Postoperative supplementary motor area syndrome: clinical evolution and prognosis in nine patients after left hemispheric tumor resection.

BACKGROUND: The postoperative supplementary motor area (SMA) syndrome may complicate unilateral surgery involving the SMA cortex and manifests as contralateral or global akinesia, mutism, or speech deficit, with complete or major recovery in weeks to months. CASE SERIES: We observed retrospectively nine patients (median age 47 years, range 27-60, five female) who underwent surgery for left premotor area tumors (six intra-axial and three extra-axial). Volumetric microsurgical resection was performed with neuro-navigational assistance (Vector Vision-BrainLab™ or SonoWand Invite™). We achieved gross or near gross total resection in all cases. The patients were followed clinically for one year, with control computed tomography scan within 24-48 hours from the operation and control magnetic resonance imaging three months and one year postoperatively. Five patients had only akinesia of the contralateral limbs, two had akinesia and mutism, and the remaining two had mutism only. All recovered within three months. The severity and duration were related to the location of resection rather than the volume removed. Cortical excision closer to the premotor area was related to more prominent SMA syndrome, while the cingular gyrus' involvement related to mutism. CONCLUSION: Prevention of SMA syndrome is not always possible in resective surgery. Given its favorable prognosis, it should be well known to the health professionals of different specialties engaged in such patients' postoperative care. The possibility of SMA should be preoperatively discussed with the patients and caregivers. HIPPOKRATIA 2020, 24(1): 38-42.

Botulinum toxin A for palmar hyperhidrosis: assessment with sympathetic skin responses evoked by train of stimuli.

Objective assessment of the effect of botulinum toxin A (BT) treatment in primary palmar hyperhidrosis (PH) is attempted by different methods. We decided to use for this purpose sympathetic skin responses evoked by train of stimuli (TSSR). Twenty patients with severe PH (five female, median age 24, range 18-36) were examined regularly over 3 months after receiving 50 UI BT in each palm. TSSR were recorded from the palms after sensory stimulation by a train of three supramaximal electric pulses 3 millisecond apart. Results were compared to longitudinally studied TSSR of 20 healthy sex- and age-matched control subjects. All hyperhidrosis patients reported excellent improvement. TSSR amplitudes decreased at week 1 (mean 54% range 48%-67%) and over the following months in a clinically significant trend (slope R=-.82, P<.0001). TSSR in controls changed insignificantly (±13% from the baseline). The difference between patients and controls was highly significant at any time point (P<.001). This study suggests that TSSR may help in assessment of treatments in PH. It confirms objectively the efficacy of BT in PH.

Clinical and EMG findings in patient with mononeuropathy multiplex associated with livedo reticularis: a case report.

We report on the combination of biopsy-proven idiopathic livedo reticularis and mononeuropathy multiplex, mild to moderate in severity and remitting-relapsing in course, observed in a young otherwise healthy woman. Neurologic relapses were always accompanied or preceded by exacerbation of the skin lesion. After 18 years followup we did not detect clinical or instrumental evidence of brain or visceral involvement. This excludes the classical Sneddon's syndrome and points at an unusual variant of this syndrome in our patient.

The "Child in the Barrel syndrome"--severe pharyngeal-cervical-brachial variant of Guillain-Barre Syndrome in a toddler.

One week after a flu-like prodrome, an 18-month-old boy developed acute severe, symmetrical, painless weakness and wasting of the shoulder girdle and upper limbs, drooling, dysphagia, dysarthria, atrophy and fasciculations of the tongue. Milder paresis involved the mimic muscles and the neck extensors. The legs were intact with brisk reflexes. The flail immobile upper limbs produced the appearance that the boy was restrained in a narrow barrel. Electrodiagnostic findings suggested demyelinating motor neuropathy sparing the legs. CSF (45 days after onset) was normal. Initial recovery was observed but 70 days after onset the child suffered severe relapse and died from respiratory arrest. This is another rare case of the pharyngeal-cervical-brachial variant of Guillain-Barre syndrome in infancy with an unusual relapsing course leading to a fatal outcome.

Correlation between cognitive P300 changes and the grade of closed head injury.

OBJECTIVE: To investigate the use of auditory oddball cognitive P300 changes in an attempt to find out the correlation between the grade and consequences of closed head injury. MATERIALS AND METHODS: Twenty patients with cerebral concussion (mean age 38.5 +/- 10.5 years) and twenty patients with cerebral contusion (mean age 35.5 +/- 9.8 years) underwent auditory oddball P300 investigation within 0.5 - 28 months after the incident. CT was performed in all of patients before P300 testing. The control group consisted of 30 healthy persons, age and sex matched to the study cohort. RESULTS: All of the patients with concussion showed normal results in P300. Sixteen cases with contusion (80%, CI 62.5-97.3%, p < 0.05) revealed abnormal P300 (latency more than 360 msec and absent P300 response in 4 cases). CONCLUSION: Years after the head injury, cognitive P300 changes make cerebral contusion objective.

Lower limb SSEP changes in stroke-predictive values regarding functional recovery.

OBJECTIVE: To assess the predictive value of lower limbs somatosensory evoked potentials (SSEPs) in the acute phase of stroke. MATERIALS AND METHODS: 94 stroke patients (mean age: 61.2; S.D.: 11.8; 43 women) were included. Computed tomography confirmed diagnosis was cortical middle cerebral artery (MCA) infarction in 35, subcortical MCA in 11, and mixed in 25. By size, infarctions were large (29), limited (33), and lacunar (9). Thalamic haemorrhage was found in eight patients, putaminal in seven, small capsular in two, massive in two and lobar in four patients. All patients presented with hemiparesis (54) or hemiplegia (40), pure in five and combined with hemihypesthesia in 89. Tibial nerve SSEPs were recorded early in the course of the disease (up to third day). SSEP parameters (presence/absence of SSEP, absolute P40 latency, amplitude and amplitude ratio-affected/healthy side of P40-N50) were evaluated and compared with motor ability using the Medical Research Council (MRC) scale, and daily living activities using Barthel index (ADLB) followed for 3 months after stroke. Disability was assessed after the Rankin scale. RESULTS: The absolute amplitude of P40 has moderately strong correlation with Barthel index (r=0.63) and nearly moderate (r=-0.46) with Rankin scale at 3 months. P40 ratio exhibits weaker correlations with clinical outcome parameters. The combination of SSEP abnormalities and MRC has stronger predictive value than MRC alone (P<0.0001 vs P<0.03). CONCLUSIONS: Tibial SSEP investigation early in stroke, independently or combined with muscle power assessment, significantly increases prognostic capability.