study of cerebrovascular disease in middle age Egyptian patients

Six probable etiologic factors were determined regarding cerebral infarction. Nine cases [47.4%] had presumed atherosclerosis. Cardiac disease was present in seven cases [36.8%]; two cases had non valvular atrial fibrillation and five patients had rheumatic valvular heart disease. Vasculopathies other than atherosclerosis were responsible in two cases [10.5%]; one of them showed a complication of meningococcal meningitis and the other one was secondary to systemic lupus erythematosus. Oral contraceptive pills were found to be the only possible etiology in one female [5.3%]. Hypertension was the probable cause of hemorrhagic stroke in 23 cases [71.9%]. It was primary hypertension in 18 cases and secondary hypertension in 5 cases. Other etiologies included ruptured vascular malformations in five cases [15.6%], ruptured aneurysms in three cases [9.4%], and bleeding disorder in one case [3.1%]. Cerebral hemorrhage was subarachnoid in four patients [12.5%], ventricular in five patients [15.6%], basal ganglionic capsular in seventeen cases [53.1%], and lobar in six cases [18.8%]. The death rate in cerebral hemorrhage [40.6%] was significantly higher than the death rate in cerebral ischemia [5.3%]. Factors related to prognosis including mass effect, site and size of hematoma as well as the presence of ventricular extension were discussed

Prognostic study of different antioedema medications in cases of cerebrovascular accidents

We studied 38 [20 females and 18 mates] consecutive selected cases diagnosed as acute stroke with a mean age of 57.86 years. The patients were randomly allocated to one of three antioedema agents; 16 on furosemide, 12 on mannitol, and 10 on dexamethasone treatments. They were clinically assessed on alternate days till the end of 21-day period of the study and scored according to a clinical scoring system. CT was done pre-medication for all cases. Mortality rate was 53% in the furosemide treated group, 25% in the mannitol group, and 30% in the dexamethasone group. In the three groups, the survivors showed improvement in postmedication and final scores. The initial level of consciousness in our cases was a good predictive of antioedema drug. Cases with better level of consciousness had better scores at the end of the study. Cases presented with midline shift had poor prognosis. We found no difference between the three antioedema drugs as regards improvement of the clinical course in the survivors

Clinical differentiation between ischaemic and haemorrhagic strokes with computed tomographic correlations

We studied the clinical features of 64 stroke patients, 34 of ischaemic and 30 of haemorrhagic strokes as proved by computed tomography. History of transient ischaemic attack, diabetes and heart disease were commoner among patients of ischaemic stroke [IS] than those of intracerebral haemorrhage [ICH]. There was statistically significant difference between ischaemic and haemorrhagic stroke patients as regards: history of hypertension and/or elevated blood pressure at onset, progression to a maximal neurologic deficit within an hour after onset, headache associating or preceding onset, disturbed consciousness, especially stupor or coma, neck rigidity, popilloedema, pupillary and eye gaze movement disorders, all in addition to vomiting were higher in cases of ICH. These findings associated larger haematomas with oedema, mass effect or intraventricular blood extension. A significant statistical correlation was observed between abrupt onset and shift of midline structures [P < 0.01], headache and size of haematoma [P < 0.05], neck rigidity and intraventricular extension of blood [P < 0.05] and between stupor or coma and size of haematoma [P < 0.01] and shift of midline structures [P < 0.01]. In IS, headache, vomiting, vertigo, neck rigidity and disturbed consciousness, when occurred, usually associated posterior fossa followed by extensive, or large supratentorial infarcts. Abrupt onset with headache was also observed in high proportion of embolic strokes. Convulsions associated or followed onset to relatively equal proportions in ICH and cerebral infacts [CI[s]], while speech difficulties were encountered in cases of CI [s] more than those of ICH. Non-fluent aphasic disturbances were correlated with lesions [haemorrhage or infarction] anterior to the rolandic fissure, while fluent aphasia was observed with lesions posterior to the rolandic fissure. Massive lesions at the same sites induced global aphasia

