Outcomes from the use of computerized neurocognitive testing in a recurrent glioblastoma clinical trial.

Assessment of neurocognitive function (NCF) is important in brain tumor clinical trials, however there are varying methodologies available. We used the Cogstate computerized NCF testing battery and the mini-mental state examination (MMSE) to prospectively assess cognition in adult patients with recurrent glioblastoma (GBM) enrolled in the CABARET randomized phase II clinical trial of bevacizumab versus bevacizumab plus carboplatin chemotherapy. We determined completion rates; compared NCF results between trial arms; and assessed baseline NCF as a predictor of survival outcome. 93 of 103 eligible patients completed baseline Cogstate NCF testing. Completion rates were between 60 and 100% across each timepoint, and 38% at disease progression. There was no evidence of difference between arms in time to deterioration in NCF using either test. Prior to disease progression, deterioration on the Cogstate tests was substantially more common (90%) than deterioration on the MMSE (37%), and decline in the Cogstate composite score within the first 8 weeks was associated with shorter overall survival. This testing methodology may be useful when determining net clinical benefit for therapies in patients with recurrent GBM.

Cancer and the nervous system.

Brain tumours should be considered when patients present with headache with diurnal variation, seizures, or progressive neurological symptoms. Spinal cord compression by tumour is a medical emergency. Prognosis for patients with glioma is better in those with tumours of low grade, and in patients younger than 50 years and with higher functional levels. Surgery, radiotherapy and chemotherapy can improve survival for patients. Anticancer therapies can have neurotoxic side effects.

Cancer associated retinopathy and non-small cell lung cancer.

The syndrome of cancer associated retinopathy is a relatively recently described entity that has characteristic clinical and electrophysiological features. It is most closely associated with small cell carcinoma and a specific antibody against a retinal protein. We present a patient with cancer associated retinopathy and a non-small cell lung cancer. The diagnosis of the clinical syndrome led to the discovery of the tumour. The antibody was not present. Therapy with chemotherapy, corticosteroids and plasma exhange did not improve the retinopathy. Earlier recognition of the syndrome may be important in detecting malignancy and attempting treatment of the retinopathy before irreversible damage is done.

Therapy for paraneoplastic neurologic syndromes in six patients with protein A column immunoadsorption.

BACKGROUND: Paraneoplastic neurologic syndromes, although rare, cause significant morbidity and mortality. They are thought to be immunologically mediated, but to date those involving the central nervous system (CNS) have not been particularly responsive to immunologic therapy. The use of the novel immunomodulator, protein A immunoadsorption, was explored to address this question. METHODS: Six patients with neurologic paraneoplastic syndromes were treated with this technique, using the "off line" method. Two hundred fifty ml of plasma was perfused through a column containing protein A covalently attached to a silica matrix. The plasma was then returned to the patient. RESULTS: Five of the patients responded to the therapy, with complete and durable responses in three patients with opsoclonus-myoclonus, objective, though transient, improvement in one patient with paraneoplastic brainstem encephalitis associated with a Merkel cell tumor, and stabilization and partial improvement in one patient with paraneoplastic limbic encephalitis. The patient without response developed a cutaneous vasculitis after the second treatment, and therapy was discontinued. CONCLUSIONS: This therapy appears beneficial for a number of paraneoplastic syndromes, most dramatically in the opsoclonus/myoclonus syndrome.

Miller Fisher syndrome mimicking stroke in immunosuppressed patient with rheumatoid arthritis responding to plasma exchange.

A patient with rheumatoid arthritis on immunosuppressive therapy was admitted to hospital with the sudden onset of diplopia and ataxia. Because of the history, a stroke was thought most likely. However, as he progressed a diagnosis of the Miller Fisher syndrome was established. He responded to plasma exchange. This presentation is highly unusual and has not previously been described. In addition, the possibility of immune dysregulation setting the stage for the development of this syndrome is discussed. The role of plasma exchange for this condition is also reviewed.

Subdural haematoma presenting with transient neurological deficits.

OBJECTIVE: To stress that transient neurological deficits do not always imply transient cerebral ischaemia, and may be produced by subdural haematoma. CLINICAL FEATURES: An 80-year-old man was seen for intermittent gait disturbance, with normal findings on initial examination. He was then admitted after the onset of a fixed neurological deficit which worsened. Subdural haematoma was diagnosed by computed tomography (CT). An 80-year-old woman was seen after she had experienced left hemisphere transient neurological deficits. A CT scan showed a left-sided subdural haematoma. INTERVENTION AND OUTCOME: Both patients underwent successful surgery with complete resolution of their symptoms and signs. CONCLUSION: Subdural haematoma is relatively common and must be considered in those with unexplained transient neurological deficits. Magnetic resonance imaging or CT are the diagnostic procedures of choice. Antiplatelet or anticoagulant therapy must not be instituted until subdural haematoma is excluded.

Comparison of transcranial Doppler with DSA in vertebrobasilar ischaemia.

To determine the role of transcranial doppler (TCD) in the evaluation of the vertebrobasilar circulation, we compared the results of TCD with intraarterial digital subtraction angiography (DSA) in 20 patients with vertebrobasilar ischaemia (VBI). TCD had a sensitivity of 87%, a specificity of 80%, a positive predictive value of 93% and a negative predictive value of 67%. It was also able to give functional data when combined with arteriography and correctly identified the main pathology in 92% of those with abnormal TCD and angiogram. The 2 patients with false negative TCD had vertebral artery occlusion, which may be missed because of the signal from adjacent arteries. TCD may be a useful screening method in patients with VBI for the detection of large vessel occlusive disease of the intracranial vertebrobasilar system. It is important to remember that proximal vertebral artery stenoses will be missed by TCD.