Tympanic plate fractures in temporal bone trauma: prevalence and associated injuries.

BACKGROUND AND PURPOSE: The prevalence of tympanic plate fractures, which are associated with an increased risk of external auditory canal stenosis following temporal bone trauma, is unknown. A review of posttraumatic high-resolution CT temporal bone examinations was performed to determine the prevalence of tympanic plate fractures and to identify any associated temporal bone injuries. MATERIALS AND METHODS: A retrospective review was performed to evaluate patients with head trauma who underwent emergent high-resolution CT examinations of the temporal bone from July 2006 to March 2012. Fractures were identified and assessed for orientation; involvement of the tympanic plate, scutum, bony labyrinth, facial nerve canal, and temporomandibular joint; and ossicular chain disruption. RESULTS: Thirty-nine patients (41.3 ± 17.2 years of age) had a total of 46 temporal bone fractures (7 bilateral). Tympanic plate fractures were identified in 27 (58.7%) of these 46 fractures. Ossicular disruption occurred in 17 (37.0%). Fractures involving the scutum occurred in 25 (54.4%). None of the 46 fractured temporal bones had a mandibular condyle dislocation or fracture. Of the 27 cases of tympanic plate fractures, 14 (51.8%) had ossicular disruption (P = .016) and 18 (66.6%) had a fracture of the scutum (P = .044). Temporomandibular joint gas was seen in 15 (33%) but was not statistically associated with tympanic plate fracture (P = .21). CONCLUSIONS: Tympanic plate fractures are commonly seen on high-resolution CT performed for evaluation of temporal bone trauma. It is important to recognize these fractures to avoid the preventable complication of external auditory canal stenosis and the potential for conductive hearing loss due to a fracture involving the scutum or ossicular chain.

Neurology without borders: neurological disease in a shrinking world.

The last half of the twentieth century has seen social, political, economic, and environmental changes which have altered patterns of health care in all parts of the world. International influences are becoming stronger each year, and the practice of medicine in any single country is becoming more and more influenced by events and practices in others. Environmental degradation may involve widespread dissemination of neurological toxins. Newly emerging or drug-resistant infections include those involving the nervous system. Effective neurological practice is more dependent than ever on knowledge of international health. Neurologists can act as effective advocates for appropriate treatment, allocation of resources, and prevention of neurological diseases.

Wada difference a day makes: interpretive cautions regarding same-day injections.

OBJECTIVE: To determine whether memory scores after second intracarotid amobarbital procedure (IAP) injections are affected by the time between the first and second injections. METHODS: Sixty-two patients received their second IAP injection on the day after the first injection. Forty-three other patients received the second injection on the same day as the first injection. Both groups underwent similar IAP protocols and memory assessments, except for the timing of the second injection. RESULTS: The second IAP memory scores in the two-day group were significantly higher (p < 0.05) than those in the one-day group. Timing of second injection was a significant correlate of second memory scores, but amobarbital dosage, first IAP memory score, and pre-IAP measures of memory and intelligence were not significant correlates. CONCLUSION: One-day and two-day IAP protocols do not result in similar memory scores after the second injection. Nineteen percent of a subset of patients in the one-day protocol were misclassified, in terms of IAP memory ratings, because of the deleterious effect of having both injections on the same day. It is recommended that correction scores be considered, for some patients who receive two IAP injections on one day, to approximate what the second IAP memory score would have been had the second injection occurred on a second day.

A comparison of rectal diazepam gel and placebo for acute repetitive seizures.

BACKGROUND: Acute repetitive seizures are readily recognizable episodes involving increased seizure frequency. Urgent treatment is often required. Rectal diazepam gel is a promising therapy. METHODS: We conducted a randomized, double-blind, parallel-group, placebo-controlled study of home-based treatment for acute repetitive seizures. Patients were randomly assigned to receive either rectal diazepam gel, at a dosage varying from 0.2 to 0.5 mg per kilogram of body weight on the basis of age, or placebo. Children received one dose at the onset of acute repetitive seizures and a second dose four hours later. Adults received three doses -- one dose at onset, and two more doses 4 and 12 hours after onset. Treatment was administered by a care giver, such as a parent, who had received special training. The number of seizures after the first dose was counted for 12 hours in children and for 24 hours in adults. RESULTS: Of 125 study patients (64 assigned to diazepam and 61 to placebo) with a history of acute repetitive seizures, 91 (47 children and 44 adults) were treated for an exacerbation of seizures during the study period. Diazepam treatment was superior to placebo with regard to the outcome variables related to efficacy: reduced seizure frequency (P<0.001) and improved global assessment of treatment outcome by the care giver (frequency and severity of seizures and drug toxicity) (P<0.001). Post hoc analysis showed diazepam to be superior to placebo in reducing seizure frequency in both children (P<0.001) and adults (P=0.02), but only in children was it superior with regard to improvement in global outcome (P<0.001). The time to the first recurrence of seizures after initial treatment was longer for the patients receiving diazepam (P<0.001). Thirty-five patients reported at least one adverse effect of treatment; somnolence was the most frequent. Respiratory depression was not reported. CONCLUSIONS: Rectal diazepam gel, administered at home by trained care givers, is an effective and well-tolerated treatment for acute repetitive seizures.

