Management of cerebral venous thrombosis in Spain: MOTIVATE descriptive study

INTRODUCTION

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults. Early, accurate diagnosis can reduce the rate and severity of complications.

OBJECTIVE

The aim of this study was to analyse the clinical characteristics, management, and treatment of CVT in different centres in Spain.

METHODS

We conducted a multicentre, retrospective, descriptive study of patients hospitalised due to CVT between 2008 and 2017 at 10 Spanish centres.

RESULTS

We included 256 patients, with a mean age (SD) of 49.8 (18.7) years; 51% of patients were women. The most frequent symptoms were headache (73%), focal deficits (50%), epileptic seizures (33%), and encephalopathy (21%). The most frequent localisations were the superior sagittal sinus (12.5%), the transverse sinus (10.9%), and 2 or more sinuses or veins (66.4%). Thrombophilia was the most frequent known aetiology (24%), and was most commonly associated with the prothrombin G20210A mutation (19%). Forty-six percent of patients were treated with antithrombotics for 3 to 6 months, 21% for one year, and 22.6% required indefinite anticoagulation. Endovascular therapy was performed in 5% of cases, and 33% required neurosurgery. Regarding outcomes, 75% of patients were independent at 3 months (modified Rankin Scale [mRS] score ≤ 2), with papilloedema (P =  .03), focal deficits (P = .001), and encephalopathy (P < .001) showing a statistically significant association with poor prognosis (mRS > 3). The in-hospital mortality rate was 4.3%, with a 3-month mortality rate of 6.3%.

CONCLUSION

The diverse risk factors and variable presentation of CVT represent a challenge in the diagnosis and treatment of this condition. To improve prognosis and reduce mortality, it is essential to establish management protocols for this entity.

Management of cerebral venous thrombosis in Spain: MOTIVATE descriptive study

INTRODUCTION

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults. Early, accurate diagnosis can reduce the rate and severity of complications.

OBJECTIVE

The aim of this study was to analyse the clinical characteristics, management, and treatment of CVT in different centres in Spain.

METHODS

We conducted a multicentre, retrospective, descriptive study of patients hospitalised due to CVT between 2008 and 2017 at 11 Spanish centres.

RESULTS

We included 256 patients, with a mean age (SD) of 49.8 (18.7) years; 51% of patients were women. The most frequent symptoms were headache (73%), focal deficits (50%), epileptic seizures (33%), and encephalopathy (21%). The most frequent localisations were the superior sagittal sinus (12.5%), the transverse sinus (10.9%), and 2 or more sinuses or veins (66.4%). Thrombophilia was the most frequent known aetiology (24%), and was most commonly associated with the prothrombin G20210A mutation (19%). Forty-six percent of patients were treated with antithrombotics for 3-6 months, 21% for one year, and 22.6% required indefinite anticoagulation. Endovascular therapy was performed in 5% of cases, and 33% required neurosurgery. Regarding outcomes, 75% of patients were independent at 3 months (modified Rankin Scale [mRS] score ≤ 2), with papilloedema (P=.03), focal deficits (P=.001), and encephalopathy (P <.001) showing a statistically significant association with poor prognosis (mRS> 3). The in-hospital mortality rate was 4.3%, with a 3-month mortality rate of 6.3%.

CONCLUSION

The diverse risk factors and variable presentation of CVT represent a challenge in the diagnosis and treatment of this condition. To improve prognosis and reduce mortality, it is essential to establish management protocols for this entity.

Allysine and α-Aminoadipic Acid as Markers of the Glyco-Oxidative Damage to Human Serum Albumin under Pathological Glucose Concentrations

