similar to that found in Toronto (14%)6 but lower thanfigures in America (20% in California') and higher thanthose in Hawaii (0%)6 and Queensland (5%).'Although fixed dilated pupils on admission are not a

reliable predictor ofoutcome after a serious submersionincident, the pupillary reflex is unaffected by the drugsgiven to electively ventilated paralysed patients and isthus a useful indicator of outcome during this form oftreatment. All children who fully recovered had normalsustained pupil reactivity within six hours after startingcardiopulmonary resuscitation. A longer period beforethe onset of pupil reactivity and the recurrence ofperiods of fixed dilated pupils was associated withneurological deficit or death.

Respiratory effort is probably the most sensitiveprognostic sign on admission in the unconscious nearlydrowned child: all children with established respirationin our study made a full recovery. Nevertheless,especially in the very hypothermic children, absence ofrespiratory effort does not necessarily predict a pooroutcome. Prolonged, poorly controlled fits beyond thefirst day after admission to hospital were associatedwith neurological deficit. This agrees with the findingsof Conn and Barker6 that late poor electroencephalo-graphic traces are associated with a poor outcome.Why should some patients apparently dead on

admission with fixed dilated pupils survive normally?It has been suggested that this is because of the divingreflex, which is more pronounced in children thanadults, in which the peripheral circulation is shut downwith a profound bradycardia, the brain achieving mostof the circulation.'4 Other work, however, suggeststhat the diving reflex is not active in humans" andsubmersion hypothermia is more likely to account forsome people surviving prolonged periods under water.The rapid fall in body temperature on immersion incold water exerts protective cranial hypothermia beforethe circulation fails. " Orlowski used the term ice waterdrowning9 as a review of published reports showed thatall the cases with a good outcome after prolongedimmersion occurred in water of temperature 100C.The protective effect of hypothermia would be more

pronounced in children than in adults because childrenhave a higher surface area to body weight ratio andtherefore cool more rapidly. Most outdoor drowningsin the United Kingdom are in water temperatures of<20°C; four of the children in our series who survivednormally with fixed dilated pupils and no respiratoryeffort had body temperatures less than 32°C and threewere profoundly hypothermic.

We thank the British Paediatric Surveillance Unit; all theconsultant paediatricians who returned cards and gave usdetails of their patients; the Welsh Scheme for Social andMedical Research for funding; the Child Accident PreventionTrust for encouragement; and, in particular, Jim Nixon fromthe Department of Child Health, Brisbane, Australia, forsupport at the start of the project. We thank all Her Majesty'sCoroners and procurators fiscal, the Royal Society forPrevention of Accidents, the Office of Population Censusesand Surveys, the Scottish Government Record Office, theIrish Government Statistical Office, and the Northern IrishOffice for information.

I Office of P'optulationi Censuses and Surveys. Deaths by cause: 1988 registra-tions. OIS, M1onitor 1989. (DH 2)

2 O'Carroll PWX', Alkon E, Weiss B. Drowning mortality in Los Angeles county1976 to 1984. ,AMA 1988;260:380-3.

3 Peterson B. Morbiditv of childhood near drowning. Pediatrics 1977;59:364-70.4 Pearn J. Neurological and psychometric studies in children surviving fresh

water immersion accidents. Lancet 1977;i:7-9.5 Pearn J, Bart RD, Yamoaka R. Neurological sequelae after childhood near

drowning: a total population study from Hawaii. Pediatrics 1979;64:187-90.6 Conn AW, Barker GA. Fresh water drowning and near drowning: an update.

Canadiar,t Anaesthetist Societe,7ournal 1984;31 :S38-44.7 Modell JH, (iraves SA, Ketover A. Clinical course of 91 consecutive near

drowning victims. Chest 1976;70:231-8.8 Frates RC. Analysis of predictive factors in the assessment of warm watcr near

drownittg itt children. Amj Dis Child 1981;135:1006-8.9 Orlowski Jl'. I)rowning, near drowning and ice water drowning. JA.M1A

1988;260:390- 1.10 Modell JH. Drown sersus near-drown: a discussion of definitions. ,rit Care

Med 1981;9:351-2.11 Frewen TC, StLmbat WO, Han VK, Amacher AL, Del Maestro RF, Sibbald

WE. Ccrcbral resuscitation therapy in paediatric near drowning.]J Pediatr1985;106:61 5-7.

