Oculostapedial Synkinesis

A 51-year-old woman with persistent oculostapedial synkinesis after successful microvascular surgical decompression of the facial nerve in the cerebellopontine angle is presented. Auditory symptoms are common in patients with hemifacial spasm manifested by a low-pitch rumbling noise, ear fullness or stuffiness, subjective reduction of hearing acuity, and as described in this case, ear tightness and "drumming." Ephaptic neural transmission is the proposed cause of hemifacial spasm. The exacerbation of auditory symptoms with voluntary blinking and eye closure can be explained by ephaptic transmission and/or aberrant regeneration. Should the aggravating and annoying symptoms of stapedial muscle dysfunction persist in the face of successful treatment of hemifacial spasm, transmeatal division of the stapedial tendon provides immediate relief.

Dyskinesia of vascular origin. Clinical data and response to therapy in 7 cases

Seven patients with dyskinesia due to cerebrovascular lesions are described. They presented hemichorea, hemiballism and focal dystonia; the site(s) of the lesion responsible, as defined by MRI (magnetic resonance imaging) or CT (computerized tomography) scan were the putamen, the caudatus, the thalamus and the subthalamic body of Luys. Data of similar cases in the literature are reviewed with reference to the location of the responsible lesions, which can aid in predicting the outcome of illness or prescribing treatment.

No neurological improvement after liver transplantation for Wilson's disease

Orthotopic liver transplantation (OLT) represents the sole etiological treatment for Wilson's disease (WD), but its efficacy in resolving the neurological symptoms is still a matter of debate. We present the case of a young male affected with WD with hepatic and neurological involvement, who underwent OLT for subacute liver failure. Clinical, neuropsychological and neuroradiological assessment were performed before and after OLT. OLT had no effect on neurological symptoms, suggesting that the basal ganglia damage may be irreversible. Nineteen months after OLT, the patient went on to develop new permanent extrapyramidal symptoms. We postulate a sequela of an early post-operative central pontine and extrapontine myelinolysis.

Hemiballismus as a presenting sign of hyperglycemia

A 53-year-old man arrived at the emergency department after the onset of progressive hemiballismus. This movement disorder was the only manifestation of his hyperglycemic state. Prompt recognition of the association of unusual movement disorders with nonketotic hyperglycemia will allow for prompt treatment.

[Huntington disease: clinical and genetic study in a Spanish population]

Clinical and genetic data of 18 unrelated patients diagnosed of Huntington's disease were studied. We examined age of onset, form of presentation, years of evolution and scores on the Shoulson-Fahn function scale, the Myers disability scale and the mini-mental state examination. The 3 clinical parameters show a linear correlation with years of disease duration. The mini-mental test was most sensitive to progression and was most closely correlated (r = 0.75, p = 0.001). Molecular analysis of the IT15 gene for all 18 patients and 96 control chromosome was performed; the range of CAG repeats was 9-29 for controls and 36-69 for patients. The correlation decreased exponentially with age of onset of symptoms and number of CAG repeats.

Comparisons of the acute effects of cholinesterase inhibitors using a neurobehavioral screening battery in rats

The clinical signs of intoxication produced by cholinesterase inhibitors, many of which are used as pesticides, are considered important information for regulatory purposes. We conducted acute studies of cholinesterase inhibitors to compare their effects as determined by a functional observational battery (FOB) and motor activity. The acute effects of two carbamates (carbaryl, aldicarb) and five organophosphates (OP) (chlorpyrifos, diazinon, parathion, fenthion, and diisopropyl fluorophosphate, or DFP) were evaluated on the day of dosing at the time of peak effect, at 1 and 3 days, and 1 week after dosing (oral gavage, in corn oil). A high dose was selected that produced clear cholinergic signs, and lower doses were chosen to produce a range of effects. Generally all cholinesterase inhibitors produced autonomic signs of cholinergic overstimulation (salivation, lacrimation, and miosis), hypothermia, mild tremors and mouth-smacking (chewing motions), lowered motor activity, decreased tail-pinch response, and altered neuromuscular function (gait changes and increased foot splay). The measures generally found to be most sensitive on the day of dosing were body temperature, motor activity, gait, and the presence of mouth-smacking and fine tremors. However, no single measure was the most sensitive across all compounds; for example, the lowest dose of fenthion decreased motor activity by 86% but did not alter the tail-pinch response, whereas the lowest dose of parathion did not lower activity but did decrease the tail-pinch response. For some measures, differences in the slopes of the dose-response curves were evident. Many effects were still observed at 24 h, but recovery was apparent for all compounds. Interestingly, residual effects at 72 h were obtained with the carbamates (carbaryl, aldicarb) as well as with the Op fenthion, but not with the other compounds. Thus, the overall clinical picture of toxicity was similar for these cholinesterase inhibitors, but compound-specific differences emerged in terms of the individual measures, dose-response, and time course.

