Case Report / Case Report + Reviews 1
Introductions serve two major functions: they must inform and they must persuade. The reader must
know immediately what the paper is about, why it was written, and what contribution this research
makes.
The basic 5 step structure of the Introduction will fulfill both of these functions, whether you carefully
write each in the order listed or choose to mix it up a bit. The 5 steps listed below form the basis for
most publication types, so once you get the hang of it, crafting successful introductions is a
straightforward process.
The 5 Steps to an Effective Introduction
1. Establish the Topic -- what is the paper about?
2. Provide Significance -- why does the topic matter? (practical, clinical, or research)
3. Review the (Relevant) Literature -- what key ideas, concepts, definitions must the reader know to
understand the paper AND be convinced that the research is warranted? (leads to gap)
4. Point out the Gap/Motivation -- what missing information (in the published literature) motivates the
paper? (this can be left implied, although readers appreciate an obvious mention)
5. Reveal the Reason -- what question does this paper answer?
1. Case Report -- why/what the case contributes to the clinical literature
2. Research Report -- the research question/statement
3. Review -- the perspective driving the review and preview of topics in the body
Case Studies
There are 3 different sorts of case studies: 1) case examples of typical or atypical patients; 2) case
studies of organizations or groups; 3) case studies of a complex problem. Generally, patient case
studies begin with a concise statement of the pathology/medical/clinical area of the case, provide a key
significance statement, followed by a brief overview of the patients being presented.
Case Report + Reviews are a hybrid genre that can be considered a case report on steroids or a review
paper with real-world (clinical) exemplification. The introduction must accomplish the normal tasks of
introducing the clinical situation, as in case reports, and also the task of framing the case into the larger
literature, as does a review.
Since both start with some mention of the topic, the opening sentences are quite similar to either case
reports or reviews. After, a more in-depth presentation of the condition follows, as in a review, leading
to a "motivation" (gap) type statement that narrows to the topic to the clinical focus of the paper. The
introduction ends there, and the next section begins the case presentation, finishing with a case-focused
review of the literature.
Case Report / Case Report + Reviews 2
#1: Lethal giant cell arteritis with multiple ischemic strokes despite aggressive
immunosuppressive therapy / http://www.ncbi.nlm.nih.gov/pubmed/20609853
Giant cell arteritis (GCA), also called temporal arteritis, is the
most common form of systemic vasculitis in adults, typically
involving large and medium-sized vessels in patients over the
age of 50. The majority of patients respond well to treatment
with high-dosed steroids. A subset of patients develops a more
malignant course with recurrent ischemic strokes from
involvement of the distal vertebral or internal carotid arteries.
We present two patients with GCA involving both the bilateral
distal vertebral and internal carotid arteries with repeated
infarcts and death despite escalating immunosuppressive
therapies.
Medical condition/situation
Problem presented by case
Brief intro to patient cases,
including outcomes
#2: Two cases of recurrent stroke in treated giant cell arteritis: diagnostic and
therapeutic dilemmas / http://www.ncbi.nlm.nih.gov/pubmed/20661069
Stroke is the most common cause of death in giant cell arteritis
(GCA),1 occurring in 3% of patients in the 10 weeks following
the diagnosis of GCA.2 The extent to which persistent
inflammatory
vasculitic
occlusion,
thrombocytosis,
procoagulant effect of inflammatory mediators, iatrogenic
effect of steroids, or coexisting atherosclerosis might
contribute to this risk is unclear.3,4 This creates a diagnostic
and therapeutic dilemma in treating patients recently diagnosed
with GCA, who present with stroke after initiation of steroid
therapy.
We report 2 patients with GCA who developed repeated
strokes in different circulatory territories following steroid
initiation, despite resolution of cranial symptoms and
normalization of inflammatory markers. The extensive and
frequent pattern of onset was disproportionate to their risk
factor profile for atherosclerosis. In the first case, MRI
imaging and repeat temporal artery biopsy (TAB) suggested
persistence of arteritis, and an increase in immunosuppressive
treatment was associated with an arrest in the sequence of
recurrent strokes. Autopsy findings in the second case
suggested persistence of arteritis. This progressive pattern of
stroke onset following corticosteroid initiation has not been
previously reported.