Prognostic value of site and size of intracerebral hematoma

We studied 40 patients presented with spontaneous intracerebral hemorrhage [ICH]. Site and size of the lesion were determined by computed tomography, and the outcome in a month period was clinically evaluated. Thalamic lesions were always small [100 percent], and basal ganglionic lesions were more often small [62.5 percent] than lobar hematomas [31.57 percent]. Medium and large hematomas were common in lobar sites. Peri-focal edema was more common in basal ganglionic lesions, medium and large hematomas while mass effect was common in lobar and large sized hematomas. Significant difference was found between survivors [15 percent good, 32.5 percent fair, 15 percent poor outcome] and fatalities [37.5 percent]. Mortality was higher in large size hematoma [66.7 percent], followed by medium [40 percent] and small ones [23.8 percent]; and was higher in lobar lesions [47.4 percent], especially temporal sites [80 percent], followed by basal ganglionic [31.3] and thalamic [25 percent].Edema and mass effect were more detected in fatal cases. So, the presence of perifocal edema and mass effect in a large volume lobar hematoma [especially temporal] are poor outcome predictors in ICH

follow-up study of neurological and computed tomographic findings in protein energy malnutritions

We studied 48 children with primary protein energy malnutrition [PEM] associated with neurological manifestations, to which no other etiology could be suspected. They were subjected to full clinical history and examination stressing on nutritional, anthropometric, developmental and neurological assessment. Twenty of these children were scanned by computed tomography [CT]. Twenty-seven out of the 48 children were followed up and re-evaluated on average 18 months after nutritional rehabilitation. We found improvement in all anthropometric measurements of all PEM groups. A persistent deficits of 9% in length, 15% in weight and 5% in head circumference were detected after nutritional rehabilitation. Some neurological and psychological abnormalities recovered completely, however, hypotonia persisted in 7.41% of follow-up group. We detected evidence of mental deficit of various degrees in 95.83% of cases at initial examination and in 77.78% at follow-up with a remarkable improvement in severity. Cerebral atrophy according to standard radiological criteria was found in 90% of PEM cases, independent of its subtypes. It showed marked improvement but still persisted in milder degrees in 75% of cases after nutritional rehabilitation. Central and cortical atrophy occurred in equal percent initially. In the follow-up examination 25% showed persistent cortical atrophy, in contrast to 66.6% who showed central atrophy. There was a positive significant correlation between cerebral atrophy and the duration of suffering from PEM. The degrees of mental deficits were found to be independent of the degrees of cerebral atrophy. The findings of this study suggest considerable cerebral insult associated with PEM. The mechanism and significance of persistence of some abnormalities and reversibility of others remain to be determined

experimental study of CNS schistosomiasis: histopathological and immunological aspects

The brain and spinal cord tissues of 54 albino Swiss mice, heavily infected with S. mansoni cercariae were examined histologically using hematoxylin and eosin stains, as well as, immunologically using the direct immunofluorescent technique. Histopathological examination revealed inflammatory mononuclear cells infiltration which was variable in its cellular composition, pattern, severity and site of infiltration, vascular changes in the form of vasculitis, intimal proliferation and/or thickened, hyalinized media with congested blood vessels and associated edema and gliosis. These histopathological changes were prominent in the early acute stage of infection with subsequent spontaneous gradual diminution as passing to chronicity. The direct immunofluorescent study revealed IgG deposits in the CNS of the infected mice. The positive immunofluorescent reaction started to develop in the early acute stage of infection and reached its maximal levels around 11[th] week of infection with subsequent spontaneous gradual diminution. No ova or adult worms could be visualized in the histologic sections or by fluorescent technique. The CNS involvement in the course of schistosomiasis mansoni infection is not necessarily dependent on the direct action of ectopic ova and the resultant granuloma formation. An immunological reaction is an alternative mechanism, through which the CNS may be involved. This immune reaction usually occurs during the early acute stage of infection with subsequent gradual spontaneous diminution. However, some cases with such reaction may be at risk of the development of chronic immune- complex disease, which may be at least in part, responsible for neurological complications seen in some cases with advanced chronic schistosomal infection

