Successful pregnancy with isolated herpes simplex virus encephalitis: case report and review of the literature.

Isolated herpes simplex virus encephalitis in pregnancy is a rare illness with an elusive diagnosis. We describe the second patient to survive this disease and the first to have no sequelae, because of prompt diagnosis and treatment with acyclovir.

Leukoencephalopathy in normal and pathologic aging: 2. MRI of brain lucencies.

A pilot study was performed to test the ability of MR to evaluate the brain lucencies shown by CT in Alzheimer disease patients and in normal control subjects. Eight patients with presumed Alzheimer disease and 47 normal controls, 12 over the age of 45 years and 35 under age 45, were studied. Each group included subjects with and without CT evidence of leukoencephalopathy. Inversion recovery, saturation recovery, and spin-echo scans were obtained using a 0.3-T permanent magnet prototype unit. Results indicated that MR was more sensitive than CT to parenchymal disease. Seven of the eight patients with Alzheimer disease showed patches of increased signal intensity on SE scans; only three had lucencies on their CT studies. None of the normal subjects under the age of 45 showed periventricular patches of increased SE signal intensity. T2-weighted SE imaging was performed in nine of the 12 normal subjects over 45 years old. Eight of the nine demonstrated periventricular patches of increased SE signal intensity. Faint CT lucencies were present in only one of these. The configuration of the patches of increased signal intensity was similar for both the normal and Alzheimer groups, but the extent of white-matter involvement was greater in the Alzheimer group.

Comparative efficacy of pergolide and bromocriptine in patients with advanced Parkinson's disease.

Treatment with pergolide was compared with bromocriptine in 25 patients, all of whom were also receiving levodopa and in all of whom the response to levodopa had diminished. All 25 patients had "on-off" phenomena. At the time bromocriptine was added to levodopa, the mean age of the patients was 61.8 years, mean duration of disease was 9.0 years, and mean duration of levodopa treatment was 6.1 years. For the group as a whole, disability as determined in the "on" period decreased by 36%, from 28.7 to 18.5; and 11 patients improved at least one stage. Disability as determined in the "off" period decreased by 25%, from 59.5 to 44.4. The number of hours in which patients were "on" increased by 62%, from 7.1 to 11.5. All of these changes were significant (p less than or equal to 0.05). Bromocriptine had to be discontinued in nine patients (eight because of mental changes). In the remaining 16 patients, bromocriptine was eventually discontinued because of diminishing efficacy. Mean dose of bromocriptine was 50 mg (range, 10-100 mg), and mean duration of treatment was 23 months (range, 2-65 months). At the time of their treatment with pergolide, the patients were older, 65.5 years, had the disease longer, 12.7 years, and were more disabled. Nonetheless, for the group as a whole, disability score as determined in the "on" period decreased significantly by 40%, from 43.5 to 26.3, and 14 patients improved at least one stage. Disability as determined in the "off" period decreased significantly by 21%, from 69.0 to 54.8. The number of hours in which patients were "on" increased significantly by 224%, from 3.4 to 11.0 hr. The mean dose of pergolide was 2.1 mg (range, 0.1-10.0 mg), and the mean duration of treatment was 6.2 months (range, 0.5-20 months). Pergolide was discontinued in eight patients: three because of asymptomatic tachyarrhythmias of unknown clinical significance (detected only by Holter monitoring); two because of orthostatic hypotension; and two because of mental changes. Although pergolide appears to be more potent than bromocriptine because of its greater effect in a larger number of patients at a more advanced stage of their disease, both drugs are useful, and both enhance our ability to manage patients with PD.

Dementia in Parkinson Disease.

In 520 patients with parkinsonism seen over eight years, 168 (32%) had moderate to marked dementia. Although the demented patients were older than the nondemented patients (70.4 versus 65.5 years), the incidence of dementia in Parkinson's disease (PD) was tenfold higher than among controls (similarly aged spouses of PD patients), and dementia is held to be related more to the disease than to age. Demented patients, in addition to being older, developed PD later, were more severely involved in a shorter time, and responded less well to levodopa. It is suggested that PD with dementia may represent a different disorder from PD without dementia.

Bromocriptine in Parkinson disease: further studies.

