Transcranial magnetic stimulation but not MRI predicts long-term clinical status in cervical spondylosis: a case series.

STUDY DESIGN: Case series. OBJECTIVE: To compare transcranial magnetic stimulation (TMS) and magnetic resonance imaging (MRI) findings between patients who underwent surgery for cervical spondylotic myelopathy and those with spondylosis who were not operated upon, and to correlate these findings with clinical functionality at follow-up. SETTING: Private practice. METHODS: Of 16 consecutive patients with cervical spondylosis 8 underwent surgery (group I) and 8 were treated conservatively (group II). We compared TMS and MRI findings between these groups and we correlated central motor conduction times (CMCTs) and MRI-measured sagittal and parasagittal diameters of the spinal canal at baseline evaluation, with clinical functionality at 2-year follow-up. RESULTS: Group I CMCTs at the lower limbs correlated significantly with modified-JoA 2 years post surgery (r=-0.71, P<0.05), but MRI-measured diameters did not. In group II baseline TMS was unrevealing, contrary to significant spinal stenosis disclosed by MRI. The condition of none of these patients deteriorated at 2 years. CONCLUSIONS: CMCTs at the lower limbs, but not cervical spinal canal diameters, correlate with long-term functional outcome following surgical or conservative treatment.

Using vestibular evoked myogenic potentials to localise brainstem lesions. A preliminary report.

BACKGROUND: Vestibular Evoked Myogenic Potentials (VEMPs) are saccular responses to acoustic stimuli. They can be recorded from the sternocleidomastoid muscle ipsilaterally to the stimulated ear. Their reflex arc includes the ipsilateral vestibular nuclei. OBJECTIVE: To determine the usefulness of VEMPs in localising brainstem lesions. METHODS: We used VEMPs, Blink Reflex (BR) and Brainstem Auditory Evoked Responses (BAERs) to evaluate six patients presenting with acute ischaemic or haemorrhagic brainstem lesions, or basilar dolichoectasia. RESULTS: MRI in patient one revealed a dorsolateral medullary infarct on the right. VEMP amplitude was reduced ipsilaterally. The R2 BR component was delayed bilaterally upon stimulation of the affected side. Patients two and three had suffered a left lateral lower pontine infarct and a right lateral lower pontine haemorrhage. In patients four and five, MRA revealed dolichoectasia of the basilar artery exerting pressure on the lower lateral pons. VEMP amplitude was reduced ipsilaterally. Patient six had an ischaemic lesion in the right upper lateral pons. The R1, R2i and R2c BR components were delayed ipsilaterally. BAERs waves IV and V were absent on the right. VEMPs were normal. CONCLUSIONS: VEMPs are affected by lesions of the lateral lower pons and upper medulla. Our results suggest that they may be a useful addition in the localisation of such lesions.

Neurophysiological monitoring of brainstem function in a patient with Wallenberg syndrome, using Vestibular Evoked Myogenic Potentials.

PURPOSE: We evaluated the use of Vestibular Evoked Myogenic Potentials (VEMPs) in the assessment of neural function, following medullary lesions. METHODS: A 54-year-old male presented with symptoms and signs typical of right lateral medullary (Wallenberg) syndrome. He underwent brain MRI and three successive neurophysiological investigations, which included VEMPs, Brainstem Auditory Evoked Responses (BAERs) and the blink reflex. RESULTS: VEMPs amplitude on the left (unaffected) side was 256.8 microv in the first investigation and remained approximately equal to that value in the following two ones. Their amplitude on the right (affected) side was 37.9 microv, 154.2 microv and 235.2 microv correspondingly. At the same time vertigo, diplopia and nystagmus gradually improved. Right blink reflex comprised a normal R1, but delayed R2 ipsilateral and R2 contralateral responses, which remained unaltered during the follow-up period. Brain MRI disclosed a right dorsolateral medullary infarct. CONCLUSIONS: VEMPs amplitude progressively increased, parallel to the improvement of vestibular symptoms. The blink reflex evolved differently, while BAERs were not affected. As the three evoked responses are mediated by separate neural circuits, they provide information on different aspects of brainstem function. Thus, VEMPs seem to be a useful method that complements existing ones in the assessment of brainstem lesions.

Waldenström's macroglobulinemia developing in a patient with multiple sclerosis: coincidence or association?

Multiple sclerosis (MS) has been reported in association with haematological abnormalities, including monoclonal gammopathies. We present a 54-year-old male patient with a 30-year history of MS who was admitted to our hospital for investigation of anaemia and increased erythrocyte sedimentation rate. A monoclonal IgM protein was detected by serum protein immunofixation, while bone marrow biopsy indicated a 70% infiltration by small lymphoplasmacytoid cells, in the context of a lymphoplasmacytoid immunocytoma, findings compatible to the diagnosis of Waldenström's macroglobulinemia (WM). To our knowledge, this is the first report of WM in a patient with MS. Further to the coexistence of the two diseases observed in the case presented here, there is additional evidence suggesting that the association of MS with plasma cell dyscrasias may not be coincidental.

A macro-directive mechanism that facilitates automatic updating and processing of the contents of Electronic Healthcare Records: an extension to the CEN architecture.

Facilitating data entry, eliminating redundant effort and providing decision support are some of the factors upon which the successful uptake of Electronic Healthcare Record (EHCR) technology is dependent. The European Standardization Committee (CEN), on the other hand, has proposed a standard EHCR architecture, which allows patient record contents to be highly diverse, customized to individual user needs; this makes their processing a challenging task and poses a demand for specially designed mechanisms. We describe the requirements for a macro-directive mechanism, pertaining to CEN-compatible EHCR software that can automate updating and processing of patient records, thus enhancing the functionality of the software. We have implemented the above-mentioned mechanism in an EHCR application that has been customized for use in the care process of patients suffering from beta-Thalassemia. The application is being used during the last two years in the Thalassemia units of four Greek hospitals, as part of their every day practice. We report on the experience we have acquired so far.