limited (2%), miscellaneous (4%), and unknown (3%). Local causes, besides an abundance of trauma, included six cases involving cysticercosis, four with wound botulism, and one with coccidiomycotic meningitis. Of 234 patients with diabetes, microvascular ischemia was the cause of TNP in only two-thirds (five had aneurysms) and 53% of those with diabetic microvascular ischemia had pupillary involvement—often bilateral, suggesting concomitant autonomic neuropathy. Only 2% of aneurysms spared the pupil. Apainful onset occurred with 94% of aneurysm and 69% of diabetic cases.

Bilateral TNPs, multiple cranial neuropathies, and accompanying neurological signs were common among our inpatients, as were causes rare in outpatient settings such as severe trauma, transtentorial herniation, midbrain strokes, and the Guillain-Barre syndrome. Few cases remained undiagnosed and nondiabetic ischemia was rare.

Scedosporial infections are usually encountered in the immunocompromised patients. However, they are now emerging in the immunocompetent population and have an affinity for the central nervous system. They represent a therapeutic challenge, since they are highly resistant to most antifungal medications.

We report the case of an immunocompetent patient with multiple cerebral abscesses secondary to Scedosporium apiospermum following extracorporeal membrane oxygenation (ECMO) and review the literature about this challenging cerebral infection.

A previously healthy 33-year-old male admitted to the hospital for a community-acquired pneumonia requiring ECMO subsequently developed multiple cerebral abscesses. He was empirically treated with caspofungin, which was changed to voriconazole once surgical aspiration revealed Scedosporium apiospermum. Despite multiple aspirations, decompressive craniectomy to alleviate intracranial pressure, and an appropriate antifungal agent, the patient did not survive this aggressive infection.

Brain abscesses with Scedosporium apiospermum present a therapeutic challenge. High clinical suspicion leading to early appropriate antifungal therapy and combined surgical interventions might improve the prognosis.