Medical condition/situation
Problem presented by case
Brief patient introduction,
including outcomes
Significance of case within the
literature – may be here or in
discussion
Case Report / Case Report + Reviews 3
#3: Neurological Evaluation by Intraoperative Wake-up During Carotid Endarterectomy
Under General Anesthesia / http://www.ncbi.nlm.nih.gov/pubmed/15211163
Local anesthesia during carotid endarterectomy (CEA) is popular,
and maintenance of consciousness enables close evaluation of
cerebral function during carotid cross-clamping. 1–4 However,
patients often experience pain, discomfort, or anxiety induced by the
surgical procedure and by lying still for a long period, particularly
when anatomic difficulties associated with a short neck, obesity, or
high carotid bifurcation are encountered. 5 General anesthesia can
relieve patients from such stressors. However, neurologic assessment
is less reliable under general anesthesia than under local anesthesia,
as the clinician must rely on electroencephalography (EEG),
somatosensory evoked potentials (SEP), stump pressure, or
intracranial hemoglobin oxygen saturation as determined by infrared
spectroscopy (rSO2), all of which represent indirect methods for
neurologic assessment. 2–4,6
The present report describes a unique anesthetic management strategy
for CEA patients incorporating the advantages of both general and
local anesthesia. Basically, general anesthesia is combined with local
anesthesia for the surgical field and airway. This technique allows not
only minimization of patient stress but also thorough assessment of
neurologic function by waking the patient from general anesthesia
during carotid cross-clamping.
Medical condition/situation
Problem presented by case
Medical condition/situation
Problem presented by case
Brief intro to patient cases,
including outcome
Your Case Report Introduction
1. What is the medical condition or situation?
2. What is the problem the case presents vis-à-vis the medical condition or situation?
3. Provide brief patient introduction: make the problem in (2) clearly related and include a brief
outcome.
4. What is the significance of this case for readers or within the literature?
#1: Gamma knife radiosurgery for essential tremor: A Case report and review of the
literature / http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851695/?tool=pubmed
Essential tremor is a common type of movement disorder that normally
affects people over the age of 65; however, this illness can occur in
younger patients as well. In recent years, ET has been categorized as a
heritable condition, which can be transferred to family members in an
autosomal dominant fashion [1]. The primary symptom of ET involves
shaking of the hands during voluntary movements, but it may also
present with movements of the head, face, tongue, and lower limbs [13]. Other than tremors, there are no other direct medical symptoms
associated with ET and it does not decrease life expectancy. However,
many patients with ET have difficulties accomplishing their daily tasks
or other activities that affect quality of life, which is how this disorder
elicits a negative impact on the social and mental wellness of the
patients who bear this illness [1,4].
There are multiple treatment options for ET patients. The most
common medications utilized are beta-blockers. Unfortunately, these
are contraindicated for many patients with asthma, diabetes, and certain
heart conditions. Anti-seizure medications and botulinum toxin
injections are also used, but they are known to cause unwanted side
effects. Stereotactic RF thalamotomy is the most common
neurosurgical procedure for treating ET. It involves MR imaging of
the thalamic target (ventralis intermedius nucleus), placement of an
electrode neurosurgically, stimulation of the target, and creation of a
lesion through tissue ablation [5]. DBS is also an invasive surgical
procedure performed as an alternative to RF thalamotomy. DBS
involves the implantation of a device that utilizes electrical impulses to
block abnormal nerve signals [5,6].
Even though surgical treatments such as RF thalamotomy and DBS are
effective in many patients with ET, there are those who are not qualified
candidates for invasive neurosurgery because of comorbid medical
conditions. These include patients who use anticoagulants, who have
advanced cardiac or respiratory disease, who are known to be
noncompliant, and who are of advanced age. An alternative for such
patients is thalamotomy using GK radiosurgery. GK thalamotomy is a
safe alternative to invasive neurosurgery, and evidence shows it is
successful in the treatment of ET and similar movement disorders [5,711]. Also, because this disorder often occurs at a late age, and
pharmaceuticals can have significant side effects, GK can be the only
treatment option for this population of medication-intolerable patients.
