Gait Disorders and Falls in the Elderly.

Gait disorders in the elderly may be based on a neurologic deficit at multiples levels, or may be secondary to nonneurologic causes. The physiology and pathophysiology of gait problems are reviewed and bedside examination and investigative tools are discussed. The reader will have an excellent working knowledge of the subject and will know how to diagnose and treat gait disorders and falls.

Angiographic Findings in the Tolosa-Hunt Syndrome and Resolution after Corticosteroid Treatment.

The Tolosa-Hunt syndrome is a rare clinical condition characterized by painful opthalmoparesis associated with idiopathic granulomatous inflammation of the orbital apex and cavernous sinus. Historically, this condition was thought to result from arteritic changes in the internal carotid artery and cavernous sinus. Modern digital angiographic techniques were unavailable when THS was initially described, and few reports exist on its high-resolution angiographic findings. Painful ophthalmoparesis, especially of the oculomotor nerve, warrants vascular imaging because of the concern for an underlying aneurysm. Here, we describe angiographic findings of THS which may be useful for clinicians when encountering patients presenting with painful ophthalmoplegia.

Vertebral artery compression of the medulla.

BACKGROUND: Intracranial arteries in the subarachnoid space may compress the brain parenchyma and cranial nerves. Most arterial compressive lesions have been attributed to dolichoectasia in the vertebral-basilar system, and prior reports have concentrated on the pressure effects of basilar artery ectasia. Much less is known about vertebral artery compression of the medulla. OBJECTIVE: To describe a series of patients with vertebral arteries compressing the medulla oblongata. DESIGN: Prospective case studies. SETTING: Tertiary care center. PATIENTS: Nine symptomatic patients, 4 men and 5 women, between the ages of 32 and 79 years. MAIN OUTCOME MEASURES: Clinical phenomena, radiographic findings, treatment, and outcomes. RESULTS: We found that compression most commonly occurs at the ventrolateral surface. The clinical features can be transient or permanent and are predominantly motor and cerebellar or vestibular, but a poor correlation exists between the clinical findings and the severity or extent of impingement. The vertebral arteries were angulated, tortuous, or dilated but not necessarily dolichoectatic to cause obvious indentation. Seven patients were treated with antiplatelets and anticoagulants or analgesics, whereas 2 underwent microvascular decompression, resulting in temporary or no relief. One surgical patient developed cranial nerve complications. Among the medically treated patients, none had progression of deficits, and those with single episodes had no recurrence of symptoms. CONCLUSION: This study is the largest collection, to our knowledge, of patients with medullary vascular compression. Further studies are needed to estimate its frequency, natural course, and preferred management.

On the coincidence of cervical spondylosis and multiple sclerosis.

Multiple sclerosis (MS) and cervical spondylosis are relatively common diseases. It is therefore inevitable that the MS clinician will be confronted with patients with myelopathy in whom the two conditions coexist. When faced with an MS patient who has cord compression secondary to cervical spondylosis as well as cord demyelination, the issue of surgical decompression of the cord arises. Whether the trauma of cord compression aggravates the MS lesions is still a matter of debate and should not influence treatment decisions. There is little prospective evidence-based support for the notion of surgical cord decompression in cervical spondylosis without MS, and none at all for surgery in MS, with only small published retrospective series available. The clinician must therefore make a judgment-based treatment decision. Guidelines for the management of patients with coincidental cervical cord compression and MS are suggested.