12 Pearni JH. FItc management of near drowning B,IJ 1985;291:1447-52.13 Pearn JH, )e Bouse P, Mohav H, Golden M. Sequential intellectual recovery

af'ter niear drowning. Med]A,ust 1979;1:463-4.14 Golden F. Problems of immersion. Br] Ilosp Med 1980;23:373-6.15 Ramev CA, Ramey D)N, Hayward J S. Dive response of children in relation to

cold water drowning. ] Appl Phvstol 1987;63:665-8.16 Harries M. D)rowning and near drowning. BM7 1986;293:123-4.

Neurology Department,Atkinson Morley'sHospital, LondonSW20 ONEA Kennedv, MRCP, neuirologvregistrarF Schon, MRCP, consultantneurologist

Correspondence to:Dr Schon.

BAII 1991;302:933-5

Epilepsy: disappearing lesions appearing in the United Kingdom

A Kennedy, F Schon

AbstractObjective -Investigation of spontaneously resolv-

ing lesions associated with epilepsy.Design-Observational study during one year.Setting-One neurology department.Patients-4 cases in patients (one of Indian

parents, one African, one white English, and oneAfro-Caribbean) resident in the United Kingdom,who presented with transient epilepsy.Main outcome measures-Findings on computed

tomography and on screening for infections.Results-In all four cases a small mass lesion in

one cerebral hemisphere was observed on computedtomography, which resolved after 9, 4, 3 and 1-5months respectively without surgery.Conclusions-The number of cases seen in one

year suggests that the lesions may be more commonin the United Kingdom than previously recognisedand that research into their cause is warranted.

IntroductionIn the United Kingdom only about 8% of adults with

epilepsy of recent onset have mass lesions on computed

tomography of the brain. Almost all of these lesions,however, are due to cerebral tumours; infectious andgranulomatous masses are rare. In contrast, in India upto 40% of such patients have solitary, small, contrastenhancing, lesions in the cerebral hemisphere.4 Theremarkable feature of these lesions is that most undergospontaneous resolution within six months. The causeof these "disappearing" lesions remains controversial.An infectious aetiology is most likely; current evidencefavours cysticercosis56 rather than an isolated tuber-culoma.' It is not clear why similar cases have so rarelybeen reported outside India. In this paper four suchcases are described in patients who presented to ourunit during the past year, suggesting that they may becommoner in Britain than previously recognised.

Case reportsCase I-A 16 year old boy of Indian parents, who

had been born in Ireland and who had lived exclusivelyin Ireland and England except for two periods of threemonths in India at ages 6 and 15, presented after asingle tonic-clonic seizure. There were no physicalabnormalities, and the only abnormal finding was in

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L..,.S _rrd: - - .. : _ )z *_ -__ _-b_b_a. . .a-d-Contrast enhanced computed tomograms for cases 14. Left:solitary, contrast enhancing lesion at presentation (arrowed). Right:complete resolution of lesion after 9, 4, 3, and 1 5 months respectively(note: images reversed)

the computed tomogram of the brain, which showed aright parietal mass (figure, a). He was treated withantituberculous drugs for nine months, after which arepeat scan showed complete resolution of the lesion(figure).

Case 2-A 32 year old African, born in Zimbabwe,who had lived in Britain for 10 years, presented afterthree tonic-clonic seizures within two weeks. Therewere no abnormal findings except in the computedtomogram, which disclosed a left temporal lobe lesion(figure, b). After four months of treatment withanticonvulsant and antituberculous drugs a repeattomogram showed that the lesion had resolved (figure).All treatment was withdrawn after nine months.

Case 3-A 21 year old white English man withoutany history of travel outside Europe presented after asingle tonic-clonic seizure. Physical examination wasunremarkable, and the sole abnormality was detected

on computed tomography, which showed a left occipitallobe lesion associated with extensive cerebral oedema(figure, c). A further scan after four weeks showedconsiderable resolution, and complete resolution hadoccurred after 12 weeks. He was treated exclusivelywith phenytoin for one year.

Case 4-A 32 year old Afro-Caribbean man born inGuyana, who had lived in Britain since the age of 4,presented with a 10 week history of attacks of transientright sided numbness starting in the leg and spreadingupwards into the trunk, arm, and then face. Eachepisode lasted three minutes; they were presumed to bedue to sensory epilepsy. Computed tomography of hisbrain showed a left parietal lobe lesion (figure, d), andhis cerebrospinal fluid contained 10 lymphocytes/ml.Despite receiving no treatment his attacks stoppedafter a further three weeks, the computed tomogramshowed considerable resolution after six weeks, andrepeat examination of his spinal fluid was unremarkable.

