Cerebral amyloid angiopathy-related inflammation: clinical features and treatment response in a case series

INTRODUCTION

Cerebral amyloid angiopathy-related inflammation (CAA-ri) is an entity characterised by an inflammatory response to β-amyloid deposition in the walls of cerebral microvessels.

METHODS

We conducted a retrospective review of a series of patients with a diagnosis of CAA-ri according to histopathological study findings or clinical-radiological diagnostic criteria.

RESULTS

The study included 7 patients (5 men) with a mean age of 79 years. Disease onset was acute or subacute in 6 patients. The most frequent symptoms were cognitive impairment (n = 6), behavioural alterations (n = 5), epileptic seizures (n = 5), focal neurological signs (n = 4), and headache (n = 2). Cerebrospinal fluid was abnormal in 3 patients (lymphocytic pleocytosis and high protein levels). The most frequent MRI findings were microbleeds (n = 7), subcortical white matter hyperintensities on T2-FLAIR sequences (n = 7), and leptomeningeal enhancement (n = 6). Lesions were bilateral in 3 patients and most frequently involved the parieto-occipital region (n = 5). Amyloid PET studies were performed in 2 patients, one of whom showed pathological findings. Two patients underwent brain biopsy, which confirmed diagnosis. All patients received immunosuppressive therapy. An initially favourable clinical-radiological response was observed in all cases, with 2 patients presenting radiological recurrence after treatment withdrawal, with a subsequent improvement after treatment was resumed.

CONCLUSIONS

Early diagnosis of CAA-ri is essential: early treatment has been shown to improve prognosis and reduce the risk of recurrence. Although a histopathological study is needed to confirm diagnosis, clinical-radiological criteria enable diagnosis without biopsy.

[From in-person didactic sessions to videoconferencing during the COVID-19 pandemic: satisfaction survey among participants]

INTRODUCTION AND AIM

COVID-19 pandemic has disturbed many hospital activities, including medical education. We describe the switch from in-person didactic sessions to videoconferencing in a Neurology department. We analyse the opinions and satisfaction of participants.

MATERIAL AND METHODS

Narrative description of the adopted measures; Online survey among participants.

RESULTS

One of the three weekly sessions was cancelled, and two switched to videoconferencing. There were more participants online than in the conference hall. 49 users answered the survey, 51% women, mean age 40.5 years (range 25-65). Satisfaction was higher for previous face-to-face meetings (8.68) than for videoconferencing (8.12) (p=0.006). There was a significant inverse correlation between age and satisfaction with virtual sessions (r=-0.37; p=0.01), that was not found for in-person attendance. Most users (75.5%) would prefer to continue with online sessions when the pandemic is over, and 87.8% support inter-hospital remote meetings, but the safety of web platforms is a concern (53.1%).

CONCLUSIONS

The change from in-person to virtual sessions is an easy measure to implement in a neurology department, with a good degree of satisfaction among users. There are some unsolved problems with the use of commercial web platforms and inter-hospital connection. Most users recommend leadership and support from educational and health authorities.

Cerebral amyloid angiopathy-related inflammation: clinical features and treatment response in a case series

INTRODUCTION

Cerebral amyloid angiopathy-related inflammation (CAA-ri) is an entity characterised by an inflammatory response to β-amyloid deposition in the walls of cerebral microvessels.

METHODS

We conducted a retrospective review of a series of patients with a diagnosis of CAA-ri according to histopathological study findings or clinical-radiological diagnostic criteria.

RESULTS

The study included 7 patients (5 men) with a mean age of 79 years. Disease onset was acute or subacute in 6 patients. The most frequent symptoms were cognitive impairment (n = 6), behavioural alterations (n = 5), epileptic seizures (n = 5), focal neurological signs (n = 4), and headache (n = 2). Cerebrospinal fluid was abnormal in 3 patients (lymphocytic pleocytosis and high protein levels). The most frequent MRI findings were microbleeds (n = 7), subcortical white matter hyperintensities on T2-FLAIR sequences (n = 7), and leptomeningeal enhancement (n = 6). Lesions were bilateral in 3 patients and most frequently involved the parieto-occipital region (n = 5). Amyloid PET studies were performed in 2 patients, one of whom showed pathological findings. Two patients underwent brain biopsy, which confirmed diagnosis. All patients received immunosuppressive therapy. An initially favourable clinical-radiological response was observed in all cases, with 2 patients presenting radiological recurrence after treatment withdrawal, with a subsequent improvement after treatment was resumed.

CONCLUSIONS

Early diagnosis of CAA-ri is essential: early treatment has been shown to improve prognosis and reduce the risk of recurrence. Although a histopathological study is needed to confirm diagnosis, clinical-radiological criteria enable diagnosis without biopsy.

[Major neurological complications of genitourinary cancers]

INTRODUCTION

Genitourinary cancers constitute a heterogeneous and increasingly frequent group of malignant tumors that have the potential to derive directly, or indirectly from the treatment applied, in a series of neurological complications that negatively impact on the quality of life of the patients who suffer them.

AIMS

To report the most relevant data on the main neurological complications of genitourinary cancers.

DEVELOPMENT

We conducted a PubMed search for articles, latest books, leading clinical practice guidelines, and scientific societies, regarding the appearance of such complications.

