Vest restraint palsy.

OBJECTIVE: Evaluate by electrophysiologic methods the cause of arm weakness and numbness in an agitated patient who struggled against a vest restraint garment. CASE PRESENTATION: An agitated patient with encephalitis required vest restraint and developed bilateral numbness of hands and weakness of distal upper extremity muscles. He was of thin stature and had abrasions in the axilla from the restraint straps. Routine nerve conduction and needle electromyographic needle studies were used to document bilateral conduction block of ulnar and median nerves between the elbow and Erb's point with minimal denervation. INTERVENTION: After identification of the vest restraint as the cause of neuropraxic palsies, adjustments were made to the vest straps. RESULTS: The symptoms and clinical signs began to resolve with adjustment of the vest restraint straps and completely resolved after the patient was no longer encephalopathic and was discharged from the hospital. CONCLUSIONS: Compressive nerve lesions in the axilla should be recognized as a potential complication of vest restraint, especially in combative patients.

Accelerated intracranial occlusive disease, oral contraceptives, and cigarette use.

We report clinical and angiographic features of accelerated intracranial occlusive disease resembling moyamoya vasculopathy in five young women who used oral contraceptives (OCs) and smoked cigarettes, but generally had no other obvious risk factors for cerebrovascular disease. Three women had been on OCs for at least 4 years, one woman each had been on OCs for 3 months and for 2 weeks. All five women had smoked cigarettes for at least eight pack-years. Intermittent and progressive multifocal cognitive, visual, motor, or sensory hemispheric symptoms and signs developed in all. All patients developed strokes, four preceded by transient ischemic attacks. Cerebral angiography demonstrated bilateral supraclinoid internal carotid artery stenosis in four patients and proximal posterior cerebral artery stenosis in one. Additional features included rete mirabile, telangiectasias, prominent lenticulostriate collaterals, and multifocal distal cerebral branch occlusions. Three had mild abnormalities of serum fibrinogen, antinuclear antibody, erythrocyte sedimentation rate, or CSF IgG. After discontinuing OCs and reducing cigarette use, four women have not had further strokes over a mean follow-up of approximately 5 years. In certain young women, clinical and angiographic features resembling moyamoya may develop with the use of OCs and cigarettes. We speculate that an immunologically mediated vasculopathy may explain, in part, this unusual cerebrovascular syndrome in otherwise healthy young women.

PIP: 5 cases of ischemic strokes in young women who used oral contraceptives and smoked cigarettes are described in clinical and angiographic detail, the risk factors for moyamoya disease are discussed in a review or strokes in pill users, and the notion that oral contraceptive and smoking may cause a moyamoya pattern of stroke is proposed. The women were aged 20-32, used the pill from 2 weeks-8 years, had smoked approximately 10-20 pack-years. 2 women had headaches and 4 had transient ischemic attacks before their multifocal symptoms in visual, somatosensory and motor function, language, speech and cognition. 2 had seizures. Angiographic patterns of either supraclinoid stenosis (4) or proximal carotid artery stenosis (1) with the collateral circulation characteristic of moyamoya disease were evident in all, but there was no evidence of hemorrhagic infarction. There were no signs of atherosclerosis. Subtle signs of an immunologic process included antinuclear antibody titer of 1:160 in 1 woman, elevated sedimentation rate and elevated circulating immune complexes in another patient, and elevated cerebrospinal protein and IgG in a third woman. 4 of the patients remained stable after stopping oral contraceptives and stopping or reducing smoking. The 5th, who continued smoking, had progressive symptoms for 10 years. It was suggested that antibodies to ethinyl estradiol, a possible cause of this disorder, be further investigated.

Myoclonus in adult Huntington's disease.

Two brothers with clinically definite adult Huntington's disease developed disabling myoclonus years after the first signs of the disease. Their electroencephalograms were consistent with a primary generalized epilepsy, although neither man had seizures. The myoclonus was controlled with valproic acid therapy.

"Effort" thrombosis of the subclavian vein in a competitive swimmer.

"Effort" thrombosis is a unique form of subclavian and axillary vein thrombosis because it is the result of an unusual variant of the thoracic outlet syndrome. Another cause of subclavian vein thrombosis is local compression from trauma, tumor, or development anomalies; a third is intimal damage from indwelling central venous catheters. This is a case report of "effort" thrombosis of the subclavian vein in a competitive swimmer. A recently developed technique of local infusion of low-dose streptokinase therapy is used for clot lysis. Early diagnosis is essential for effective thrombus dissolution with streptokinase. The rationale, risk, and method of streptokinase administration are discussed. Since "effort" thrombosis is secondary to thoracic outlet syndrome (TOS), decompression of the thoracic outlet by removal of the first rib after clot lysis is recommended.