Hemiplegic migraine during pregnancy: unusual magnetic resonance appearance with SPECT scan correlation.

OBJECTIVE: This article discusses the pathophysiology and implications for treatment of hemiplegic migraine within a case study presentation. BACKGROUND: We evaluated a 31-year-old white woman for hemiplegia in her 36th week of pregnancy. She initially presented with severe headache, dysarthria, lethargy, and left-sided numbness and weakness. Hemiplegic migraine remains a diagnosis made by exclusion; neurologic examination of these patients is localizing, but nonspecific. DESIGN: Magnetic resonance imaging and single photon emission computed tomography scanning were performed on this patient during an exacerbation of headache associated with dense hemiplegia. RESULTS: Magnetic resonance imaging showed a superficial cerebral hemispheric signal abnormality with enhancement. Single photon emission computed tomography scanning confirmed hyperperfusion of that hemisphere. CONCLUSIONS: We believe the imaging evidence in our patient suggests that hemiplegia was caused and sustained by hyperperfusion. This case lends supportive evidence to a primarily vasodilatory mechanism and hyperperfusion as an etiology of the paralysis in such headaches and perhaps migraine with aura.

Outcome of severe brain injury: a multimodality neurophysiologic study.

We screened all head-injured trauma patients admitted to Lehigh Valley Hospital during a 2-year period. From 725 screened patients, 69 patients in a coma on the second day after trauma were entered into this study. During the first week, these patients underwent electroencephalography (EEG), evoked potentials, ocular pneumoplethysmography, and transcranial Doppler (TCD) sonography. Clinical examinations were undertaken 2 and 7 days after trauma. Test results were correlated with functional clinical outcome at 6 months. In a multiple regression analysis, EEG was the major independent variable that significantly predicted 6-month outcome based on Glasgow Outcome Scale score. Transcranial Doppler sonography contributed a small additional component. Though EEG was the most significant predictive factor in this neurophysiological battery, it did not add significantly to the predictive power of Glasgow Coma Scale score determined at day 7. These findings suggest that in neurophysiologic testing in this type of patient is not useful in improving predictive outcome data.

Internal carotid artery redundancy is significantly associated with dissection.

BACKGROUND AND PURPOSE: Redundant internal carotid arteries have been considered a risk factor in tonsillectomy, adenoidectomy, and surgical treatment of peritonsillar abscess and also a potentially treatable cause of stroke. However, an association between internal carotid artery redundancy and spontaneous dissection has not yet been clearly demonstrated. METHODS: We reviewed, for spontaneous carotid artery dissection, records of all patients admitted to our institution during the period from 1986 through 1992 with the diagnosis of stroke or transient ischemic attack. We also reviewed 108 percutaneous cerebral arteriograms performed between September 1992 and December 1992 for presence of carotid artery redundancies. RESULTS: Thirteen patients exhibited spontaneous dissection. Of these, 8 of 13 (62%) patients and 13 of 20 (65%) internal carotid arteries, viewed to the siphon, had significant redundancies, kinks, coils, or loops. Of 108 consecutive arteriograms of patients without dissection, in which 187 internal carotid arteries were viewed to the siphon, there were 20 (19%) patients and 22 (12%) of 187 vessels with significant redundancy. Five patients in the dissection group and 2 in the nondissection group had bilateral internal carotid artery redundancy (P = .0019 and P = .0001, respectively). CONCLUSIONS: We found a significant correlation between internal carotid artery redundancy and dissection, particularly if redundancy is present bilaterally.

Development of a novel EEG rating scale for head injury using dichotomous variables.

We developed a new EEG rating scale for electrographic assessment of head injured patients. Phenomena present in posttraumatic EEG were scored as dichotomous variables (present or absent). These phenomena included background activity (alpha, beta, theta, delta), sleep spindles, focal abnormalities, reactivity and variability, epileptiform activity, and specific comatose patterns. Each variable was weighted according to its perceived prognostic value: i.e., normal alpha 10, flat EEG -10, spindles 4, etc. Combinations of possible scores ranged from +23 to -10. Fifty-seven EEGs from different head injured patients were independently and retrospectively analyzed by two investigators. There was a high correlation for intra- (r = 0.95) and inter- (r = 0.85) observer rating using the dichotomous test. When patients with scores over 15 (i.e., with reactive alpha) and patients with scores of -10 (i.e., ECI records) were excluded, the intra-rater and inter-rater correlations were still high (0.81 and 0.76, respectively). There was a high correlation between Glasgow outcome score at discharge and the dichotomous EEG score. This EEG scale scores most major categories of EEG activity, utilizes a multipoint scale for correlation purposes, and allows data to be analyzed in sub-categories (i.e., spindles in coma). The separate weighting score allows for refinement of the scale after data collection (i.e., to fit prospective outcome). We feel that this scale is reproducible and valid, and may be applicable to other patient groups with severely altered EEGs.

