The Neurologist最新文献

Introduction: Acute oculomotor nerve (CN III) palsies are commonly attributed to microvascular disease or compressive lesions and aneurysms, but may rarely be associated with ischemic large vessel disease. We report a case of an extracranial internal carotid artery (ICA) dissection heralded by CN III palsy with review of the relevant literature.

Case report: A 24-year-old right-handed man presented with right-sided weakness preceded by vomiting 2 days earlier. The following day, the family noted his left eye to be deviated outward with enlarged pupil and droopy eyelid. On the day of admission, he had a fall owing to right-sided weakness. His neurological examination revealed significant aphasia, left third nerve palsy, right homonymous hemianopsia, and right-sided hemiplegia with hemisensory deficits. A brain magnetic resonance image showed an acute ischemic infarct in the left middle cerebral artery distribution without mass effect. Magnetic resonance angiogram showed a left extracranial internal cerebral artery (ICA) dissection with absence of flow within the distal cervical and intracranial ICA segments. He underwent a decompressive left hemicraniectomy with partial improvement in his deficits.

Discussion: Oculomotor nerve palsy as a result of ICA disease is a rare entity but has been reported in cases of stenosis, occlusion, and dissection. It is likely to be caused by hypoperfusion of CN III secondary to low flow or microembolism in the arteries feeding the nerve. The risk of CN III palsy in patients with ICA disease is higher in the presence of a fetal posterior cerebral artery.

Conclusions: Acute oculomotor nerve palsies with pupillary involvement warrant thorough investigation. When routine work-up fails to elucidate an etiology, extracranial carotid pathology should be considered.

Objectives: The precise innervation of the sternocleidomastoids is uncertain. Of clinical interest is whether a unilateral hemispheric lesion leads to an ispilateral or contralateral sternocleidomastoid weakness.

Methods: Sternocleidomastoid strength was assessed in 124 consecutive acute stroke patients during yaw, pitch, and roll head movements. This was correlated with limb paresis and neuroimaging findings.

Results: The incidence and the degree of sternocleidomastoid paresis were low (16.9%). In all cases, head rotation weakness away from the affected hemisphere was observed. Lateral tilt and vertical head rotations were unaffected. No weakness was detected in lesions that did not cause manifest limb paresis.

Conclusions: Our data point to an ipsihemispheric sternocleidomastoid control. Sternocleidomastoid paresis in stroke is expected only with concomitant limb paresis and is always less severe. Head tilt is not affected probably due to sparing of ancillary neck-muscle function.

Introduction: Trihexyphenidyl is 1 of the most effective agents for treatment of young-onset dystonia. As such, women of childbearing potential use trihexyphenidyl despite inadequate information about potential effects on pregnancy, labor, and fetal development.

Case report: We report 2 uncomplicated pregnancies in 1 woman with early-onset, sporadic, primary generalized dystonia (DYT1 negative) treated with high dosage trihexyphenidyl and review the literature on antidystonic agents and pregnancy.

Conclusion: Although there is limited data, our case demonstrates that high-dosage trihexyphenidyl treatment is not necessarily a contraindication to pregnancy.

Background: The trigeminocervical system is integral in cervicogenic headache. Cervicogenic headache frequently coexists with complaints of dizziness, tinnitus, nausea, imbalance, hearing complaints, and ear/eye pain. Controversy exists as to whether this constellation of symptoms may be cervically mediated.

Objectives: To determine whether a wider spectrum of cervically mediated symptoms exist, and to investigate a potential role of greater occipital nerve blocks (GON) and trigger point injections (TPI) in these patients.

Methods: Retrospective review of GON/TPI performed in a tertiary otoneurology/headache clinic from May 2006 to March 2007 for suspected cervically mediated symptoms. Data included chief complaint, secondary symptoms, response to injection, pre-GON/TPI posterior vertex sensation changes to pinprick, cervical spine examination, and response to vibration of cervical and suboccipital musculature.

Results: Total number of 147 patients were included. Chief complaints in decreasing frequency: dizziness (93%), tinnitus (4%), headache (3%), and ear discomfort (0.7%). Overall symptoms in decreasing frequency: dizziness (97%), headache (88%), neck pain (63%), tinnitus (23%), and ear discomfort (22%). Improvements after GON/TPI: neck range of motion (71%), headache (57%), neck pain (52%), ear discomfort (47%), dizziness (46%), and tinnitus (30%). Dizziness responders had neck position asymmetries (84%), reproducible dizziness by cervical and suboccipital musculature vibration (75%), and preinjection posterior vertex sensory changes (60%).

