PRACTICAL NEUROLOGY最新文献

The most common ictal psychiatric symptom is fear, followed by ictal depression, and least commonly ictal psychosis. A 44-year-old man with poststroke focal epilepsy developed new-onset behavioural change, disorientation, hallucinations and delusions, persisting for several months before medical evaluation. He was agitated, disorientated, with impaired memory and disorganised thinking, but had no minor epileptic motor signs. His EEG showed electroclinical status epilepticus. His psychotic symptoms persisted despite seizure control and required antipsychotic treatment. Ictal psychosis is rare but clinicians should suspect this in people with epilepsy with new-onset behavioural change. Rarely, it can persist for months, sometimes needing antipsychotic treatment.

Instances of recovery from a functional neurological disorder (FND) can shine a light on the nature of the condition and its potential treatment. Unexpected recovery of FND symptoms can occur after a comatose state or an anaesthetic, or after various other scenarios. Two illustrative cases exemplify the phenomenon. A 59-year-old man had an 8-year history of functional paraparesis that had developed subacutely following a car crash. The paralysis recovered dramatically after an episode of medically induced coma, administered because of SARS-CoV-2 acute respiratory distress. A 40-year-old woman had complete recovery of FND-related arm paralysis and associated chronic pain after a deliberate overdose that led to a comatose state necessitating a brief period of ventilation. We compare these with similar recoveries in other scenarios, such as following hypnosis or extreme external stress. We discuss the potential mechanisms for recovery and the implications for FND treatment.

Complement inhibition is a highly effective strategy for preventing relapse and disability accumulation in neuromyelitis optica spectrum disorder (NMOSD). Invasive infection with Neisseria meningitidis, the principal risk of complement inhibition, is largely mitigated by adequate vaccination. However, vaccination in the context of treatment sequencing from other immunosuppressive therapies, in particular rituximab, presents unique challenges. We present a 17-year-old woman with a severe NMOSD relapse despite B-cell depletion, who subsequently developed meningococcal sepsis after treatment with ravulizumab, despite prior vaccination; and we propose strategies to manage risk in this patient population.

Expert opinion, based on a careful medical history and detailed neurological examination, remains the gold standard to diagnose Parkinson's disease (PD). Neuroimaging is deemed unnecessary in those presenting with a characteristic phenotype. We encountered two patients in whom our expert clinical opinion, namely not to scan, was 'overruled' because structural brain imaging had been performed elsewhere. The MR scans unexpectedly showed an underlying cause for the parkinsonian symptoms, with unequivocal therapeutic implications. Neither patient had any unambiguous non-motor symptoms. Stimulated by these two cases, we present a nuanced view on the possible indications for brain MRI in people with apparently classical motor PD. We propose to count the absence of any unambiguous non-motor symptoms as a double (rather than single) red flag, thus requiring this to be countered by two supportive signs, and suggest lowering the threshold for brain scanning in such patients.

We describe a case of cerebral air embolism in a man with vascular Ehlers-Danlos syndrome. The key learning point is that cerebral air embolism can cause a florid encephalopathy and MR imaging appearance, yet the causative diagnosis may be made only by carefully scrutinising the CT scan, rather than the MRI. This patient was incorrectly diagnosed with posterior reversible encephalopathy syndrome before subsequent closer inspection of the CT scan at presentation disclosed the true diagnosis. Other diagnostic clues were the close temporal proximity to events that might introduce air into the systemic circulation (eg, thoracic procedures) or syndromes that predispose people to cerebral air embolism. The likely cause in this case was a transient bronchovenous fistula associated with vascular Ehlers-Danlos syndrome. Prompt identification of cerebral air embolism allows supportive measures to be started to prevent potentially fatal sequelae.