De novo psychogenic nonepileptic seizures after epilepsy surgery.

PURPOSE: The occurrence of de novo nonepileptic seizures (NES) after epilepsy surgery have been reported only twice in the literature (one article and one abstract). METHODS: We report three patients whose de novo NES were documented by video-EEG telemetry after epilepsy surgery. These patients were drawn from a sample of 166 consecutive patients who underwent epilepsy surgery at our center between 1989 and 1996. RESULTS: Two patients became seizure free after surgery, and one had significant improvement of her seizures. The interval between the date of surgery and the development of the symptoms was variable (8, 10, and 47 months, respectively). The clinical phenomena of NES differed from those of the epileptic seizures preceding surgery. Their diagnosis had not been suspected in two patients before the diagnostic video-EEG monitoring study. After the diagnosis of NES, spells stopped in two patients and recurred rarely in one. CONCLUSIONS: We conclude that de novo NES appears to occur rarely after epilepsy surgery. Given that the possibility of NES was suspected in only one patient, its incidence after surgery may be higher than so far reported. Physicians should therefore consider NES in the differential diagnosis of recurrent seizures after a seizure-free period after epilepsy surgery.

Preventable neurological diseases worldwide.

Neuropsychiatric disorders make up a large proportion of medical conditions causing disability and death worldwide. This paper reviews the most significant neurological disorders, emphasizing the preventability of most of them. The worldwide impact of cerebrovascular disease, protein-energy malnutrition causing cognitive impairment, tetanus, dementia, meningitis, and epilepsy is summarized. The burden of neurological dysfunction as a complication of tuberculosis, measles, road accidents, congenital anomalies, malaria, falls, war, violence, alcohol, HIV, diabetes, syphilis, and rheumatic heart disease might also be lessened by preventive measures. As in other health problems, major risk factors are poverty, poor access to health care, and social instability.

Special report from the World Federation of Neurology. The worldwide impact of new drugs: development, distribution, and use.

Access to appropriate drug treatments and preventive agents for neurologic disorders is determined by medical, economic, political, social, and personal choices and policies. The development of new agents is dominated by large, often transnational companies located in economically advanced countries. Adequate breadth and stability of pharmaceutical supplies may be jeopardized by local economic, physical, and organizational constraints. Appropriate medical choices of drugs, their number, routes of administration, and sources, are made by physicians informed by their basic and continuing medical education but also influenced to varying degrees by patient expectation, financial incentives, and marketing information provided by the drug industry. Attempts to increase the availability of necessary drug treatment for all include initiatives by the World Health Organization, attention of national health planners to drug development, supply, and use, and industry-government cooperation. Although there are significant differences among countries, many national health planners have taken similar approaches: increasing attention to cost-effectiveness in prescribing and to competitive purchasing; the use of essential drug lists, formularies, and generic drugs; the devising of economic incentives for the development of needed but unprofitable drugs; careful planning of drug procurement and storage; and an emphasis on professional and patient education.

Weight loss in patients taking felbamate.

Felbamate is a new antiepileptic drug (AED) with a good safety profile. Anorexia has been reported in patients taking felbamate, but the incidence and severity of this side effect have not been adequately investigated. We studied 65 patients with intractable seizures who received adjunctive felbamate therapy as part of clinical research trials or in a compassionate-use program. Mean treatment time on felbamate was 23 weeks (+/- SD 16; range, 6-116 weeks). Forty-nine patients (75%) lost weight during the trials. For subjects older than 15 years, there was a mean weight loss of 3.17 kg or 4.11% of body weight (T = 191.5, z = 4.18, p < 0.001). For subjects 15 years or younger there was a mean weight loss 0.20 kg or a loss of 1.77% of body weight (T = 52.5, NS). Twenty-two patients (34%) lost > 4 kg, and seven patients (11%) lost > 8 kg. Adjunctive treatment of adults with severe epilepsy with felbamate may be associated with clinically significant weight loss.

Bilateral Todd's paralysis after focal seizures.

Transient postictal hemiparesis or monoparesis is not uncommon after partial (focal) seizures. We report 2 patients who complained of severe bilateral limb weakness after generalized tonic-clonic seizures (GTCS) beginning focally. Bilateral Todd's paralysis was verified and documented in both patients. EEG and clinical evidence indicate the supplementary motor cortex as the most likely source of the seizures in both cases.

A device to measure cutaneous temperature sensitivity in humans and subhuman species.

A device is described to maintain restricted areas of skin at any temperature between 5 and 45 degrees C. Changes in temperature of controlled intensity up to 10 degrees C at rates from 0.03 degrees C to 2 degrees C/s can be delivered in either the warm or cool directions. The stimulator, which is in contact with the skin, is sufficiently simple so that a number of them can be constructed, each with a different contact area up to 18.2 cm2. The current control apparatus that operates a Peltier device in the stimulator is a feedback control system that maintains a precisely controlled temperature at the stimulator-skin interface. Safety features make it suitable and safe for use in human psychophysical studies and subhuman behavioral measurements of temperature sensitivity. Electrostatic shielding makes it compatible with the electronic instruments used in electrophysiological studies of the temperature sense.