We present an inspiring case of an ET patient, whose daily life was
drastically modified by the severity of her hand tremors, until GK
thalamotomy treatment restored her ability to control movement and
pursue her passion of painting.
Case Report / Case Report + Reviews 4
Topic sentence – identifies
condition
Extended definition/basic
introduction to condition -also provides significance (in
gray)
Lit review narrowing to
clinical focus
Well-developed problem
statement – motivation for
case and also justifies review
Patient case, including
outcome
#2: Cerebral amyloid angiopathy related inflammation: three case reports and a
review / http://www.ncbi.nlm.nih.gov/pubmed/20935328
Cerebral amyloid angiopathy (CAA) is characterised by β amyloid
deposition in the walls of small to medium sized arteries, and less
frequently veins and capillaries, of the leptomeninges and brain.1 2
CAA can occur sporadically or rarely as a hereditary syndrome.3 The
pathogenesis remains uncertain but it is likely that amyloid is
produced locally in the brain and accumulates as a result of reduced
clearance.4–6
CAA is found in between 23% and 57% of an asymptomatic elderly
population on histopathology examination.7 CAA is also found in a
number of disease states, most commonly dementia and intracerebral
haemorrhage (ICH). In a review of four population studies with
histopathological data, 55–59% of patients with dementia had
evidence of CAA compared with 7–24% of patients without
dementia.8 CAA associated ICH accounts for 10–34% of ICH and
typically occurs in patients in their eighth decade or older. CAA
associated ICH is more likely to be lobar in location, is often
multifocal and tends to recur more frequently than hypertensive
haemorrhage. CAA is also associated with transient neurological
symptoms, particularly in older patients, who may present with
multiple, stereotyped episodes of predominantly sensory symptoms.
These transient symptoms are presumed to be focal seizures and the
episodes often respond to antiepileptic medication.
A less common manifestation is CAA related inflammation (CAA-I).
CAA-I presents with acute or subacute onset of headaches, cognitive
and behavioural changes, seizures and focal neurological deficits. In
addition to CAA-I, this condition has been labelled primary angiitis of
the CNS associated with CAA; amyloid angiopathy and
granulomatous angiitis of the CNS; cerebral amyloid inflammatory
vasculopathy; cerebral amyloid angiitis; cerebral amyloid angiopathy
associated with giant cell arteritis; and amyloid β related angiitis.9–15
All of these names emphasise the association between cerebral
amyloid angiopathy and inflammation of blood vessels. We prefer the
label CAA-I as perivascular inflammation may also be found.
We report three patients with pathologically confirmed sporadic
CAA-I who presented between 2001 and 2007. Patients were included
if they presented with encephalopathy and had histopathological
evidence of perivascular or intramural vascular inflammation and
deposition of amyloid in blood vessels in those parts of the cerebral
cortex and leptomeninges affected by the inflammatory changes. The
findings from 69 previously published cases are summarised. We
propose diagnostic criteria for CAA-I.
Case Report / Case Report + Reviews 5
Topic – identifies condition/medical
situation
More basic info – incudes hint of
research significance signaled by
the word “uncertain”
Significance (practical and clinical) +
lit review
Relevant clinical information +
motivation for case/review
Patient case, including outcomes +
review and its contribution
Case Report / Case Report + Reviews 6
Structure of the Case Report + Review Introduction
1. What is the medical condition or situation? (sometimes includes more information, an extended
definition) What is the significance of this condition/situation?
2. Lit Review that focuses on motivation for case report and review
3. What is the problem the case presents vis-à-vis the medical condition or situation?
4. Provide brief patient introduction: make the problem in (2) clearly related and include a brief
outcome.
5. What is the significance of this case for readers or within the literature? Provide a preview or
focus statement of the body sections.