MRI deterioration in herpes simplex encephalitis despite clinical recovery.

OBJECTIVES: Herpes simplex virus type 1 is a sporadic cause of viral encephalitis. Relapse of encephalitis occurs in up to 10% of patients, manifested by recurrent symptoms, clinical and MRI findings, and the presence of herpes simplex virus type 1 DNA in the cerebrospinal fluid (CSF). METHODS: We describe the clinical features, MRI findings and outcome in 2 patients with herpes simplex encephalitis during the acute phase and 6 months after the onset of encephalitis. RESULTS: Both patients had a good response to treatment and an excellent recovery. Despite clinical recovery, in a 6-month follow-up MRI lesions consistent with recurrence were disclosed, without any clinical findings or CSF abnormalities. CONCLUSIONS: The mechanism underlying this MRI deterioration is unclear and an immune-mediated mechanism may be involved. Thus, MRI deterioration after herpes simplex encephalitis should be interpreted with caution and it does not always represent a relapse, especially when the imaging studies do not correlate with the clinical and CSF findings.

Agenesis of the corpus callosum associated with narcolepsy-cataplexy.

We describe a 24-year-old man with episodes of intense desire to sleep for periods ranging from 2min to 3h, episodes of generalized weakness and inability to speak without alteration of consciousness, frequent hypnagogic hallucinations during sleep and occasionally transient paralysis of limbs upon awakening. Brain MRI demonstrated elevation of the third ventricle, a characteristic lack of depiction of the corpus callosum and extension of the bihemispheric fissure to the third ventricle. We assume that structural changes of the base of frontal lobes, diencephalon and brainstem, can be accountable for symptomatic narcolepsy and cataplexy.

Multiple sclerosis presented as clinically isolated syndrome: the need for early diagnosis and treatment.

OBJECTIVE: To aid in the timely diagnosis of patients who present with clinically isolated syndrome (CIS). PATIENTS AND METHODS: We studied 25 patients (18 women, 7 men), originally presented in our clinic with a CIS suggestive of multiple sclerosis (MS). All patients underwent the full investigation procedure including routine tests, serology, cerebrospinal fluid (CSF) examinations, evoked potentials (EPs), and magnetic resonance imaging (MRI) of brain and cervical spinal cord. Patients were imaged at baseline, and every three months thereafter up to a year. RESULTS: The CIS was consisted of optic neuritis in 12 cases, incomplete transverse myelitis (ITM) in 7 cases, Lhermitte sign in 2 cases, internuclear ophthalmoplegia (INO) in 2 cases, mild brainstem syndrome in 1 case, and tonic-clonic seizures in 1 case. Using the baseline and three-month scans 18/25 (72%) patients developed definite MS in one year of follow up while 7 (28%) had no further findings during this observation period. Immunomodulatory treatments were applied to all definite MS patients. CONCLUSION: In light of new treatments available, MRIs at 3 month intervals are helpful to obtain the definite diagnosis of MS as early as possible.

Thrombosis and recanalization of straight sinus.

We describe a case of a 14-year-old boy who presented to the emergency department with nausea, vomiting, headache, and mental status changes. Noncontrast computed tomography scan of the brain in the emergency department revealed bilateral thalamic and striatocapsular infarcts. The patient was diagnosed with possible thrombosis of the thalamostriate veins, which was confirmed with urgent magnetic resonance venography (MRV). Magnetic resonance venography revealed that the thrombosis was extended to the straight sinus and the internal cerebral veins. Thrombosis of the straight sinus in children results in a rare stroke with inconsistent clinical manifestations, depending on collateral venous circulation of the thrombosed sinus. The diagnosis is quite difficult, especially when symptoms are nonspecific and variable. Timely diagnosis, based on the decision of performing emergency magnetic resonance imaging and MRV, followed by the administration of anticoagulation therapy may reverse this condition as in our patient who made an excellent recovery.

Neurological manifestations of connective tissue diseases mimicking multiple sclerosis.

The objective of the study was to analyze retrospectively the clinical, laboratory and imaging findings of multiple sclerosis (MS), such as the manifestations in a cohort of 132 patients referred to the neurology in and outpatient clinic. The proposed clinical and laboratory diagnostic criteria for MS and connective tissue disorders were systematically assessed in 132 consecutive patients. Cerebrospinal fluid serology and brain or spinal cord MRI were studied in all cases. In patients suspected for connective tissue disorder, schirmer test, rose bengal staining and biopsy of minor salivary glands were performed. A total of 115 (87%) patients were diagnosed to have definite MS, while 17 (13%) were diagnosed to have connective tissue disorder. Positive neurological and MRI findings were observed in both groups. The majority of patients with connective tissue disorder demonstrated extra-neurological manifestations like Raynaud's phenomenon, arthritis, livedo reticularis, purpura and presence of multiple autoantibodies in their sera. All patients with MS should be screened systematically for connective tissue disorder. In the absence of pathognomonic clinical and laboratory findings, the diagnosis of MS is a diagnosis of exclusion.

Patient compliance with SSRIs and gabapentin in painful diabetic neuropathy.

BACKGROUND: Anticonvulsants are widely used for treatment of painful diabetic neuropathy. Selective serotonin reuptake inhibitors (SSRIs) are not first-line drugs but are commonly prescribed medicines for chronic pain. The majority of patients are hesitant to use these drug groups, thus their compliance remains an issue. OBJECTIVE: To compare patient compliance and the effectiveness of 2 SSRIs (paroxetine or citalopram) and 1 anticonvulsant (gabapentin) in patients with painful diabetic neuropathy. METHODS: This was a 6 months prospective trial in 101 patients with painful diabetic neuropathy and minimum score of 2 on a pain intensity scale ranging of 0 to 4. Compliance was assessed with patient interviews and pill counts. Adverse events, early discontinuation or satisfaction with treatment were also evaluated. RESULTS: Patients receiving SSRIs reported greater satisfaction and fewer concerns of the side-effects with their treatment (P<0.05) compared with the patients taking gabapentin. There was statistically significant better mood in the SSRI group (P<0.05). Overall, 43.5% of those taking SSRIs noticed no effect on the pain control, 50% felt better, and 6.5% felt worse. Among the patients taking gabapentin, 51% felt better, 40.5% noticed no effect, and 8.5% felt worse. Finally, on the pill count, more patients on SSRIs (93.5%) than on gabapentin (82.9%) were taking over the 75% of their medication (P<0.05). CONCLUSIONS: The lack of negative effects on quality of life, the better compliance, and the comparable efficiency of SSRIs suggest that these drugs may be considered as alternative to gabapentin in painful diabetic neuropathy.

Increased sensitivity to N-methyl-D-aspartate receptor-induced excitotoxicity in cerebellar granule cells from interleukin-1 receptor type I-deficient mice.

The effects of chronic exposure to excitatory amino acids (EAAs) were examined in cultured cerebellar granule cells (CGCs) from wild type (WT) and interleukin-1 receptor type I (IL-1RI)-deficient mice. After 8 days in culture, the cells were exposed to 100 microM glutamate or 300 microM N-methyl-D-aspartate (NMDA) for 24 h. Analysis of cell viability, as assessed by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) reduction assay and phase-contrast microscopy revealed that CGCs from IL-1RI-deficient mice were more vulnerable to EAAs as compared to the WT controls. The results indicate that IL-1RI signalling is important for neuronal survival. The effect of glutamate on the CGCs from IL-1RI-deficient mice was decreased by the non-competitive NMDA-receptor antagonist MK-801, supporting the involvement of NMDA receptors in the glutamate-induced excitotoxicity.