Atypical transient ischemic attacks in thrombocythemia of various myeloproliferative disorders

Neurological symptoms of transient unsteadiness, dysarthria, dysphasia, dysbasia, transient monoor hemiparesis, hemiparesis, scintillating scotomas, amaurosis fugax, vertigo, dizziness, migraine accompaniments, syncope and seizures were the presenting manifestations of thrombocythemia in various myeloproliferative disorders. Erythromelalgia preceded or followed the neurologic ischemic attacks. The neurologic and ocular attacks usually had a sudden onset, lasted for a few seconds to several minutes and occurred independently or sequentially rather than simultaneously. This clinical syndrome is caused by platelet-mediated ischemic and thrombotic processes in the end-arterial microvasculature and reflects the existence of a platelet dependent and aspirin responsive arterial thrombophilia in thrombocythemia as novel disease entity, which confirms and elucidates Mitchell's hypothesis.

The myeloproliferative disorders. An historical appraisal and personal experiences

According to strict morphological, biochemical and cytogenetic criteria Philadelphia chromosome positive essential thrombocythemia and chronic granulocytic leukemia constitute a separate malignant and individual disease entity, whereas Philadelphia chromosome negative essential thrombocythemia, polycythemia vera and agnogenic or megakaryocytic myeloid metaplasia form a chronic proliferation of three hematopoietic cell lines. Histopathology from bone marrow biopsies permits the characterization and diagnostic differention of the various myeloproliferative disorders and appears to be a main and specific diagostic criterion for polycythemia vera and essential thrombocythemia. Hemorrhagic thrombocythemia is a clinical syndrome of recurrent spontaneous mucocutaneous and secondary hemorrhages often preceded by thromboses, extremely high platelet counts, pseudohyperkalemia, increased bone marrow cellularity and frequently splenomegaly. The diagnostic criteria of essential thrombocythemia with paradoxical occurrence of thrombotic events and hemorrhagic manifestations are a platelet count in excess of 1000 x 10(9)/L and increased bone marrow cellularity in the majority of the cases. Erythromelalgia and other microcirculatory ischemic or thrombotic events or accidents in essential thrombocythemia and polycythemia vera already occur at platelet counts in excess of the upper limit of normal. First line treatment options in essential thrombocythemia and polycythemia vera are control of platelet function with low-dose aspirin and reductive control of platelet count and erythrocytes by bloodletting, interferon and busulfan or hydroxyurea monochemotherapy.

Hereditary neuropathy with liability to pressure palsies: distinguishing clinical and electrophysiological features among patients with multiple entrapment neuropathy

Hereditary neuropathy with liability to pressure palsies is caused by deletion of the PMP-22 gene. As its relatively mild symptoms may escape detection by clinical examination alone, we screened the gene in patients with multiple entrapment neuropathy (MEN) that had been diagnosed by nerve conduction studies (NCS). Two of the eight patients with MEN had deletion of the gene. The characteristic features that distinguished them from the other MEN patients were predominantly sensory deficits associated with mild weakness and subclinical polyneuropathy as detected by NCS.

Donor site morbidity of the anterior iliac crest following cancellous bone harvest

Anterior iliac crest donor site morbidity was analysed retrospectively at 154 sites in 137 patients who had undergone secondary bone grafting of the cleft alveolus. The applied surgical anatomy and operative technique utilizing a medially based osteoplastic flap are described. The results show a low incidence of donor site morbidity.

Tingling extremities in a young man

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Bilateral block: is it safe and more efficient during removal of third molars?