Understanding the molecular basis of the disease is of the utmost scientific interest as it contributes to the development of targeted strategies of prevention, diagnosis, and therapy. Protein carbonylation is a typical feature of glyco-oxidative stress and takes place in health disorders such as diabetes. Allysine as well as its oxidation product, the α-amino adipic acid (α-AA) have been found to be markers of diabetes risk whereas little is known about the chemistry involved in its formation under hyperglycemic conditions. To provide insight into this issue, human serum albumin was incubated in the presence of FeCl3 (25 μM) and increasing glucose concentrations for 32 h at 37 °C. These concentrations were selected to simulate (i) physiological fasting plasma concentration (4 mM), (ii) pathological pre-diabetes fasting plasma concentration (8 mM), and pathological diabetes fasting plasma concentration (12 mM) of glucose. While both allysine and α-AA were found to increase with increasing glucose concentrations, the carboxylic acid was only detected at pathological glucose concentrations and appeared to be a more reliable indicator of glyco-oxidative stress. The underlying chemical mechanisms of lysine glycation as well as of the depletion of tryptophan and formation of fluorescent and colored advanced glycation products are discussed.

Comparison of two PCR and one ELISA techniques for the detection of small ruminant lentiviruses (SRLVs) in milk of sheep and goats

The aim of the present study was to compare the efficiency of two PCR techniques for the diagnosis of small ruminant lentiviruses (SRLVs). Detection of the proviral genome by PCR, though sensitive, is difficult due to the heterogeneity of the SRLV genomes. One of the PCR techniques amplifies a fragment in the pol gene (pol-PCR) and the other PCR targets the LTR region of the proviral genome (LTR-PCR). Milk from 194 sheep and 163 goats from farms in the Central Spain was analyzed by both techniques and compared to results obtained by ELISA. When compared to the serologic assay, the agreement of both PCR techniques was very low (0.024 and 0.020 in sheep, and 0.124 and 0.114 in goats). In view of these results, it may be concluded that the efficacy of PCR for the diagnosis of SRLVs is low and a combination of PCR and ELISA should be used for diagnosis.

Application of fluorescence in situ hybridization as a diagnostic tool in melanocytic lesions, using paraffin wax-embedded tissues and imprint-cytology specimens

BACKGROUND

Accurate histopathological diagnosis of certain melanocytic skin lesions as benign or malignant can be notoriously difficult. Recently, four-colour fluorescence in situ hybridization (FISH) has emerged as an important tool for classifying these lesions.

AIM

To evaluate the sensitivity and specificity of a melanoma FISH probe kit for accurate diagnosis of melanocytic tumours, and to validate its use with imprint-cytology specimens from the cut surface of tumours.

METHODS

In total, 50 melanocytic skin lesions (31 malignant melanomas, 10 benign melanocytic naevi, and 9 histologically challenging benign melanocytic skin lesions) were evaluated. The samples comprise 47 tissue specimens embedded in paraffin wax, and three imprint-cytology specimens from the cut surface of melanomas. FISH was performed using four locus-specific identifier probes [Ras responsive element binding protein (RREB)1, myeloblastosis viral oncogene homologue (MYB), cyclin (CCN)D1 and centromere of chromosome (CEP)6], and results were compared with the clinical long-term follow-up and histopathological diagnosis data.

RESULTS

The melanoma FISH probe distinguished between naevi and melanomas with a sensitivity of 100% and a specificity of 94.1%. The most sensitive criterion was a gain in 6p25 (RREB1), seen in 100% of cases, followed by CEP6-related MYB loss (48.1%), CCND1 gain (37%) and MYB gain (22.2%). More than three-quarters (77.8%) of melanomas were positive for two or more criteria. Positive FISH results were also obtained for the imprint-cytology specimens.

CONCLUSIONS

FISH is a valuable diagnostic tool for differentiating between benign and malignant melanocytic lesions, providing a high degree of sensitivity and specificity. The probes displayed exceptional discriminative capacity in difficult or ambiguous lesions. To our knowledge, his is the first reported use of imprint-cytology specimens for FISH diagnosis.

[Advances in our knowledge of the causation and pathophysiology of reflex epilepsies]

AIMS

In recent years our knowledge of the pathophysiology and aetiology of reflex seizures and epilepsies has advanced significantly due to the contributions made by modern functional neuroimaging and neurophysiology techniques, as well as the findings of research being conducted in molecular biology. The aim of our review is to summarise and integrate these contributions in order to describe the current state of our knowledge on the subject.