Role of plasmapheresis in treatment of myasthenia gravis

We followed up the results of treatment with plasmapheresis in 21 patients of generalized myasthenia gravis [MG]. These patients were of: IIA, IIB and IV stages according to Osserman classification. They were treated with plasmapheresis because of being failed to achieve a sustained satisfactory improvement with an adequate courses of anticholinesterases prednisone and azathioprine. They were clinically evaluated before the start of plasmapheresis and on the 7[th] day after the last exchange and were followed up for 6 months later. Good improvement, with shift in Osserman stage was obtained in 13 [61.9%] patients, three of them were symptomless at the end of the therapy. Mild improvement was observed in six patients [28.57%]. The response was transient extending only for 2 - 4 weeks in six patients [28.57%] and for 2 - 4 months in seven patients [33.3%], while a prolonged remission of more than six months was observed in other six patients [28.57%]. The response to plasmapheresis was not altered by sex, duration of illness or initial clinical state before exchange. The serum levels of immunoglobulin A, M and G were reduced in all patients after plasmapheresis. The patients who achieved marked improvement [grade 2] had had the lowest serum levels of immunoglobulins [Igs] before and after plasmapheresis

Myopathic charges in bilharzial hepatosplenomegaly; clinical and histopathological studies

We studied neuromuscular changes in 35 patients suffering from bilharzial hepatosplenomegaly. Bilateral symmetrical weakness and wasting in the shoulder girdle muscles were detected in 28 patients. The severest degree of muscle wasting was present in 6 patients presenting with massive ascites. The level of serum albumin was below 3 gm% and there was history of repeated abdominal tapping for ascites in 2 patients. Muscle biopsy was studied in patients with moderate and severe muscle wasting. The study revealed definite myopathic changes in 7 patients with marked variation in the size of muscle fibres, degenerative changes with loss of transverse striations. The subsarcolemmal nuclei were definitely increased in number and size and became centrally migrated in hyalinosed muscle fibres. There was an increase in the amount of fibrous and fatty tissues between the muscle fibres. Trichrome and myophosphrylase stains showed type I fibres predominating type II fibres which favour myopathic changes

Neurological, biochemical, visual evoked potential and computed tomography studies in cases of protein energy malnutrition

Our study was conducted on 100 Egyptian infants and children [63 males and 37 females] suffering from neurological manifestations due to protein energy malnutrition [PEM]. Their ages ranged from for 4-30 months. They were classified according to wellcome classification into three groups. Kwashiorkor [KWO] 10 cases, marasmic-kwashiorkor [M-KWO]: 45 cases and marasmus [M]: 45 cases. The head circumference revealed a positive correlation between the duration of malnutrition and the affection of brain growth. Higher mental functions were affected as evidence by delayed verbal and motor development after the start of the disease [35% and 58% respectively], abnormal persistence of neonatal reflexes [28%] and behavioral and emotional changes [75.5% in M group and 100% in the other 2 groups]. Thirty-seven percent of PEM patients were presenting mainly with hypertonia, while 49% were presenting with hypotonia. Serum electrolytes, magenesium and phosphours showed reduction in their levels in the three groups. The reduction of sodium, potassium and phosphorus was more marked in cases with hypotonia, while the reduction of calcium and magnesium was more marked in cases with hypertonia. Visual evoked potential [VEP] studies showed prolonged latency to the peak of Cii in comparison to the control group. The mean delay in KWO [Lt eye 183.33 msec., Rt eye 168.33 msec.] was more than M-KWO and M groups. Computed tomography [CT] showed cerebral atrophy in both hypotonic and hypertonic cases. VEP and CT results suggest disturbance in neuronal function and myelination process in PEM during a critical period of brain development and that mental and motor disorders may be of a central origin due to the affection of brain growth

Childhood epilepsy "A correlative study of clinical, electroencephalography and computed tomography"

This work was carried out on 100 epileptic children. Clinical examination and EEG record were done for all patients while CT examination was done for only 42 patients. Correlative study between the above mentioned three methods was done and we found out that; CT yielded the highest incidence of abnormal findings among children presented with neurological deficits and in those with focal persistant EEG changes. It follows, that the three methods are complementery in the diagnostic work up of children with seizure disorders