DiscussionThese four cases, which closely resemble over 200

cases reported from India, all had negative investi-gations of blood and spinal fluid for likely infections,including tuberculosis, toxoplasmosis, cysticercosis,cryptococcosis, and HIV infection. Results of testsfor sarcoidosis and multiple sclerosis were negative.Although multiple sclerosis can also cause spon-taneously resolving lesions, these are normallysituated deep in cerebral white matter rather than insuperficial grey matter and the disease rarely presentswith epilepsy.The evidence implicating cysticercus as the

aetiological agent is as follows. Firstly, in one seriesof 15 excision biopsy specimens of similar lesionscysticercosis was found in seven cases.5 Secondly,serological investigations in a series of 35 patients werepositive for cysticercosis in 12.6 Thirdly, computedtomographic studies in areas of endemic cysticercosisin South and Central America have shown two majorpatterns: patients with longstanding disease, whousually have multiple calcified cysts, and patientsthought to have an acute lesion, many ofwhom presentwith epilepsy and have a solitary lesion similar to thedisappearing lesions common in India.' Of course,more than one aetiological agent may cause theselesions. An early study implicated tuberculosis because25% of patients had active extracranial tuberculosis atthe time of presentation.

Clearly it is vital to try and identify this subgroup ofpatients despite being currently unable to arrive at adefinite diagnosis because in these patients, in contrastwith most patients with cerebral space occupyinglesions, early neurosurgical intervention is not indicated.This subgroup should initially be treated with anti-convulsant drugs alone. If significant spontaneousresolution has not occurred after three months furthermedical treatment with drugs active against cysti-cercosis or tuberculosis needs to be considered as wellas stereotaxic biopsy. We hope that a wider awarenessof this fascinating clinical problem will help bothin patient management and in stimulating furtherresearch into its causes.

We thank Mr Uttley and Drs Monro and McKeran forpermission to report their cases, and Mrs Sharon Frank forexpert secretarial help.

1 Wadia RS, Makhale CN, Kelkar AV, Grant KB. Focal epilepsy in India withspecial reference to lesions showing ring or disc-like enhancement on contrast

computed tomography. J Neurol Neurosurg Psychiatry 1987;50:1298-301.2 Bansal BC, Abha Dua, Gupta R, Gupta MS. Appearing and disappearing CT

scan abnormalities in epilepsy in India-an enigma. J Neurol NeurosurgPss'htitrv 1989;52:1185-7.

3 Goulatia RK, Verma A, Mishra NK, Ahuia GK. Disappearing c rlesions in

epilepsy. Epilepsia 1987;28:523-7.

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4 Chandy 1\J, Raishekhar V. Prakash S, et al. Cysticcrcosis causing single smallCT lesions in Indian paticiats with scizures. Lintcet 1989;i:390-1l

Ra'shekhar \, Abraham J. Disappearing CT lcsions in Indiaii patients withepilepsy.] Neurol NeuroswurgPsychiars 1990;53:818-9.

6 Ahuja (GK, Beghari MI, Prasad K, Goulatia RK, Jailkham B. Disappearing CTllcsions in epilepsy: is ttiberculosis or cysticercosis the cause? _7 NeturolNeurosurgPsschiatry 1989;52:915.

7 Zegers De Beyl D, HerinanDts N, Collc H, Goldman S. Focal scizures with

reversible hypodensity on the C 1 scan. 7 Neurol Neurosurg Psschlatrr1985;48: 187-7.

8 Feinstein A, Ron M, Wesselh S. Disappearing brain lesions, psychosis andepileps: a report of two cases. ] Neuirol Neurosurg PIss'chlatan' 1990;53:244-8.

9 Minguetti G, Yerreira MVC. Compttted tomography in neurosysticercosis.7 Neurol Neurosurg Psychtiatry 1983;46:936-42.

(Accepted 6 Februtrv 1991)

Hospital for Sick Children,Great Ormond Street,London WC1N 3JHRodney C G Franklin, MRCP,research fellowFergus J Macartney, FRCP,professor ofpaediatriccardiologyKate Bull, MRCP, seniorlecturer in paediatriccardiology

MRC Biostatistics Unit,Cambridge CB2 2BWDavid J Spiegelhalter, PHD,senior statistician

Correspondence andrequests for reprints to:Dr Bull, thoracic unit.