DEVELOPMENT

The fundamental pathophysiological pattern is common to all types of reflex epilepsy and is based on the existence of a hyperexcitable cortical or subcortical neuronal area that can respond to a physiological stimulus in an exaggerated manner. This focal hyperexcitability may derive from a predisposing genetic substrate (idiopathic reflex epilepsy) or from a focal cortical lesion (lesional reflex epilepsy). Some genetic substrates have been reported in isolated families and there are many candidate genes, but we still do not know enough about the genetic base. The lesion-based aetiology is very heterogeneous, but disorders affecting cortical development are the lesions with the greatest capacity to cause reflex epilepsy. Clinical expression is conditioned by the topography of the lesion and not by the type of underlying lesion.

CONCLUSIONS

Future characterisation of reflex epileptic seizures and syndromes must include a diagnosis centred around three axes, that is, topographic, lesional and genetic.

[Acute disseminated encephalomyelitis due to hymenoptera stings]

INTRODUCTION

Hymenoptera stings can give rise to a variety of conditions. The most common is a self-limiting local allergic reaction, but occasionally they may produce potentially serious systemic reactions. Neurological complications are rare, but very varied and of differing degrees of severity. Some such consequences are those of a demyelinating nature, which can affect the central and/or peripheral nervous system. Their exact pathogenesis remains unknown but an autoimmune mechanism has been suggested.

CASE REPORT

We report the case of a 28-year-old female who had a clinical picture compatible with acute disseminated encephalomyelitis ten days after being stung several times by a bumblebee. The diagnosis was based on findings from magnetic resonance imaging and on the clinical-radiological course after a one-year follow-up. The patient was treated with massive doses of intravenous corticosteroids and immunoglobulins, which brought about partial recovery from the neurological deficit.

CONCLUSIONS

Hymenoptera stings can produce demyelinating neurological complications, presumably related to the autoimmune system, which could benefit from treatment with immunomodulators such as corticosteroids, immunoglobulins or plasmapheresis.

[Migraine prophylaxis with calcium antagonists: a haemodynamic study using transcranial Doppler ultrasound]

INTRODUCTION

Despite its widespread use, a good explanation for the mechanism of action of calcium antagonists (CA) in the prophylaxis of migraine has still not been proposed.

AIMS

To determine whether nicardipine and flunarizine therapy is capable of inducing changes in the brain haemodynamics of migraine sufferers that lend support to a vascular mechanism of action for these drugs, as evaluated by transcranial Doppler ultrasound (TCD).

PATIENTS AND METHODS

We present a prospective, descriptive study based on observation conducted in a Neurology outpatients department. Patients between the ages of 16 and 50 with migraine (following IHS criteria) who were being treated with nicardipine and flunarizine as a prophylactic measure and did not fulfil any of the exclusion criteria were selected consecutively. The TCD study was performed before and during treatment with CA (flunarizine or nicardipine), for a minimum of one month. The following haemodynamic variables were determined: mean speed, Gosling's pulsatility index and cerebrovascular reserve, determined by the breath holding index. Pre and post-prophylaxis variables were compared using the Wilcoxon signed rank test.

RESULTS

Eight patients with migraine were included in the study and no significant differences in any of the three haemodynamic variables were observed between the values obtained prior to or during treatment.

CONCLUSIONS

The absence of haemodynamic changes in TCD does not lend support to a vascular mechanism of action for CA in migraine.

[Malignant middle cerebral artery infarction: medical or surgical treatment?]

INTRODUCTION

Post-ischemic brain edema occurs in 10-20% of cases of infarction of the middle cerebral artery and is the main cause of early death following a completed stroke. This complication, which is known as malignant middle cerebral artery infarction (MMCI), has a mortality rate of 78% when treated medically and thus requires a different management, such as a decompressive craniectomy. The main aim of this study is to review this procedure.

DEVELOPMENT

We conducted a search in the literature published over the last 20 years on this subject. Most of the studies are series of clinical cases with very favourable surgical outcomes. In non-random case-control studies the mortality rate was seen to decrease in the surgical group, and more so if the intervention was carried out early, as compared to the group that underwent medical treatment. Another study that compared decompressive craniectomy with hypothermia showed a higher survival rate in the surgical group. The post-surgery morbidity rate has not been determined, although it seems to be lower in infarction of the non-dominant hemisphere and in younger patients.