Case study: neuroleptic withdrawal dyskinesia exacerbated by ongoing stimulant treatment

Risk factors for neuroleptic withdrawal dyskinesia in children have not been well studied. The authors present a case of a child who had been treated with a combination of neuroleptics and stimulants for nonpsychotic aggressive behavior. A severe withdrawal dyskinesia precipitated by neuroleptic tapering was ameliorated by discontinuation of the psycho-stimulant. Although stimulants have been reported to increase certain involuntary movement disorders, this is the first known report of psychostimulant exacerbation of withdrawal dyskinesia.

[A true aneurysm of the right internal mammary artery, accompanied by diminished grasping power of the right hand]

A 69-year-old man was admitted to our hospital after an abnormal shadow was found on a chest radiograph. The preoperative diagnosis was right subclavian aneurysm. Loss of grip in the right hand developed, and the patient underwent surgery. During surgery, the aneurysm was found to have originated from the right internal mammary artery. The root of the right internal mammary artery was tied and the right subclavian artery, which had been compressed and displaced by the aneurysm, was replaced. A chest radiograph obtained 6 months after surgery showed that the trachea was no longer displaced. However, the gripping force of the right hand had not recovered.

Effects of aortopulmonary collaterals on cerebral cooling and cerebral metabolic recovery after circulatory arrest

BACKGROUND

Aortopulmonary collaterals (APC) have been associated with an increased risk of choreoathetosis after deep hypothermic circulatory arrest (DHCA). To study the effects of APC on cerebral hemodynamics and metabolism before and after DHCA, a piglet model was developed.

METHODS AND RESULTS

Protocol 1: Eight 4- to 6-week-old piglets underwent placement of a left subclavian-to-main pulmonary artery shunt. Control shunts (n = 4) were ligated, APC shunts (n = 4) were left patent. All animals were placed on cardiopulmonary bypass (CPB) and cooled in identical fashion for 20 minutes. Temperature probes were placed in the nasopharynx, cortex, and deep brain. Control animals achieved significantly lower temperatures in all three areas by the end of cooling (17.5 degrees C versus 20.1 degrees C, 19.0 degrees C versus 22.3 degrees C, and 17.5 degrees C versus 21.0 degrees C, respectively, P < .005). Protocol 2: Six control and six APC animals were instrumented as described. All were placed on CPB, cooled to 18 degrees C, arrested for 90 minutes, and rewarmed to 37 degrees C. Cerebral blood flow (CBF) was measured with radioactive microspheres while warm on CPB, after cooling, and after rewarming. Arterial and sagittal sinus blood gases and CBF were used to calculate the cerebral metabolic rate of oxygen consumption (CMRO2). Both CBF and CMRO2 were significantly higher after rewarming to 37 degrees C in control versus APC animals (28 +/- 3 versus 14 +/- 2 mL/100 g per minute and 1.72 +/- 0.21 versus 1.04 +/- 0.14 mL O2/100 g per minute, respectively, P < .05).

CONCLUSIONS

APC decrease the rate of cerebral cooling on CPB and even if temperature is controlled result in increased cerebral metabolic derangement after DHCA. Patients with such collaterals may need additional measures to optimize cerebral protection.