BMNj 1991;302:935-9

Evaluation of a diagnostic algorithm for heart disease in neonates

Rodney C G Franklin, David J Spiegelhalter, Fergus J Macartney, Kate Bull

AbstractObjective-To develop, test, and validate an

algorithm for diagnosing disease in neonates duringan over the telephone referral to a specialist cardiaccentre.Design-A draft algorithm requiring only data

available to a referring paediatrician was generated.This was modified in the light of a retrospectivereview of case records. A questionnaire to elicitall the data required by the algorithm was thengenerated. There followed a prospective three phaseevaluation during consecutive over the telephonereferrals. This consisted of (a) a conventional phasewith unstructured referral consultations, (b) a phasewith referrals structured around the questionnairebut independent ofthe algorithm, and (c) a validationphase with the algorithm (and its previous errors)available during the referral consultation.Setting-59 paediatric centres in south east

England and a central specialist paediatric cardiologyunit.Patients-Consecutive neonates (aged <31 days)

referred with suspected heart disease. The retro-spective review was of records of 174 neonates from1979. In the prospective evaluation (1987-90) theconventional phase comprised 71 neonates (over 5-5months), the structured phase 203 neonates (over 14months), and the validation phase 195 neonates(over 12 months).Main outcome measures-Diagnostic accuracy

(assigning patients to the correct diagnostic category(out of 27)), of the referring paediatrician, thespecialist after the referral consultation, and the algo-rithm as compared with the definitive diagnosis byechocardiography at the specialist centre, and scorefor the appropriateness ofmanagement in transit.

Results-Simply structuring the consultation byquestionnaire (that is, proceeding from the con-ventional phase to the structured phase) improvedthe diagnostic accuracy of both paediatricians (from34% (24/71 cases) to 48% (97/203) correct) andspecialists (from 54% (38/71 cases) to 64% (130/203)correct). The algorithm (structured phase) wouldhave been even more accurate (78% (158/203 cases);p<001). Management scores in the structuredphase were also better than in the conventionalphase (80% (162/203 cases) v 58% (41/71) appropriate;p<0-01). Management scores would have improvedto 91% appropriate (185/203; p<0001) had thealgorithmic diagnoses dictated management. Thesuperiority of the algorithm was maintained but notbettered in the validation phase.Conclusions-Applying the algorithm should

reduce the morbidity and mortality of neonateswith critical heart disease by aiding clinicians intherapeutic decisions for in transit care.

IntroductionThe outcome of neonates with critical congenital

heart disease is prejudiced if they arrive at a specialist

centre in poor condition, no matter how aggressivetheir subsequent management.`13 Ideally, appropriatemanagement should begin at the referring hospital andcontinue in transit to the specialist centre, which maytake several hours.4 Despite the dangers of inadequate,inappropriate, or overzealous treatment,56 however,management must usually be initiated on the basis of apresumptive clinical diagnosis, typically arrived at by anon-specialist without special training in cross sectionalechocardiography (by which a definitive diagnosis isultimately made).

District paediatricians refer the patients by telephoneand discuss starting supportive treatment. We aimed atdeveloping, testing, and validating a diagnostic aid foruse during this over the telephone consultation. Itsdiagnostic accuracy and implications for managementin transit would then be compared with conventionaldiagnostic and referral methods, with the aim ofimproving the condition of neonates arriving atspecialist centres.

Patients and methodsRetrospective review-The clinical findings and pro-

visional diagnoses of all 174 consecutive neonates whopresented to the Hospital for Sick Children at under 31days of age in 1979 were reviewed. In 1979 neithercross sectional echocardiography nor prostaglandinwas available and our cardiologists made an initialdiagnosis based on data comparable to those availableto referring paediatricians during this study.

Conventional phase -Conventional over the telephonereferrals are unstructured by questionnaires oralgorithms. Prospectively, at the end of each of 71consecutive referral conversations over 5 5 months,both the general paediatrician and the paediatriccardiologist were asked to specify a diagnosis based onthe clinical findings and investigations discussed. Thefinal diagnosis was determined by cross sectionalechocardiography after the child's transfer.

DIAGNOSTIC ALGORITHM

An algorithm for diagnosing congenital heart diseasein neonates had been devised (by FJM) as a teachingaid. The algorithm required only basic clinical dataavailable to any clinician dealing with a neonate-namely, results of a clinical examination, an electro-cardiogram, chest x ray appearances, and, sometimes,arterial blood gas tensions. In the light of the retro-spective review this draft algorithm was amended and aseries of defaults created to allow for incompleteinformation so that it could be run for all patients (seeappendix). At this stage the algorithm, in near finalform, distinguished 27 diagnostic categories, includinglung disease masquerading as heart disease and dis-turbances of the transitional circulation.

For prospective testing a questionnaire t6 elicit thedata required by all pathways of the algorithm wasgenerated. The study was explained by letter to the 115paediatricians who referred neonates to our institution,enclosing a sample questionnaire.

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