CONCLUSIONS

The low degree of conclusiveness of the studies published to date only enables us to offer one practical opinion concerning this issue: decompressive craniectomy should be evaluated on an individual basis in patients with MMCI who do not respond to medical treatment. The final decision and the most appropriate moment to operate on the patient following the stroke must be based on the family's opinion and on the clinical features of the patient.

[Room tilt illusion: Report of two cases and terminological review]

The room tilt illusion is a transient misperception of the visual image as tilted on its side or even upside down; in this case it has been termed acute upside down reversal of vision. We report on two cases of room tilt illusion as manifestation of VIII nerve neuritis (herpes-zoster infection) and cerebellar hemorrhage. Room tilt illusion has been reported in association with vertebrobasilar stroke, migraine, multiple sclerosis, epilepsy and labyrinthine disorders. The pathophysiology of this rare visual illusion has been related to a lesion of the visual or vestibulo-otolith pathways. In animals the neurones of the parieto-insular vestibular cortex areas are multisensory. So, they can respond to somatosensory, optokinetic and visual stimuli. In humans the knowledge about vestibular cortex function and localization is less precise than in animals. However, we propose a disorder of multisensorial vestibular cortex, resulting from a lession of vestibular pathways or association cortex, as mechanism of this phenomenon.

[Mean velocity and pulsatile index in primary headaches]

INTRODUCTION

Several authors have used transcranial Doppler studies (DTC) in the study of changes occurring in migraine. They found an increase in mean velocity (VM) as compared with controls. However there are few studies of this in tension headache.

OBJECTIVE

To determine possible differences in VM and pulsatility index (IP) between patients with migraine and those with episodic tension headache by means of DTC.

PATIENTS AND METHODS

We studied 26 patients with migraine, 30 with episodic tension headache (criteria of the IHS) and 21 controls using DTC (Multi Dop P/TCD DWL). We determined the VM and IP of the middle cerebral arteries at a depth of 50 60 mm. Uni bivariate statistical analysis was done using the computer programme SPSS.

RESULTS

The VM were: 75.92 cm/s in migraine; 65.96 cm/s in episodic tension headache and 72.28 cm/s in the control group (the differences were not statistically significant: NS). The IP were: 0.80 in migraine and 0.76 in control and tension headache groups (NS). No differences were found either when the VM of migraine and tension headache were compared directly (p=0.067). The theoretical number of patients necessary for a study with results giving statistically significant tendencies was calculated as 44 in each group.

CONCLUSIONS

1. No statistically significant differences were found, probably due to lack of statistical power, since the migraine group showed a tendency to a higher velocity. 2. Further studies on larger numbers of patients are necessary to evaluate the differences between migraine and episodic tension headache.

Evaluation of virus excretion by cells persistently infected with the bovine leukaemia virus (BLV) using monoclonal antibodies

BACKGROUND

bovine leukaemia virus (BLV) is the causative agent of enzootic bovine leukaemia. Studies in vitro usually require the use of infected cell lines, mostly to produce antigen. Two of the most widely used cell lines are FLK-BLV and BLV-bat2.

OBJECTIVE

the dynamics of the excretion of BLV proteins and whole virus by the persistently BLV-infected cell lines mentioned above was studied using an indirect ELISA in combination with eight monoclonal antibodies (mAbs) and cow and rabbit serum.

STUDY DESIGN

tissue culture flasks were seeded with different concentrations of cells (13000-67000 cells per cm2, corresponding to 1-5 million cells per 75 cm2 flask) and were studied for 20 days. Samples (1.5 ml) were removed every 24 h and the presence of BLV proteins was determined using an indirect ELISA assay in which the antigen reaction with the monoclonal antibodies was evidenced by peroxidase labeled anti-mouse immunoglobulins.

