Epistaxis during a generalized seizure leading to an atypical ictal SPECT finding at the skull base

INTRODUCTION: Generalized tonic-clonic seizures (GTCS) are among the most dramatic types of epileptic seizures and may be accompanied by rising blood pressure and pulse rate, physical injuries from falling, muscular convulsions, tongue biting, or aspiration pneumonia. Epistaxis is an uncommon complication of generalized seizures and investigations should exclude local or systemic disorders. OBJECTIVE: We aim to report a 29-year-old male patient with medically intractable right temporal lobe epilepsy whose ictal SPECT showed a conspicuous high extracerebral accumulation of the tracer at the skull base. METHODS: The tracer 99mTc-ECD was injected during a GTCS complicated by simultaneous epistaxis during a long term video-electroencephalographic monitoring. RESULTS: Initially, SPECT images showed an unexpected hot spot at the skull base suggesting pharyngeal or pituitary tumors. Clinical history disclosed chronic sinusitis and rare episodes of epistaxis. White and red cells blood count, platelet count, serum biochemistry, coagulation tests, and rest arterial blood pressure were normal. Computed tomography and MRI excluded sinusoidal expansive or vascular lesions, head trauma, fractures or acute infections. Subtracted SPECT disclosed a focal high concentration of the radiotracer within the left sphenoid sinus, probably related to the nose bleeding. CONCLUSION: This is a singular case of a brain SPECT artifact secondary to a nasal bleeding during a generalized seizure that was misinterpreted as neoplastic disease. Also, this case raises concerns about the pathophysiological relationship among epileptic seizures, nasal bleedings and chronic sinusitis.

INTRODUÇÃO: As crises generalizadas tônico-clônicas (CGTC) constituem-se em formas dramáticas de crises epilépticas e podem acompanhar-se de aumento da pressão arterial e da freqüência cardíaca, traumas decorrentes de quedas, abalos musculares, mordedura de língua e pneumonias aspirativas. A epistaxe é uma complicação incomum e investigações médicas devem excluir distúrbios locais ou sistêmicos. OBJETIVO: Relatar o caso de um paciente de 29 anos de idade com epilepsia do lobo temporal direito clinicamente intratável e cujo SPECT crítico mostrou uma área de acúmulo anormal do traçador na base do crânio. MÉTODO: O traçador 99mTc-ECD foi injetado durante uma CGTC complicada por simultânea epistaxe na narina esquerda durante a monitorização vídeo-eletroencefalográfica. RESULTADOS: O SPECT crítico evidenciou área de acúmulo anormal do traçador na base do crânio sugerindo tumor de natureza neuronal ou glial e de origem faríngea ou pituitária. A história clínica evidenciou sinusite crônica e raros episódios de epistaxe. Exames hematológicos das series branca e vermelha, contagem de plaquetas, bioquímica sérica, testes de coagulação e medidas de pressão arterial em repouso foram normais. A Tomografia Computadorizada e a Ressonância Magnética (RM) excluíram lesões expansivas ou vasculares, trauma craniano, fraturas ou infecções agudas. A subtração baseada em voxel das imagens de SPECT crítico e intercrítico alinhada ao espaço 3D da RM evidenciou uma alta concentração do traçador no seio esfenoidal esquerdo. CONCLUSÃO: Este é um caso singular de um artefato ao SPECT crítico secundário ao sangramento nasal durante uma crise epiléptica e que foi inicialmente interpretado como doença neoplásica. Este caso também indaga sobre o possível relacionamento fisiopatológico entre crises epilépticas, sangramentos nasais e sinusite crônica.

SPECT and PET Imaging in epilepsy: principles and clinical applications

Functional neuroimaging with single photon emission computed tomography (SPECT) and positron emission tomography (PET) has documented several perfusion, metabolic and neurochemical dysfunctions in a variety of neurological conditions. In the presurgical workup of medically intractable epilepsies, a group of investigations is included to ascertain the lacalization of the epileptogenic zone. The aim of the present study is to review the principles and revelant investigations about the application of SPECT and PET to the epilepsies. We reviewed the physiological aspects of cerebral blood flow during seizures, pharmacological characteriristics of radiopharmaceuticals, and clinical applications of SPECT in the investigation of epileptic seizures, and provided a review of the main clinical contributions of PET in epilepsy. SPECT and PET have an important and complementary role in the presurgical evaluation as well as in pathophysiological researchs about epilepsy. Both may evaluate the ictal and interictal states of cerebral functions, playing a particular role in those patients who present with inconclusive studies of both Magnetic Resonance Imaging and the Video - EEG monitoring. Additionally, they may avoid or guide invasive neurophysiological studies, and help suggest the localization of the epileptogenic zone in those cases with extensive or multiple lesions