OBJECTIVE- to assess the safety, acceptability, and efficacy of removing bilaterally impacted wisdom teeth as a one-stage rather than a two-stage procedure. DESIGN- randomised controlled trial. Setting - district hospital. SUBJECTS- 100 consecutive patients who required removal of bilaterally impacted third molars. INTERVENTIONS- 50 patients were randomised to have the teeth removed in two stages, 3-4 weeks apart, the other 50 to have the teeth removed at one visit. All operations were done under local anaesthetic (2% lignocaine and 1/80 000 adrenaline) and intravenous midazolam 0.07-0.13 mg/kg titrated against sedative effect individually. Main outcome measures - morbidity, time off work, anxiety scores (assessed by visual analogue scale), and patient opinions. RESULTS- 5 patients were withdrawn because they were not given the randomised treatment, and 10 were lost to follow-up, leaving 40 in the two-stage group and 45 in the one-stage group for analysis. Two patients in the one stage group developed SaO2 of less than 90% which was corrected by deep breathing, and another had a temporary parasthesia of the inferior alveolar nerve that resolved within a week. One patient in the two stage group had a haemorrhage after the first stage that required packing of the socket in the emergency department, and this patient refused to have the second tooth removed. The mean number of days taken off work was significantly less in the one stage group (mean 3 days compared with 5 days (P < 0.005), and the anxiety scores did not differ significantly between the two groups. A quarter of the patients in the two-stage group would have preferred a one-stage procedure, but none in the one-stage group would have preferred a two-stage operation. CONCLUSIONS- removal of bilaterally impacted wisdom teeth under local anaesthesia and sedation in one session is safe, cost effective and acceptable to patients.

Bilateral central pain

A unique case of a woman with a subparietal cavernoma presenting for a time with bilateral central pain to the arms is reported. This case highlights brain mechanisms of pain processing.

Hand problems in 100 vibration-exposed symptomatic male workers

Long-term use of hand-held vibrating tools may induce various types of hand problems. One hundred symptomatic men exposed to vibration from such tools were interviewed and examined with special reference to neurosensory and vasospastic problems. Three distinct symptomatic groups were identified: isolated neurosensory symptoms (48%), isolated vasospastic problems (20%), and combined neurosensory and vasospastic problems (32%). Abnormal cold intolerance (pain and coldness without blanching of the fingers on exposure to cold) occurred in 27% of the patients. Neurosensory problems were more predominant than vasospastic ones, especially during the first 20 years of vibration exposure. Of 80 patients with neurosensory symptoms, only 22 had signs of a carpal tunnel syndrome (CTS). It is concluded that vibration-induced neurosensory and vasospastic symptoms can occur separately or together, and that the neurosensory symptoms are often not due to a CTS.

A comparison of questionnaire versus monofilament assessment of neurosensory deficit

PURPOSE

Because neurosensory deficit is commonly reported by patients after orthognathic surgery, it is important to know how accurately patients can report their own sensory deficit. This analysis compares the results of objective neurosensory tests with the results of a subjective patient questionnaire.

MATERIALS AND METHODS

Before and 6 months after bilateral mandibular sagittal ramus split osteotomy, 101 patients with class II facial deformities were asked to rate sensations of numbness or tingling in the area of the mental nerve. Simultaneously, they were objectively tested using monofilament neurosensory tests (light touch and brush stroke direction).

RESULTS

More than 70% of patients subjectively reported neurosensory problems, but objective assessment identified neurosensory deficits in less than 60% of the patients. The sensitivity and specificity of the patients' subjective assessments were 75.3% and 52.8%, respectively, for the light touch test, and 77.9% and 59.8%, respectively, for the brush stroke test.

CONCLUSIONS

It was concluded that when monofilament neurosensory testing is used as the gold standard, patients appear to overreport neurosensory problems; ie, the positive predictive value of patient reports is only 63.2%, resulting in frequent false positives.

Deep brain stimulation for essential tremor

We examined the effects and safety of deep brain stimulation (DBS) as a treatment for essential tremor (ET). Ten ET patients with disabling medication-refractory tremor underwent stereotactic implantation of a DBS lead in the left Vim thalamic nucleus and completed a 6-month follow-up. The Clinical Tremor Rating Scale and disability assessments were performed at baseline, 1-, 3-, and 6-month follow-up. There were significant improvements in dressing, drinking, eating, bathing, and handwriting as reported by the subjects. Tremor severity, writing, pouring, and spiral and line drawing were significantly improved as rated by the examiner. Improvements persisted through the 6-month follow-up period. Although global disability significantly lessened in the group as a whole, one subject with hand-finger tremor accentuated by writing had no change in disability status. In this 6-month open-label study, DBS was effective and safe in reducing tremor and functional disability in ET.

Bilateral mandibular nerve damage following root canal therapy

A case of bilateral inferior dental nerve paraesthesia following accidental introduction of root canal filling material into the canal is described. The significance of early recognition of the complication and prompt surgical intervention is highlighted.