RESULTS

cell line FLK-BLV produced a complete monolayer as early as 4 days after passage, 3 days earlier than BLV-bat2. Using mAbs, the amount of viral proteins in the supernatant showed a cyclic pattern, with two evident peaks at days ca. 8 and 16. These peaks occurred even in the absence of passage or medium change, which causes depletion of essential nutrients and acidity. In comparison to polyclonal serum, mAbs gave more clear and defined values and are useful for determining the dynamics of viral production.

CONCLUSION

when aiming for high viral yield, BLV should be harvested between days 6 and 8 after passage, when viral shedding is at its maximum. These results are very useful for preparing antigen for monoclonal antibody production, or for techniques such as ELISA or Western blot.

Comparative study of PCR as a direct assay and ELISA and AGID as indirect assays for the detection of bovine leukaemia virus

The choice of a diagnostic method depends on the characteristics of the herd to be analysed. Two herds with different prevalences of enzootic bovine leukaemia were chosen to study the concordance between agar gel immunodiffusion (AGID), enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR) methods. PCR, an increasingly used virological method, was performed with four sets of primers, amplifying different genomic regions (env, pol and tax), from DNA extracted either from peripheral blood monocytes (PBMCs) or milk leucocytes. The highest percentage of positive animals was obtained using PCR performed with DNA extracted from PBMCs using primers which amplified either env or pol, followed by PCR using PBMCs and primers which hybridized with tax, then ELISA using serum and finally AGID. The results of PCR were more consistent with PBMCs than when milk leucocytes were used.

Seroepidemiological survey of infection by feline leukemia virus and immunodeficiency virus in Madrid and correlation with some clinical aspects

A study of 180 healthy cats found that 15.6% were feline leukemia virus (FeLV) positive, 8.3% were feline immunodeficiency virus (FIV) positive, and 1.1% were FIV and FeLV positive, which corresponded to 30.4, 13.8, and 2.6, of 115 cats with FIV- and FeLV-related symptoms, respectively. Differences were seen in the sexes and ages of the populations studied. Anemia, leukopenia, and lymphopenia were the most frequent hematological abnormalities in infected cats.

[Cerebrovascular reactivity by means of the breath holding index (voluntary apnea): the reliability of early repetition]

INTRODUCTION

The Breath Holding Index (BHI) is a non-invasive method for evaluation of cerebrovascular reactivity, the results of which correlate with those obtained by using intravenous acetazolomide and CO2 inhalation, so that it can be used as an alternative method to these in cooperative patients. However, the technique is not completely defined. Therefore Markus et al make a second measurement of the BHI 2-3 minutes later and take the arithmetical mean of the two readings as the final result.

OBJECTIVES

To assess the intra-observer concordance between two BHI obtained with less than two minutes difference, and therefore whether the second index obtained may be used as an indicator of cerebrovascular reactivity.

PATIENTS AND METHODS

Our study included 18 patients (7 men and 11 women; average age: 28.8 years; limits 17-50 years) with primary headache and no known cerebrovascular disease, diabetes mellitus or arterial hypertension. Using transcranial Doppler 28 measurements of the BHI (BHI1) were made in the middle cerebral arteries (right and/or left) in a similar way to that described by Markus. Once the average arterial velocity returned to basal levels the procedure was repeated in the first two minutes (BHI2) after the first index. Statistical analysis was done using the Student's t test and the kappa index between the two BHI after taking 0.8 as the cut-off point.

RESULTS

The BHI2 (average +/- DT: 0.79 +/- 0.34) was significantly lower than that of BHI1 (average +/- DT: 1.04 +/- 0.44) (p < 0.005, t = 3.683). The kappa index between the two indices was very low: 0.058 +/- 0.158.

CONCLUSION

The BHI2 is not a reliable index of cerebrovascular reactivity since it under-estimates it in relation to the previous index, even when the average arterial velocity has returned to basal levels.

[Paroxysmic anarthria in multiple sclerosis]

INTRODUCTION

The paroxystic clinical features of multiple sclerosis (MS) include trigeminal neuralgia, itch, transient diplopia, Lhermitte's sign, akinesia, dystonia, Uhthoff's phenomenon and others which are very characteristic, such as paroxystic ataxia and dysarthria.

