The clinicoradiological profile of cerebral venous thrombosis.

The clinical presentation, diagnostic and radiological aspects and the probable aetiology in 20 consecutively studied patients with cerebral venous thrombosis (CVT) are described. In this retrospective analysis patients were evaluated extensively according to a stroke investigative protocol. Computed tomography signs for CVT may be identified in the majority of cases and frequently obviate the need for angiography. In those patients in whom no satisfactory precipitating factor was recognised further haematological tests revealed abnormalities that are known causes of thrombosis in 7 patients. Eighty-five per cent of the patients made an excellent recovery. It is concluded that CVT can often be diagnosed non-invasively, the presumptive cause can be found in the majority of patients and the prognosis is excellent.

Spinal cord schistosomiasis. A clinical, laboratory and radiological study, with a note on therapeutic aspects.

Fourteen patients with schistosomiasis of the spinal cord are described. They fall into two groups: 7 patients had clinical and computer-assisted myelographic evidence of lesions in the conus medullaris or cauda equina, or both. The clinical picture in the remaining 7 patients was usually that of acute or subacute transverse myelitis with normal or equivocal CT myelographic appearances. Granulomas containing bilharzial ova were found in 2 female patients with conus swelling subjected to laminectomy and biopsy. In 1 of these the ova were identified as S. haematobium while in the second, unidentified bilharzial ova were found. A presumptive diagnosis of spinal cord schistosomiasis was made in the remaining 12 patients based on characteristic clinical and investigative profiles. All 13 patients tested showed evidence of bilharzial infection based on positive blood serology or the detection of bilharzial ova, or both. All but 1 patient showed at least one of the following abnormalities on CSF examination: pleocytosis, an elevated protein content and as indicated by the presence of oligoclonal IgG bands, an elevated IgG index and an increased CSF IgG synthesis rate. A CSF bilharzia enzyme-linked immunosorbent assay (ELISA) test, developed to indicate the presence of schistosomal infection within the theca, was found to be sensitive although not entirely specific for the diagnosis of spinal cord schistosomiasis. Eleven of the 14 patients showed rapid clinical improvement, 8 after praziquantel and corticosteroid treatment, 2 after operation and 1 spontaneously. Significant reductions in the CSF cell count, protein concentration and bilharzia ELISA titre, and in intrathecal antibody production, occurred following praziquantel and corticosteroid therapy. The CSF sugar level showed a significant rise. A reduction in conus size was observed in 3 patients when CT myelography was repeated after medical therapy. The normalization of most of the laboratory parameters after combined medical treatment with praziquantel and corticosteroids, together with clinical and radiological improvement, strengthened the presumptive diagnosis of cord schistosomiasis and supports the policy of early intensive medical treatment (as opposed to surgical therapy) for this condition when diagnosed on indirect evidence.

The value of immunological approaches to the diagnosis of schistosomal myelopathy.

Myelopathy due to schistosome infection is a rare, yet probably frequently unrecognized, form of schistosomiasis. This condition is clinically difficult to diagnose, and without specific biopsy evidence final confirmation relies largely on circumstantial evidence. We describe here immunological attempts to diagnose schistosomal myelopathy. ELISA performed on the cerebrospinal fluid (CSF) was the most successful, detecting 12/12 cases tested prior to or within one month of treatment. This is based on a "normal" value established on neurological patients without myelopathy. Only 13/149 non-schistosomal myelopathy patients from an endemic area gave positive results in this test. Oligoclonal bands were detected in the CSF of 5/9 schistosomal myelopathy patients and 11/18 cases of myelopathy of other known causes, but in 0/7 cases of myelopathy where the cause was not established. Western blotting was unable to distinguish between myelopathy due to schistosomiasis and other causes. It is recommended that the ELISA be performed on CSF and the results be compared with a "normal" level for neurological patients. In our laboratory this system gives a high sensitivity and a negative result can be confidently used to exclude schistosomal myelopathy.

Myelopathy associated with human T cell lymphotropic virus type I (HTLV-I) in natal, South Africa. A clinical and investigative study in 24 patients.

Unexplained spastic myelopathy in black (Zulu) patients, similar to that seen in the tropics, has previously been described from Natal, South Africa. Following reports linking the human T cell lymphotropic virus type I (HTLV-I) to spastic myelopathy, we undertook a prospective and retrospective search for HTLV-I antibodies in 36 patients who were labelled as having unexplained myelopathy; 24 (66%) were positive and HTLV-I was isolated from 4 out of the 6 patients whose peripheral blood lymphocytes were cultured. Eighteen (75%) gave a short history (less than 6 months). There was a female preponderance (71%), spinothalamic dysfunction was common (55%) and as many as half were severely disabled (50% wheelchair bound). Routine laboratory studies showed no specific trends apart from hypergammaglobulinaemia and CSF pleocytosis (greater than 5 cells/microliter in 66% of patients). The total CSF protein was raised (greater than 0.4 g/l) in 45% of patients. The IgG index was greater than 0.7 in 15 of 19 patients. Conventional myelography did not show any specific abnormalities. Computer assisted myelography was undertaken in 22 patients; 3 showed arachnoiditis and 2 spinal cord atrophy. Periventricular lucencies were seen in 1 of 10 patients who had computed tomography of the head. Nerve conduction studies demonstrated abnormalities in 46% of the patients indicating that subclinical peripheral nerve dysfunction was common. Visual evoked responses were abnormal in only 1 patient but brainstem auditory evoked response studies showed some abnormality in 42% of the patients. The finding of HTLV-I antibodies in a significant number, and the isolation of HTLV-I from the blood in 6 of our black patients with noncompressive myelopathy, represents a substantial clinical advance. Future studies should define more clearly the role of the virus in this disorder.