Restless legs syndrome and periodic movements of sleep.

Two entities of special interest in sleep disorders medicine are restless legs syndrome and periodic movements of sleep. Most patients with restless legs syndrome have periodic movements of sleep, but most patients with the nocturnal disorder do not have restless legs when awake. In both conditions, the underlying cause is obscure, and the frequency of occurrence increases with advancing age. In most patients with restless legs syndrome, the results of complete blood cell counts and iron, ferritin, folate, and vitamin B12 levels are normal. No hematologic or chemical abnormalities have been reported in patients with periodic movements of sleep who do not also have restless legs syndrome. Various pharmacologic agents, including benzodiazepines, opiates, and levodopa, have been proposed for the treatment of both disorders. Although some patients respond to a single drug for long periods, in many patients tolerance develops and the efficacy diminishes. In such circumstances, a reasonable approach is to alternate chemically unrelated agents on a weekly or biweekly schedule. Transcutaneous electric nerve stimulation may be beneficial.

Vertebral-basilar distribution infarction following chiropractic cervical manipulation.

Previous case reports of vertebral-basilar system infarction following chiropractic cervical manipulation have emphasized the role of predisposing factors such as cervical spondylosis, atherosclerosis, and congenital asymmetry of the posterior circulation. Ten patients without prior neurologic symptoms had vertebral-basilar system infarction promptly after chiropractic maneuvers. One patient, who was free of clinical and radiographic evidence of predisposing factors, subsequently died. Autopsy studies revealed massive nonhemorrhagic brainstem infarction due to bilateral vertebral artery thrombosis. Nine patients survived with residual neurologic deficits due to lesions in various locations of the posterior circulation. No patient received anticoagulants. Previous case reports are summarized and the kinetic anatomy of the vertebral arteries is reviewed to clarify the potential mechanisms involved in the pathogenesis of this entity. Although a causal relationship may be difficult to establish in individual cases, cervical manipulation seems to be the major identifiable factor in the pathogenesis of stroke in some patients.