CLINICAL CASE

We present the case of a 30 year old man who consulted for multiple episodes lasting only a few seconds, of complete inability to speak. This symptom recurred several times a day and in many different situations. It was often triggered off by external stimuli such as having to speak in front of several people. The disorder disappeared without treatment seven days after onset. Magnetic resonance using fast spin echo image sequences showed multiple hyperintense lesions in mid right cerebellar peduncle, right pons, left temporal lobe, white substance of both internal capsules, periventricular and semioval centres. Biochemical study of the cerebrospinal fluid showed that there were 9 cells/microliter (mainly lymphocytes), proteins 45 mg/dl and a normal glucose level. The Tibling-Link level was 0.73. Cortical somestesic evoked potentials showed slowed conduction after stimulation of the right median nerve and both peroneal nerves. Acoustic evoked potentials of the brain stem were conducted more slowly by the right acoustic pathway at intraxial level. The patient was diagnosed as having clinically defined MS.

CONCLUSIONS

We consider that our patient's symptom was a kind of paroxystic dysarthria which we call paroxystic anarthria. Differential diagnosis of this symptom should be basically with phonatory or dysphasic simple partial seizures.

[Prevention and treatment of headache due to intracranial hypotension]

INTRODUCTION

In spite of the large number of authors who have studied headache following lumbar puncture and spontaneous intra-cranial hypotension, many aspects remain little known, and there is still no completely satisfactory non-invasive treatment.

DEVELOPMENT

In one group of patients there is an increased risk of post lumbar-puncture headache: adults between 20 and 50 years old, of low body weight and a previous history of chronic bilateral headache. In these patients all possible prophylactic measures should be taken whilst the lumbar puncture is being performed, so as to avoid the onset of headache. Use of modern atraumatic needles of small diameter and with a lateral opening have been shown by many studies to be satisfactory. There are also other manoevres which help to reduce the frequency of post lumbar-puncture headache, such as the insertion and withdrawal of the needle with the bevel parallel to the fibres of the dura mater and reinsertion of the stylet before withdrawing the needle. Once the patient has developed post lumbar-puncture headache, or spontaneous intracranial hypotension, initially treatment with cerebral vasoconstrictors such as oral caffeine may be used. After a period of time (2-4 weeks) which makes spontaneous regression of the headache unlikely, the treatment of choice involves epidural patches.

CONCLUSION

Well-designed studies are necessary to demonstrate the efficacy of oral caffeine (and other drugs) in post lumbar-puncture headache.

[Intracerebral hemorrhage and treatment with platelet aggregation inhibitors: study of 21 cases]

INTRODUCTION

The place of platelet antiaggregants in the aetiology of intracerebral hemorrhage (IH) has not been extensively studied.

OBJECTIVE

To analyze the characteristics of IH in patients treated with platelet antiaggregants and the possible clinical and prognostic differences from other primary IH.

PATIENTS AND METHODS

A retrospective study of patients admitted to hospital with primary IH from 1985 to 1997. The cases were IH patients while being treated with platelet antiaggregants. For each case we selected two controls with IH and similar age and IH risk factors. The following data was analyzed: start of clinical condition; type, dose, indication and duration of treatment with antiaggregants; mortality, localization, volume and extension of IH to the ventricles. The last four variables were compared with the control group using the ji squared test (chi 2) and the t student test.

RESULTS

21one patients had a primary IH while being treated with antiaggregants: 20 with salicylates (17 aspirin and 3 riflusal) and one with ticlopidine. The dose of aspirin was 500 mg or less in 90% of the cases. In the group treated with salicylates, this was given for more than 20 months in 90% of the cases. Initially there was no clinical progression in any case. No significant differences were observed between the variable compared, although there was a tendency to greater volume, extension to the ventricles and mortality in the group treated with antiaggregants.

CONCLUSIONS

More studies with larger numbers of patients are necessary to be able to confirm the tendencies observed.

[Auditory changes in spontaneous intracranial hypotension]

Descriptive report dealing with the auditive disturbances of 3 patients with spontaneous intracranial hypotension, disorder typified for orthostatic cephalea without a know ground explaining the descent of the cerebrospinal fluid pressure. The patients presented with hypoacusis, hyperacusis, feeling of plenitude, blockade and ear pressure. The clinical picture is supposed to be linked to a low endolabyrinthine pressure, secondary to an intracranial hypotension. Review of auditive symptoms reported in the bibliography among individuals showing benign intracranial hypertension and intracranial hypotension owing to several causes.