Alzheimer's disease in Down's syndrome with SPECT.

Alzheimer's disease often occurs in patients with Down's syndrome. SPECT scanning with I-123 IMP and Tc-99m HMPAO identifies decreased cerebral perfusion and metabolism in these patients at lower cost. In this case, SPECT scanning revealed changes in Alzheimer's disease in a Down's syndrome patient.

A private practice model for teaching and research activities.

The majority of neurologists in the United States are in fee for service patient management, dividing their time between hospital and office based practice. Many have had subspecialty training or have had research experience. It is our belief that research should be a component of a neurologist's practice. This is particularly true for an assessment of outcome. In order to accomplish this, we have developed a system which includes patient management, teaching, and clinical research, within our fee for service model.

Episodic low-amplitude events: an under-recognized phenomenon in clinical electroencephalography.

In a series of 20 EEGs from 15 patients, well-defined brief attenuations occurred interspersed among the background activity. These episodic low-amplitude events (ELAEs) typically lasted 0.5-4 s. They were hemispheric or bisynchronous and occurred in patients with coma of various etiologies, including status epilepticus. The episodes of attenuation were brief and no bursts of activity were present, distinguishing this finding from burst-suppression. Prognosis was poor in the patients with coma due to entities other than status epilepticus. In the setting of status epilepticus, the prognosis depended on the etiology. This pattern may be an ictal phenomenon, or a product of waveform simplification. ELAEs are a manifestation of seriously abnormal EEG activity and correlate with a 50% mortality.

Patterns of osseous injuries and psychosocial factors affecting victims of child abuse.

The aim of this paper is to document experience in the management of cases of child abuse with suspected osseous injury, at the Adelaide Children's Hospital, during the period January 1974-December 1986. The study is a retrospective review of the casenotes, radiographs and radiologists' report of 108 consecutive cases with suspected osseous injuries. Information regarding the osseous injuries sustained and the pyschosocial environment surrounding the circumstances of the patients admitted was recorded. Of 108 cases of suspected osseous injuries, 90% had confirmed osseous injury, of whom 56 cases (52%) had multiple fractures. Twenty of the 41 cases of single osseous injury were due to skull fractures. In children less than 12 months of age, long bone injuries were the most common form of presentation, and in 83% of these the injuries were multiple. Metaphyseal injury in association with other fractures was present in 14% of cases, and 8% of cases showed evidence of periosteal reaction to injury. There were two deaths during the period of this study, as a direct consequence of abuse. The main cause of death in both of these cases was the combination of cerebral haemorrhage and liver trauma. There were 10 other deaths not associated with fracture during this period. The analysis of psychosocial factors demonstrated that 48% of the children were first-born and 67% of parents were unemployed. Of the alleged abuser, the mother was known to be responsible in 50% of cases. In 10% of cases, the parent responsible for the injury admitted to the offence at the time of presentation at the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

A neurologist's approach to a patient with hearing impairment.

This article is a review of the central auditory pathways from an anatomic and clinical perspective. An approach to the assessment of patients with hearing impairment of central origin is provided. The review of the patient's history, physical examination, and laboratory assessment are dealt with in detail.

Presenile dementia with Lewy bodies and neurofibrillary tangles.

A 55-year-old man showed progressive mental deterioration over a five-year period along with a syndrome of "normal pressure hydrocephalus." At autopsy the main finding was the presence of two age-related neurocellular changes, the neurofibrillary tangle and the Lewy body, in limbic structures and in the pigmented nuclei of the brain stem. Cortical changes were mild, and senile plaques were not present. Electron microscopy occasionally showed an intimate relationship between the paired helical filaments of the neurofibrillary tangle and Lewy bodies in nerve cell processes in the hypothalamus. The findings suggest a closer relationship between Lewy bodies and neurofibrillary tangles than usually suspected. We also speculate that the presence of one type of age change in the brain may accelerate or predispose to other age changes.