Neuroleptic malignant syndrome in striatonigral degeneration

A 6-year-old boy with striatonigral degeneration had an episode of neuroleptic malignant syndrome after an upper respiratory infection. Dantrolene treatment was successful. Some reports have demonstrated that anesthetic and antipsychotic agents lead to neuroleptic malignant syndrome in disorders of the basal ganglia. However, neuroleptic malignant syndrome attributable to a respiratory infection has not previously been reported. Our patient illustrates the potential morbidity of neuroleptic malignant syndrome in patients with striatonigral degeneration.

Bobble-head doll syndrome and drop attacks in a child with a cystic choroid plexus papilloma of the third ventricle. Case report

The authors report an unusual case of a 2-year-old boy with a 3-month history of episodic rightward anterolateral head tilt and large-amplitude positional anteroposterior head bobbing reminiscent of bobble-head doll syndrome. This child experienced a sudden onset of drop attacks and then, within several hours, deep coma. The causative lesion was a contrast-enhancing, partially cystic third ventricular mass, which ultimately obstructed the aqueduct, producing profound obstructive hydrocephalus. An emergency ventriculostomy and endoscopic fenestration of the septum pellucidum was performed. Four days later, the tumor was completely resected by a transcallosal-transforaminal approach. The lesion was freely mobile within the third ventricle and contained a large cyst within its posterior pole; following drainage of the cyst, the lesion was easily delivered through the foramen of Monro. The histopathological diagnosis was choroid plexus papilloma. The child's neurological deficits, head tilt, and head bobbing resolved immediately after operation. To the best of the authors' knowledge, this represents the first well-documented report of bobble-head doll syndrome and drop attacks secondary to a choroid plexus papilloma. The highly mobile nature of the cystic lesion presumably led to its intermittent impaction within the foramen of Monro and/or proximal aqueduct; this produced the intermittent head tilt and bobble-head symptoms and, ultimately, resulted in acute obstruction of the aqueduct, causing the child's precipitous neurological decline.

Neurobehavioral and psychosocial functioning of children with opsoclonus-myoclonus syndrome

Childhood opsoclonus-myoclonus syndrome (OMS) is a movement disorder which typically strikes children in the early preschool years, seriously affecting intellectual, social-emotional and general adaptive development. This series of 13 cases with well-documented neurological histories, aged 1.7 to 16.3 years, provides an initial systematic evaluation of these children's neuropsychological, psychosocial and adaptive status. As expected, children with OMS had significantly reduced intelligence and severe speech and motor output problems; however, most of them also demonstrated a range of preserved neurocognitive abilities and impressive goal-directedness and communicative effort. Psychosocial problems included mild behavioral impairment on the Achenbach Child Behavior Checklist, and severe adaptive limitations on the Vineland Adaptive Behavior Scales despite relatively strong social skills. Developmental factors and likelihood of subcortical localization are discussed, and practical guidelines are provided for behavioral and educational management of these children.

Is there a rationale for iron supplementation in the treatment of akathisia? A review of the evidence

BACKGROUND

An association found between akathisia and iron deficiency led to the suggestion that iron supplementation might be a useful therapeutic intervention for patients with akathisia. There is, however, a body of literature on the abnormal deposition of iron in the brain in several degenerative diseases like Hallervorden-Spatz syndrome, Parkinson's disease, and Alzheimer's disease. Given the ability of neuroleptics to chelate iron and promote its deposition in the brain, we questioned whether peripheral measures of iron are an accurate reflection of central iron levels and thus whether there was a rationale for iron supplementation in akathisia.

METHOD

A MEDLINE search for literature relating to iron and akathisia, tardive dyskinesia, and Parkinson's disease was carried out and critically reviewed.

RESULTS

Evidence is presented for the ability of neuroleptics to chelate iron, mobilize it from peripheral stores, and deposit it in the basal ganglia. The effect of iron on dopaminergic receptor activity in brain and the potential role of iron in degenerative and neuroleptic-induced movement disorders are reviewed. The preponderance of the evidence shows a relationship between iron excess in the basal ganglia and the movement disorders. We found no studies that have examined the regulation of central levels of iron in patients with akathisia.

CONCLUSION

The rationale for iron supplementation in the treatment of akathisia is relatively weak, and there are potentially adverse long-term consequences as outlined in our review. More research is required to directly measure the level of iron in the brain of patients with akathisia, e.g., using magnetic resonance imaging, before such therapeutic intervention can be recommended.