[Intracranial hemorrhage with fluid level. A case report without coagulation alterations]

The presence of intracranial hemorrhage with a fluid-blood level in patients receiving anticoagulant medication or with coagulopathy is an infrequent but well-documented complication. We reported a patient with a fluid-blood level with normal haemostasis. A 62-year-old-man was admitted with a left putaminal hemorrhage containing a fluid-blood level, but without abnormal haemostasis. Five months later the patient returned to the hospital because of a transient ischemic attack. A cranial CT demonstrated a hypodensity in the left putamen nucleus and corona radiata. Electrocardiogram revealed atrial fibrillation and a cardiac ultrasonographic examination showed mitral annulus calcification and left atrial enlargement. The finding of intracranial fluid-blood level has been seen in patients with arteriovenous malformations, primary and metastatic neoplasm, radiation-induced necroses, cerebral amyloid angiopathy, intrainfarct hematoma and without any identified aetiology. We suggest that in our patient this disorder was due to a intrainfarct hematoma.

[Spontaneous intracranial hypotension. Radiological findings]

INTRODUCTION

Spontaneous intracranial hypotension (SIH) is an uncommon condition. The main symptom is headache which appears on standing and is relieved by lying down. Diagnosis is confirmed if a CSF pressure of less than 6 cm of water is found in the absence of other causes of intracranial hypotension.

OBJECTIVE

To describe the cranial MR and CT findings of 7 cases with SIH.

MATERIAL AND METHODS

We studied 7 patients in whom the diagnosis had been confirmed by lumbar puncture. The findings of 5 cranial CT studies (not using contrast), 5 MR without gadolinium and 4 MR with gadolinium were studied. The CT were carried out during the first week after clinical signs appeared, and the MR at between 1 week and 4 months after onset. We reviewed previous findings in the literature.

RESULTS

1. Cranial CT: in one case there was an enlarged subarachnoid space; 2. MR without gadolinium: there was descent of the cerebellar tonsils in 4 patients, meningeal thickening in 5 cases and subdural collections in two patients. In no case was descent of the iter seen; 3. MR with gadolinium: aural contrast was taken up in all cases.

CONCLUSIONS

The CT without contrast done at the onset of the condition did not usually give data which was useful for diagnosis. The principal MR findings in our series (meningeal thickening, descent of the cerebellar tonsils, subdural collections and gadolinium uptake) in an appropriate clinical context may be sufficient for diagnosis of this condition before lumbar puncture.

[Cerebrovascular stroke, the cause of the death of the caliph al-Hakam II]

al-Hakam II was the ninth sovereign in the Hispano-Omeyan dynasty and the second caliph of Spain under the Moors. In the night of the 1st of October 976 he died as the result of a disease that had afflicted him for two years old. Cerebrovascular stroke first manifested as hemiplegia. The disease that afflicted the caliph was called al-'illat alfalichiya, or alfeliche in Castilian Spanish, which means the disease of hemiplegia. The caliph was 61 years old and led a sedentary life and was therefore predisposed to suffer ischemic cerebrovascular events. Climate may have played a role in triggering the stroke. Several authors have found that the incidences of ischemic infarcts and intracranial hemorrhages increase during the winter months and on cold days, particularly in patients under 65. The chronicler of the al-Razi period tells us that heavy snow fell in and around Córdoba in 974 and that the following months saw rain and strong winds. We can deduce that caliph al-Hakam II died of a cerebrovascular event and that, based on the few data available, it is likely that the infarction was ischemic and of atherothrombotic origin. Caliph al-Hakam II moved his household from Madinat al-Zahra' to Alcázar de Córdoba as a result of the "recommendation of his doctors because the cold of the Sierra stirred up his humors". This interpretation is correct according to Arab medicine, which is following the line of the ancient Greeks regarding natural faculties, the elements and their corresponding humors.