False localizing signs in upper cervical spinal cord compression

Proprioceptive loss, paresthesias, and atrophy of the hands can occur with disorders afflicting the upper cervical spinal cord. The diagnosis might be erroneous, because compression in this region might produce signs and symptoms that seem to originate in the lower cervical cord. This article reviews the clinical presentation and radiographic data of a consecutive series of 11 patients who presented between 1992 and 1994 with an extradural lesion above the C4 level. Each patient had a characteristic syndrome of finger and hand dysesthesia, hand atrophy, and occipital or cervical pain. These complaints usually preceded the development of spasticity and gait disturbance. Initial diagnoses included brachial plexopathy, shoulder dysfunction, viral syndrome, and cervical spondylosis at a lower segment. Cervical spondylosis or a herniated disc was the most common pathogenesis. The most commonly involved level was C3-C4. Nine patients underwent a surgical procedure; eight showed significant postoperative improvement (mean time of follow-up examination, 9.7 mo; follow-up range, 1-24 mo). One patient was lost to follow-up. Although the pathophysiology of these findings is unknown, theories include anterior spinal artery ischemia, venous obstruction, and differential decussation of the forelimb and hindlimb fibers of the corticospinal tract. Recognition of this syndrome might prevent inappropriate operative intervention in patients with coexisting pathological conditions of the lower cervical spinal cord.

Risk factors for unpleasant paresthesiae induced by paresthesiae-producing deep brain stimulation

Paresthesiae-producing deep brain stimulation (stimulation of ventrocaudal nucleus-VC, medial lemniscus-ML or internal capsule-IC) is one of the few procedures to treat the steady element of neural injury pain (NIP) currently available. Reviewing the first 60 patients with NIP submitted to deep brain stimulation (DBS) from 1978 to 1991 at the Division of Neurosurgery, Toronto Hospital, University of Toronto, we observed that 6 patients complained of unpleasant paresthesiae with paresthesiae-producing DBS, preventing permanent electrode implantation in all of them. Such patients accounted for 15% of the failures (6 out of 40 failures) in our series. In an attempt to improve patient selection, we reviewed our patients considering a number of parameters in order to determine risk factors for unpleasant paresthesiae elicited by paresthesiae-producing DBS. The results showed that this response happened only in patients with brain central pain complaining of evoked pain, secondary to a supratentorial lesion. Age, sex, duration of pain, quality of the steady pain, size of the causative lesion and site (VC,ML,IC) and type (micro or macroelectrode) of surgical exploration were not important factors. Unpleasant parethesiae in response to dorsal column stimulation, restricted thalamic lesion on computed tomography and the occurrence of associated intermittent pain were considered major risk factors in this subset of patients and the presence of cold allodynia or hyperpathia in isolation and the absence of sensory loss were considered minor risk factors. It is our hope that the criteria here established will improve patient selection and so, the overall results of DBS.

Femoral nerve palsy after arthroscopic surgery with an infusion pump irrigation system. A report of three cases

One patient developed complete, and two patients, partial, femoral nerve palsy after arthroscopic surgery in which an infusion pump was used to operate an irrigation system. In one case, hip flexor and quadricep function was completely lost after the patient underwent arthroscopic partial medial meniscectomy without the use of a tourniquet. A CT scan of the pelvis demonstrated considerable fluid accumulation in the thigh and inguinal regions. The remaining two patients developed quadriceps weakness, but not complete femoral nerve palsy, after arthroscopic-assisted anterior cruciate ligament reconstructions. Although tourniquets were used in these latter two procedures, the pressures were low (300 to 325 mm Hg) and the tourniquet times not excessive, suggesting that femoral nerve palsy in these two patients resulted from fluid extravasation. In all three cases, muscle function returned within 6 to 7 months, but sensory nerve deficits were still present at that time.

Treating the oral sequelae of an acoustic neuroma

This article describes the treatment of oral complications that arose after surgery for the removal of an acoustic brain tumor. The authors contend that a thorough oral examination can pinpoint the cranial nerves that have been affected by the tumor or the surgery, and that dental appliances can offer special protection after surgery.