Fragile X syndrome: clinical, electroencephalographic and neuroimaging characteristics

We studied 11 patients (9 males) with cytogenetic diagnosis of fragile X syndrome (FXS) with the purpose of investigating the neural circuitry involved in this condition. The ages ranged from 8 to 19. All the individuals presented large ears, elongated faces and autistic features. Ten patients had severe mental retardation. Attention disorder was found in 10 individuals. Electroencephalographic recordings were abnormal in 6 of 10 patients examined, showing focal epileptiform discharges predominantly in frontal and parietal areas. All patients underwent magnetic resonance imaging studies which were abnormal in 8 of them. The most important abnormalities were reduction of the cerebellar vermis and enlargement of the IV ventricle. Single photon emission computerized tomography (SPECT) was performed in 7 patients and was abnormal in all of them, the most frequent finding being a hypoperfusion of the inferior portions of the frontal lobes. Based on the clinical picture, neuropsychological findings and functional and structural imaging studies we suggest that FXS presents with a dysfunction involving a large area of the central nervous system: cerebellum - basal frontal regions - parietal lobes. The literature points to a disturbance involving the same neural circuitry in patients with austin.

Evolução clínica de pacientes submetidos à ventriculectomia esquerda parcial / Outcome of Patients Submitted to Partial left Ventriculectomy

OBJECTIVE: To assess the efficacy of partial left ventriculectomy as a treatment for patients with end-stage heart failure. METHODS: From February to June 1995, 7 patients with end-stage heart failure underwent partial left ventriculectomy. Subsequently, patients underwent clinical evaluation every 2 months, and 2-dimensional echocardiography at the 6th and 12th months after cardiac surgery. All patients were given digitalis and diuretics at conventional doses, and captopril or enalapril at maximal tolerated doses. RESULTS: Two (28) patients died; 1 from cardiac arrhythmia associated with gastrointestinal hemorrhage, and the other suddenly. One (14) patient developed an embolic cerebrovascular accident. Four (57) patients were hospitalized for congestive heart failure; all of them had either decreased the daily dose of captopril or enalapril or discontinued the drugs by themselves. Twelve months after ventriculectomy, left ventricular ejection fraction values were greater and left ventricular diastolic dimension and functional class values lower than those found before cardiac operation. CONCLUSION: Beneficial effects of partial left ventriculectomy are observed one year after the surgical procedure. This technique, therefore, can be useful for the treatment of patients with end-stage heart failure.

Experiência inicial com a ventriculectomia parcial esquerda no tratamento da insuficiência cardíaca terminal / Initial experience with partial left ventriculectomy as a treatment for end-stage heart failure

PURPOSE: To evaluate the efficacy of left ventriculectomy, on a short term basis, as a treatment for patients with end-stage heart failure. METHODS: From February to June 1995, 7 patients with end-stage heart failure underwent partial left ventriculectomy. Before the surgical procedure, 7 (100) patients were in functional class IV. Three (42) patients needed inotropic support for hemodynamic stability. The mean daily dose of furosemide was l48.67 +/- 128.27 mg, of captopril 87.50 +/- 95.20 mg and of digoxin 0.23 +/- 0.04. Mean left ventricular diastolic dimension determined by 2-D echocardiography was 78.29 +/- 12.63 mm, mean left ventricular ejection fraction, determined by radionuclide ventriculography, was 0.15 +/- 0.05 whereas mean transpulmonary gradient and pulmonary vascular resistance in Wood units, determined by right heart catheterization, were 16.80 +/- 8.80 and 6.57 +/- 3.22, respectively. RESULTS: Sixty days after the surgery, the mean functional class was 1.71 +/- 0.48 (p = 0.009), the mean left ventricular diastolic dimension 64.67 +/- 11.41 mm (p = 0.02) and the mean left ventricular ejection fraction 0.22 +/- 0.04 (p = 0.02). CONCLUSION: The left ventriculectomy is a promising treatment for patients with end-stage heart failure.