Conclusions: A wider spectrum of cervically mediated symptoms may exist by influence of trigeminocervical and vestibular circuitry through cervical afferent neuromodulation. Certain examination findings may help to predict benefit from GON/TPI.

Objectives: Managing nonconvulsive status epilepticus (NCSE) poses many challenges that would benefit from additional early measures to predict patient outcomes. Here, we evaluate clinical and electroencephalographic responses to an acute antiepileptic drug trial as an added measure for predicting outcomes in patients presenting with suspected NCSE.

Methods: We analyzed all patients referred to our Neurology Service with suspected NCSE assessed by a standard acute intravenous (IV) benzodiazepine (BDZ) protocol. We correlated patients' clinical and electrographic (EEG) responses to the BDZ trial with their subsequent outcomes, including survival, recovery of consciousness, and functional status at hospital discharge.

Results: From 1990 to 2001, we identified 62 patients with NCSE who were initially evaluated with an acute IV BDZ protocol trial. A favorable clinical response with improvement in consciousness was observed in 22 patients (35%), whereas 40 (65%) were clinical nonresponders. All of the positive clinical responders (100%) survived, recovered consciousness, and exhibited good functional outcomes. In contrast, outcomes were significantly poorer (P<0.001) for the clinical nonresponders; only 14 (35%) recovered consciousness and 22 (55%) survived, with 59% of those survivors demonstrating poor functional outcomes. EEG improvement with BDZs also predicted better outcome, but it was less robust than the clinical response, with better subsequent recovery of consciousness (P<0.05), but not functional outcome or survival.

Conclusions: This study demonstrates that a clinical and, to a lesser degree, EEG response to an acute trial of IV BDZs are predictive of subsequent outcome in patients with suspected NCSE, and warrant further consideration and investigation for assessing and managing patients.

Background: Pure motor monoparesis (PMM), an isolated motor deficit that occurs after ischemic stroke (IS) in a single arm or leg without accompanying cranial or sensory dysfunction, is rare and easily misdiagnosed as other causes of weakness.

Review summary: Cortical infarctions of the precentral knob and the anterior cerebral artery territory (for upper and lower limbs, respectively) are the most commonly reported lesion sites in PMM. Other sites include the subcortex, corona radiata, internal capsule, and brainstem; these sites are cited less frequently than those afflicted by cortical infarctions. PMM shows a complex weakness pattern; however, distal-dominant weakness, as well as the absence of pyramidal signs is most commonly observed in PMM owing to IS. Nevertheless, the overall prognosis is generally good.

Conclusions: Physicians should carefully assess acute monoparesis, particularly in elderly patients with conventional risk factors, and should include IS in the differential diagnosis. Diffusion-weighted imaging is the most useful tool for diagnosing PMM owing to IS.

Objective: Rasagiline, a monoamine oxidase type B inhibitor, is indicated for both the initial treatment of Parkinson disease (PD) and as adjunctive (add-on) treatment for patients already taking dopaminergic therapy. This open-label prospective community-based clinical trial was designed to determine the time-to-onset and the magnitude of the beneficial effects of rasagiline in PD patients.

Methods: Patients received rasagiline of 1.0 mg once daily as monotherapy or 0.5 mg once daily as adjunct therapy (adjunct therapy dose could be increased to 1 mg/d if clinically indicated) for 12 weeks. Dietary restrictions and recommendations regarding concurrent antidepressant treatment consistent with the Food and Drug Administration (FDA) regulations were in keeping with typical usage. Effectiveness was measured as change from baseline in bradykinesia scores and physicians' and patients' global impression. Patients were prospectively monitored for treatment emergent dopaminergic side effects, tyramine reactions, and possible interactions with commonly used antidepressants.

Results: Objective and subjective measures of symptom severity improved at 1 week in 272 PD patients treated with once-daily rasagiline (n=123 monotherapy, n=149 adjunct therapy). The magnitude of beneficial effect was similar in monotherapy and adjunct therapy patients. No significant dopaminergic side effects, tyramine reactions, or interactions with antidepressants were observed in the 12-week trial.

Conclusions: Rasagiline has a measurable beneficial effect on PD symptoms within 1 week of treatment. Rasagiline has a similar magnitude of benefit in monotherapy and adjunct therapy patients. Adverse interactions between antidepressants and rasagiline were not observed in patients in this trial. The usual use of rasagiline in community neurology practice, consistent with the FDA labeling, seems safe and effective.