Early predictors of malignant course of middle cerebral artery infarction: clinical, laboratory and radiological study

Early predictors of deterioration may improve therapeutic decision in patients with acute cerebral ischemia. This study investigated whether measurement of serum protein S100B, beside other clinical and radiological determinants can predict a malignant course of infarction in acute middle cerebral artery [MCA] occlusion. The study included 24 stroke patients admitted within 24 hours after the symptoms onset. In all patients, the stroke was caused by middle cerebral artery infarction as proved by transcranial Doppler [TCD] or computed tomography [CT]. Patients of this study were divided into two groups: group I: included 17 patients with non malignant middle cerebral artery infarction [MCAI]. Group II: included 7 patients with malignant MCAI [mMCAI]. All patients were subjected to complete history taking and thorough neuroglical examination using National Institutes of Health Stroke Scale [NIHSS], brain imaging by computed tomography, transcranial Doppler examination and routine laboratory studies. S100B serum levels were determined in all patients [on admission and 24 hours later] and in 15 age and sex matched control subjects. The functional state of patients was evaluated on discharge by Barthel index [BI] and after 2 months by modified Ranken Scale [MRS]. Patients with mMCAI had significantly higher S100 serum level after 24 hours, and higher NIHSS after 48 hours. These patients had higher incidence of poor outcome both early on discharge [lower BI] and after 2 months [MRS > 3]. On CT examination patients with mMCAI had significantly higher frequency of early hypodensity, large sized infarction, with more severe mass effect. Regarding S100B protein: it could not be detected in any one of the control group. While no significant difference could be found between the two patients' groups on admission, its levels were significantly higher in patients with mMCAI after 24 hours. At that time, levels of S100 were significantly correlated to NIHSS at 48 hours, the infarct volume and the severity of mass effect. Again S100B protein could be correlated to functional outcome of the patients both on discharge and after 2 months. In this study predictors of stroke poor outcome were increased mean age of the patients, presence of diabetes, hypertensions, rapid deterioration in the first 48 hours, and significantly higher S100B after 24 hours from admission. Beside those clinical and laboratory data, neuroradiologic features such as the presence of early hypodenisty, large sized infarction [more than one lobe] and marked mass effect were good predictors of poor functional outcome. Serum S100B concentration 24 to 48 hours after the onset can predict a malignant course of infarction after MCA occlusion and may provide a valuable information for both neurological status and functional impairment on discharge and on long term outcome. Other predictors of the malignant course are early clinical deterioration of the patients, early hypodensity on CT with large sized infarction and severe mass effect. All of these factors beside old age and diabetes can also predict poor outcome after MCAI

CT and MR imaging of cerebral tuberous sclerosis

Tuberous sclerosis is heredofamilial neurocutaneous syndrome, or phakomatosis, with multisystem involvement including the brain. The four major intracranial manifestarions [of TS are cortical tubers, white matter abnormalities, subependymal nodules, and subependymal giant cell astrocytoma. Eighteen patients with a clinical diagnosis of Tuberous sclerosis were examined by MR imaging. Their ages ranged from 3 months to 20 years. In 18 [100%] patients, MR examinations showed subependymal nodules, multiple peripheral gyral lesions consistent with cortical tubers were demonstrated in 14 [77%] patients. Subependymal nodules were best visualized on spin-echo images obtained with short repetition times [TR], although hypointesity within the nodules consistent with calcification was present in 15 patients and was most evident on long TR spin-echo images. Cortical tubers were more frequently demonstrated on long TR spin-echo images. White matter lesions were detected in 8 [44%] patients and subependymal giant cell astrocytoma in 4 [22%] patients. Computed tomographic scans were obtained for comparison in 15 patients. Intracranial calcification was more accurately diagnosed with CT. However, MR imaging was more sensitive than CT in detecting cortical tubers. Therefore MR may be better for screening family members and others in whom tuberous sclerosis is a possibility

frequency of idiopathic intracranial hypertension associated with anticardiolipin antibodies

Anticardiolipin antibodies [ACL-Ab] are associated with various neurologic syndromes, but idiopathic intracranial hypertention [IIH] has only rarely been reported in this context. So, we tried to detect the frequency of ACL-Ab in IIH Thirty patients with IIH fulfilling the inclusion criteria were identified. Their mean age was 29. years [range 19-39 years], and 27 [90%] were female.All patients were evaluated clinically, radiologically and screened laboratory to look for the ACL-Ab. Patients who were found on at least 2 separate occasions to have increased IgG and IgM titers of ACL-Ab were identified and compared with patients without ACL-Ab. Twelve [40%] of 30 patients with IIH had ACL-Ab. The detection of both IgG and IgM isotypes was significantly more valuable than the detection of each one of them and that IgG isotype was more frequently detected than IgM. So, we can conclude that anticardiolipin antibodies may cause IIH through mechanisms unrelated to major venous thrombosis. Idiopathic intracranial hypertension is frequently associated with ACL-Ab and can be the presenting symptom of the antiphospholipid syndrome. There are no major clinical, laboratory, or radiological features that distinguish between patients with IIH with and without ACL-Ab