Objetivo - Avaliar a eficácia da ventriculectomia parcial esquerda, a curto prazo, no tratamento de pacientes com insuficiência cardíaca terminal. Métodos - De fevereiro a junho de 1995, 7 pacientes com insuficiência cardíaca terminal foram submetidos a ventriculectomia parcial esquerda. Antes do procedimento cirúrgico, os 7 (100%) pacientes apresentavam-se em grau funcional IV. Três (42%) pacientes faziam uso de inotrópicos para estabilização hemodinâmica. A dose média de furosemide era de 148,67 ± 128,17mg/dia, a de captopril 87,50 ± 95,20mg/dia e a de digoxina 0,23 ± 0,04mg/dia. A dimensão diastólica média do ventrículo esquerdo (VE), medida ecocardiograficamente, era de 78,29 ± 12,63mm, a fração de ejeção média do VE, determinada radioisotopicamente, era de 0,15 ± 0,05, enquanto que o gradiente transpulmonar e a resistência vascular pulmonar, em unidades Wood, estabelecidos por cateterismo, eram de 16,80 ± 8,80 e 6,57 ± 3,22, respectivamente. Resultados - Após 60 dias do procedimento cirúrgico, a classe funcional era, em média, 1,71 ± 0,48 (p= 0,009), a dimensão diastólica média do VE de 64,67 ± 11,41mm (p=0,02) e a fração de ejeção do VE 0,22 ± 0,04 (p=0,02).Conclusão - A ventriculectomia esquerda é um tratamento promissor para pacientes com insuficiência cardíaca termina

Alteraçöes no fluxo sangüíneo cerbral em pacientes esquizofrênicos: relato preliminar / Alterations of cerebral blood flow in schizophrenic patients

Através de Tomografia Computadorizada com Emissåo de Fótons únicos (SPECT), com injeçåo de Tc99m-HMPAO em condiçöes de repouso, foi mensurado o Fluxo Sangüíneo Cerebral regional (rCBF) em sujeitos destros: 30 esquizofrênicos (DSM-III-R) e 17 controles normais. O grupo controle nåo apresentou alteraçöes no rCBF. Os pacientes eram 21 homens e 9 mulheres com média idade de 29,1 (+-7,07). 23 pacientes (70 por cento) apresentaram alteraçöes do rCBF em alguma área cerebral, dos quais mais de um terço, exclusivamente hipoperfusåo nos lobos frontal e temporal. Quatro pacientes com alucinaçöes auditivas e 1 com alucinaçöes visuais proeminentes mostraram aumento do rCBF no lobo temporal e na área visual, respectivamente. De acordo com os escores obtidos na PANSS e seguindo a proposta de Crow para os subtipos de esquizofrenia, 1 pacientes eram positivos e 7 negativos. Na primeira forma, havia 4 pacientes com rCBF normal, 2 com reduçåo do lobo temporal e 1 nos lobos frontal e temporal, enquanto 4 pacientes apresentavam, simultaneamente, rCBF aumentado em umas áreas e diminuído em outras. Todos os 7 pacientes do subtipo negativo apresentaram diminuiçåo do rCBF. Em conclusåo, as alteraçöes do rCBF såo mais encontradas nos lobos frontal e temporal; o subtipo negativo representa um grupo mais homogêneo, com hipoperfusåo cerebral; pode existir correlaçåo entre alucinaçöes e aumento do rCBF

Cisto de colédoco. Diagnóstico por métodos näo invasivos: relato de caso / Choledochal cyst. Diagnosis by noninvasive methods: a case report

Os cistos de colédoco raramente ocorrem em adultos. O diagnóstico é feito pelos ultra-sons e pela opacificaçäo dos dutos biliares para identificaçäo radiológica. É relatado o caso de paciente masculino de 39 anos, cujo diagnóstico foi feito pelos ultra-sons e pela cintigrafia hepatobiliar. Este método pode ser de utilidade para o diagnóstico, principalmente na presença de infecçäo