Bromocriptine was administered to 66 patients with advanced Parkinson disease (PD) and increasing disability despite optimal treatment with levodopa/carbidopa (Sinemet). Forty-five patients tolerated at least 25 mg per day of bromocriptine (the "adequately treated" group) in addition to Sinemet and had significantly decreased rigidity, tremor, bradykinesia, gait disturbance, and total score, but increased involuntary movements. Twenty-five of these 45 patients improved by at least one stage. Among the 45 patients, 27 had "on-off" effects, and in 19 the "on-off" effects decreased on bromocriptine. The mean dose of bromocriptine in adequately treated patients las 47 mg, permitting a 10 percent reduction in the dose of levodopa. Twelve adequately treated patients received bromocriptine for at least 1 year, and 8 continued for longer than this. Bromocriptine was discontinued in 29 of 66 patients because of adverse effects, including mental changes (14 patients) and involuntary movements (9 patients). All adverse effects were reversible. Despite adverse effects, expense, and scarcity, bromocriptine, when added to levodopa, is useful in patients with advanced disease who no longer respond satisfactorily to levodopa, and for whom no other treatment is available.

Lergotrile in Parkinson disease: further studies.

Lergotrile was administered to 53 patients with advanced Parkinson disease (PD), who had increasing disability despite optimal treatment with levodopa/carbidopa (Sinemet). Thirty-nine patients who could tolerate at least 20 mg per day lergotrile (thus considered "adequately treated") had significant descreases in rigidity, tremor, bradykinesia, gait disturbance, and total score without increased involuntary movements. Twenty-one of these 39 patients improved by at least one stage. Among the 39 patients, 23 had "on-off" effects, and in 13 of these the "on-off" effects decreased on lergotrile. The mean daily dose of lergotrile in adequately treated patients was 49 mg, permitting a 10 percent reduction in the dose of levodopa. Lergotrile was discontinued in 33 of the 53 patients because of adverse effects, including hepatotoxicity (11 patients), mental changes (12 patients) and orthostatic hypotension (8 patients). Although lergotrile, when added to levodopa, has a definite antiparkinsonian effect, the incidence of adverse effects, particularly hepatotoxicity, makes it unlikely that this ergot alkaloid will become widely available for the treatment of PD. Analogues of lergotrile have been synthesized, and it is hoped that they will duplicate the antiparkinsonian effect of this drug without its toxicity.

Use of high dose corticosteroids in patients with inoperable brain tumours.

Eleven patients with inoperable brain tumours were treated with high doses of corticosteroids (methylprednisolone 200-2000 mg/day) for up to 151 days (mean 55 days). Neurological improvement occurred in eight patients on high doses after deterioration on concentional doses (methylprednisolone 80-120 mg/day). In two patients steroids could be completely discontinued for several months. Serious adverse effects included sepsis in three patients and myopathy in tow. All three patients with sepsis also received chemotherapy. There were no deaths that could be attributed to steroids. The most likely effect of high dosage steroids is reduction of cerebral oedema. It is conceivable that in some instances high dose steroids may also result in tumour inhibition or oncolysis or both.

Ruptured intracranial aneurysms. Case morbidity and mortality.

The authors review 100 consecutive cases of ruptured intracranial aneurysms to assess the overall morbidity and mortality. Patients were placed on a regimen of bed rest, sedation, control of blood pressure, anticonvulsants, and antifibrinolytic therapy. Surgery was performed on 86 patients with hypotensive anesthesia and microsurgical techniques. The incidence of early rebleeding while on epsilon aminocaproic acid and control of blood pressure was 11.8%. The overall surgical mortality was 8.1%, and the surgical mortality of patients in Grades 1, 2, and 3 was 6.3%. Of the 100 patients, 60 were able to return to their prior activities, and 25 had moderate neurological deficits that required limitation of their activities. The total case mortality was 15%. The evidence presented indicates that the regimen of active medical treatment before microsurgical intervention has improved the overall case morbidity and mortality, as well as the chance for long-term survival.

Comparison of dopa decarboxylase inhibitor (carbidopa) combined with levodopa and levodopa alone in Parkinson's disease.

A double-blind study comparing the effects of carbidopa and levodopa combined in a single tablet with levodopa alone was undertaken in 50 patients with Parkinson's disease. After 6 months, there was a statistically significant improvement over baseline in total score, rigidity, and tremor only in the patients randomized to carbidopa/levodopa. In addition, 40 percent of the patients treated with carbidopa/levodopa showed obvious clinical improvement (a greater than 50 percent reduction in their total score) over treatment with levodopa alone. However, after 2 years, only 20 percent continued to show this improvement. Nausea, vomiting, and anorexia developed in 56 percent of patients on levodopa but in only 27 percent of patients on carbidopa/levodopa. However, abnormal involuntary movements, observed in 48 percent of patients on levodopa, were present in 77 percent of patients on carbidopa/levodopa. Despite the increase in abnormal involuntary movements, carbidopa/levodopa is more effective than levodopa.