Idiopathic spinal cord hernia.

Idiopathic spinal cord hernia (ISCH) is a rare cause of slowly progressive spinal cord dysfunction. It is readily diagnosed on magnetic resonance imaging of the spine. The neurological deficit related to ISCH is often reversible once surgical exploration and reduction of the hernia is achieved. We present the case of a 37 year-old lady with a ventral ISCH at the T4 level. There was a significant post-operative improvement in her myelopathy post-operatively. ISCH should be considered in the differential diagnosis of progressive spinal cord neurological deficit.

Use of topically applied rt-PA in the evacuation of extensive acute spinal subdural haematoma.

Spontaneous spinal subdural haematoma is a rare cause of spinal cord compression, usually confined to a few vertebral levels. When the haematoma extends over several spinal segments, surgical decompression is a major undertaking. Recombinant tissue plasminogen activator (rt-PA) has previously been used in a number of surgical procedures, but not in the setting of acute spinal subdural haematoma. A minimally invasive technique of decompression, using topical rt-PA, is presented in two patients with extensive spinal intradural haematoma. Two patients receiving long-term anticoagulation therapy presented with acute-onset back pain progressing to paraparesis. Magnetic resonance imaging of the spine demonstrated spinal subdural haematomas extending over 15 vertebral levels in one patient and 12 in the other. An angiography catheter was introduced into the subdural space through a limited laminectomy. Thrombolysis and evacuation of haematoma was then achieved by intermittent irrigation of the subdural space with rt-PA, followed by saline lavage. Postoperative imaging demonstrated satisfactory decompression in both patients. There was significant improvement of neurological function in one patient. Topical application of rt-PA for spinal subdural haematoma allows evacuation of the haematoma through a limited surgical exposure. Decompression of the subdural space by this minimally invasive technique may be advantageous over extensive surgery by minimising surgical exposure, reducing postoperative pain and risk of neuronal injury. This technique may be useful in patients presenting with compression extending over several vertebral levels or poor surgical candidates.

Evaluation of patient knowledge regarding oral anticoagulants.

Warfarin sodium [Coumadin] is widely used since its introduction in 1954. The dosage varies from individual to individual and is subject to adjustment due to interactions with other medications and alcohol. It is therefore important for the patient to be educated fully regarding warfarin therapy as outside the narrow therapeutic range either failure to prevent thromboembolism or serious bleeding with potential fatal complications may occur. Patient comprehension of the risks of anticoagulation, tablet recognition skills and knowledge of complications of warfarin therapy were evaluated in 150 patients attending the anticoagulation clinic in a Dublin teaching hospital. The majority, 125 (83%) perceived that they had received education about the therapy. Concomitant aspirin was avoided by 125 (83%) patients, but 25 (17%), thought it safe in combination with warfarin; 33 (22%) believed that alcohol was safe in combination with warfarin. When asked about the colours and strengths of warfarin tablets, 125 (83%) patients identified the 1 mg tablet correctly. Only 105 (70%) identified the 3 mg tablet and 98 (65%) the 5 mg tablet correctly. In 42 (28%), patients could not describe their current therapy. Potential complications from over- and under-dosage with warfarin were unknown to 89 (59%) and 90 (60%) patients respectively. This study suggests that patient knowledge regarding anticoagulation therapy is not optimal. A significant group may be at risk from serious complications because of inadequate knowledge. We suggest improving patient knowledge may improve control, reduce complication and therefore reduce the burden on the health service.

Screening for familial intracranial aneurysm: resource implications.

In this descriptive study, we estimate the resource implications of screening 18-65 year-old first degree relatives of patients with a first degree family history of intracranial aneurysm (IA). A postal survey of 374 patients who underwent operative clipping of IA between July 1994 and June 1997 was performed, enquiring about first degree family history of IA and first degree family structure. The response rate was 68.2% (255/374). Thirty-five out of 255 patients (14.0%) reported IAs in first degree relatives and 21 (8.2%) in second degree relatives giving a total of 57 (22.0%) with a reported family history. The average number of screenable relatives currently living in Ireland was 5.6 per high-risk family. Assuming a national prevalence of 0.45% for ruptured IA, these data give a point prevalence for high-risk families of 816 in the Republic of Ireland (1996 census population 3.6 x 10(6). Thus, the number of currently screenable relatives (5.6 per family) is 4814. A 15% yield has previously been reported from screening of first degree relatives in Northern Ireland. A national screening programme should thus detect over 700 individuals with asymptomatic IAs. The time required to screen the screenable population once would be 2.3 years by digital subtraction angiography (DSA) and 1.1 years by magnetic resonance angiography (MRA). In order to detect de novo aneurysms, screening has been suggested in this suspect population at 6-monthly to 5-yearly intervals after the initial study. In the absence of a biological marker, the results of our survey suggest that screening for familial IA disease would pose a significant logistical burden and have major financial implications for health care services.