[Immobility syndrome in patients being care for in a home care unit]

OBJECTIVES

to asses in a group of elderly patients included in a Home Care Unit, the level of immobility, the functional status based on the Katz's index and the Red Cross scale, and their medical, psychological and social consequences.

METHODS

assessment of elderly patients visited during three consecutive months, through and standardized protocol with 14 items related with the previous aspects.

RESULTS

114 elderly patients (71% females) were visited during this time. The mean age was 82.4 years. 71 patients (65.7%) had immobility, with a mean age of 83.4 years and females predominance. Based on the level of immobility, 24 patients were in bed and 44 patients were able to be in bed-armchair. 74% of the patients were severely disabled on the activities daily living (Katz G); 85% of the patients had a severe physical disability (Red Cross scale 4-5), whereas a lower percentage (36%) had severe mental disability (Red Cross scale 4-5). Neurological disorders were the most frequent etiology of immobility (72%), with only one cause in 27 patients, two causes in 20 patients and more than three causes in 24 patients. Medical consequences were the most frequent, mainly urinary and chest infections, pressure sores and constipation.

CONCLUSIONS

Immobility's syndrome represents a common medical problem in the geriatric care, related specially with the neurological and osteo-articular disorders, conditioning a high mobility.

White matter lesions and disequilibrium in older people. II. Clinicopathologic correlation

OBJECTIVE

To identify the cause of subcortical white matter lesions seen on magnetic resonance imaging in older patients with progressive deterioration of gait and balance.

DESIGN

Postmortem examination of three patients with objective impairment of gait and balance thought to be due to subcortical white matter lesions identified on magnetic resonance imaging. Brain sections were stained with routine methods and for glial fibrillary acid protein using an immunoperoxidase technique.

PATIENTS

Part of a prospective study of gait and balance problems in older people. None had a history of hypertension or discrete strokelike episodes.

RESULTS

Other than a few small infarcts in the basal ganglia and internal capsule in the patient with the mildest gait disorder, there were no gross or microscopic features on routine examination post mortem to explain the white matter hyperintensities on magnetic resonance imaging or the progressive gait deterioration. By contrast, immunohistochemical staining with anti-glial fibrillary acid protein showed prominent astrocytosis T2-weighted high-intensity signal areas on magnetic resonance imaging.

CONCLUSIONS

The astrocytes presumably swell as they take up extravasated protein at the site of a breakdown in the blood-brain barrier, and the increased water content per unit volume increases the magnetic resonance imaging proton signal. We hypothesized that the astrocytes may have been initially activated by small infarcts or subclinical ischemia, but the process then became self-perpetuating, ultimately involving most of the white matter and producing the severe gait disorder.

Transient involuntary movement of the leg (monoballismus) during cerebral angiography

Transient involuntary movement of the leg developed during diagnostic or therapeutic angiography in five patients. The movement was jerky, brisk flexion/extension of the hip and knee joints on the side contralateral to acute ischemia. This movement may occur as a result of thromboembolic cerebral ischemia or as an ischemic complication of angiography.

White matter lesions and disequilibrium in older people. I. Case-control comparison

OBJECTIVE

To investigate the relationship between subcortical white matter lesions identified on magnetic resonance imaging and gait and balance problems in older people.

DESIGN

Magnetic resonance imaging scans of the brain in 27 community-dwelling older patients (> 75 years of age) who had subjective and objective abnormalities of gait and balance of unknown cause were compared with those of 27 age- and sex-matched control subjects. The T2-weighted intense lesions of the subcortical white matter were graded on a scale of 0 to 2.

SETTING

Outpatient clinic.

RESULTS

The patient had significantly (P < .01, chi 2) more severe subcortical white matter hyperintensities on magnetic resonance imaging than did the control group. Patients fell more frequently than did the control subjects and had slower motor responses and prolonged reaction times compared with the control subjects.

CONCLUSIONS

Subcortical white matter lesions identified on magnetic resonance imaging are associated with gait and balance dysfunction in ambulatory older people. These lesions probably interfere with central processing of sensorimotor signals leading to impaired postural responses.