Clinical features and prognosis of intracranial artery dissection.

BACKGROUND: Intracranial artery dissections (IADs) are an important cause of stroke or subarachnoid hemorrhage (SAH). Outcome of IAD in the anterior circulation or presentation without SAH is rarely investigated and might be different. OBJECTIVE: To evaluate the clinical features and prognosis of patients with IAD, with special emphasis on the location (anterior vs posterior circulation) and clinical presentation (SAH or cerebral ischemia). METHODS: Between January 1998 and May 2012, 60 patients with IAD were included in this single-center cohort study. Clinical features, functional outcome, mortality, and prognostic factors were evaluated. Unfavorable functional outcome was defined as a modified Rankin scale score of 3 to 6. RESULTS: In 18 patients (30%), IAD was located in the anterior circulation. At a median follow-up of 6.4 months, 35.3% of patients with IAD in the anterior circulation had an unfavorable functional outcome vs 39.0% in patients with IAD in the posterior circulation (P = .79). Forty-two patients (70%) presented with SAH. Clinical presentation with SAH was not significantly associated with poor functional outcome (41.5% vs 29.4%, P = .39). Low Glasgow Coma Scale score on admission (odds ratio, 0.72, P = .003) and older age (odds ratio, 1.04, P = .04) were independent predictors of unfavorable functional outcome. Mortality rate was 13% and did not significantly differ with location or clinical presentation. CONCLUSION: Low Glasgow Coma Scale score on admission and older age were independent predictors of unfavorable functional outcome. IAD presenting with SAH was not significantly associated with poor functional outcome.

[White matter abnormalities following attempted suicide]. / Wittestofafwijkingen na een zelfmoordpoging.

BACKGROUND: Delayed post-hypoxic leukoencephalopathy (DPHL) is a demyelinating disorder characterized by neuropsychiatric symptoms occurring a few days to some weeks following cerebral hypoxia. CASE DESCRIPTION: A 50-year old female patient showed rapidly progressive cognitive deterioration with apathy, mutism and regressive behaviour a few weeks after a suicide attempt with carbon monoxide (CO). This eventually leads to a state of akinetic mutism. Magnetic resonance imaging (MRI) of the brain showed diffuse white matter abnormalities. These MRI findings combined with CO intoxication and the clinical picture were highly suggestive for DPHL. CONCLUSION: This case emphasizes that a neurological cause should be considered if rapidly progressive neuropsychiatric symptoms occur, and that after suspected auto intoxication it is important to take possible hypoxia and its after-effects into consideration. Recognition of DPHL is important so that unnecessary invasive diagnostics and treatment can be avoided. Considering the favorable natural course of DPHL appropriate measures should be taken in order to provide supportive care and rehabilitation.

Progressive multifocal leukoencephalopathy during treatment with rituximab and CHOP chemotherapy in a patient with a diffuse large B-cell lymphoma.

A 74-year-old woman with a diffuse large B-cell lymphoma was treated with rituximab and CHOP chemotherapy. After three cycles of chemotherapy she developed progressive symptoms of motor imbalance, fatigue, weight loss and impaired cognitive function, which was interpreted as toxicity of the CHOP chemotherapy. The sixth cycle CHOP chemotherapy was withheld and three additional cycles of rituximab were given. Two weeks later, neurological symptoms appeared, including abducens nerve palsy of her left eye, ataxia and hemiparesis of her right body. MRI of the brain revealed two hyperintense lesions on T2-weighted and fluid-attenuated inversion recovery images without oedema or gadolinium enhancement. A PCR on John Cunningham (JC) virus DNA in cerebrospinal fluid was negative, but subsequent brain biopsy diagnosed progressive multifocal leukoencephalopathy (PML). She rapidly deteriorated and died. Awareness of PML during immunosuppressive therapy can be lifesaving, since only immune reconstitution can prevent mortality in these patients.