CONCLUSIONS

Neurological complications of genitourinary cancers generate a significant burden of morbidity and mortality in cancer patients. In a paradoxical manner, owing to the raised survival of these patients, the likelihood of metastatization at the nervous system level and/or adverse effects related to the treatment received, especially due to chemotherapy, is also increased. Currently, diagnosis and management of neurological complications associated with genitourinary cancers represent a very important area of growing interest for the development of research projects that allow to improve the prognosis and quality of life genitourinary cancers subjects and their relatives and/or caregivers. For this purpose, it is necessary to know more about the etiopathogenesis and pathophysiology that leads to the occurrence of these type of complications in genitourinary cancers individuals, in particular paraneoplastic syndromes. Moreover, on the other hand, to carry out further well-designed randomized controlled clinical trials that expand the therapeutic arsenal with new chemotherapeutic drugs that possess a better antineoplastic effectiveness and improve the safety related to the neurotoxic side effects.

TARDBP mutation associated with semantic variant primary progressive aphasia, case report and review of the literature

Semantic variant primary progressive aphasia (svPPA) is a clinical syndrome included in the frontotemporal dementia (FTD) spectrum. Unlike other forms of FTD, it is sporadic in the majority of cases and not commonly associated with motor neuron disease (MND). We describe a case of svPPA associated with MND in the same family, due to a mutation of the transactive response DNA binding protein (TARDBP) gene, and review the literature.

Slowly progressive behavioral frontotemporal dementia with C9orf72 mutation. Case report and review of the literature

We present a 86-year-old woman without relevant medical history and two brothers who died by dementia, who started at 55 years with depression and personality changes with ongoing worsening (>30 years) and functional decline. Screening dementia blood test and brain magnetic resonance imaging did not show results that pointed to a secondary cause. The patient met the diagnostic criteria for possible behavioral frontotemporal dementia with a slow progression (bvFTD-SP), suggesting a benign variant. A genetic study confirmed a C9ORF72 hexanucleotide expansion, making this the sixth case mentioned in the literature. We review and discuss the other cases described previously.

Dyskinesia and motor state detection in Parkinson's disease patients with a single movement sensor

Parkinson's Disease (PD) is a neurodegenerative disease that alters the patients' motor performance. Patients suffer many motor symptoms: bradykinesia, dyskinesia and freezing of gait, among others. Furthermore, patients alternate between periods in which they are able to move smoothly for some hours (ON state), and periods with motor complications (OFF state). An accurate report of PD motor states and symptoms will enable doctors to personalize medication intake and, therefore, improve response to treatment. Additionally, real-time reporting could allow an automatic management of PD by means of an automatic control of drug-administration pump doses. Such a system must be able to provide accurate information without disturbing the patients' daily life activities. This paper presents the results of the MoMoPa study classifying motor states and dyskinesia from 20 PD patients by using a belt-worn single tri-axial accelerometer. The algorithms obtained will be validated in a further study with 15 PD patients and will be enhanced in the REMPARK project.

Epilepsy training needs for Spanish neurologists: ARPE study results

INTRODUCTION

This study was designed to create an updated training program on epilepsy to solve whatever problems that general neurologists may detect in patients during consults.

OBJECTIVES

To understand general neurologists' training needs in order to plan a specific program that may improve/standardize the clinical management of patients with epilepsy.

MATERIAL AND METHODS

122 general neurologists non-subspecialized on epilepsy were surveyed in all regions of Spain regarding the following issues: initial diagnosis, treatment, special situations by population group and/or comorbidity, prognosis and follow-up as well as whatever other topics the training program should cover.

RESULTS

Neurologists agreed that treatment was the most interesting topic for them (100%), followed by diagnosis (46.67%), special situations by population group and/or comorbidity (30%), and prognosis/follow-up (7.14%). There were insignificant differences attributable to age and sex.

CONCLUSIONS

Training ensures success, provided that it takes into account pedagogical considerations and professional targets to be trained, as well as technological and formal issues.

[The role of lithium in neurodegenerative diseases: new registries for old actors]

INTRODUCTION

Lithium has been used for more than one century in medicine. Currently, it is used effectively in acute phase treatment and in the prevention of manic-depressive symptoms of patients with bipolar disorder. Lithium acts by inhibiting a protein- kinase called glycogen synthase kinase 3 (GSK3) that has important actions on the intracellular signal transmission by protein phosphorylation.

METHOD

A review has been made of the studies conducted in vivo and in vitro on the utility of lithium in animal models of neurodegenerative disease and its efficacy in studies performed in humans.

DEVELOPMENT

Research on lithium on GSK-3 inhibition in animal models of disease with aggregates of hyperphosphorylated protein tau and Alzheimer's disease has provided promising results. Inhibition of this enzyme also seems to have a neuroprotector effect in other neurodegenerative disease models such as amyotrophic lateral sclerosis, spinocerebellar ataxia type 1 and Huntington's disease. There is indirect evidence in humans on a possible neuroprotector effect in chronic patients with bipolar disorder and on slow down of the progression of the disease in patients with amyotrophic lateral sclerosis.

CONCLUSIONS

Lithium, and in a more extensive way, GSK-3 inhibitors, are proposed as a new drug generation with potential action on the progression of different neurodegenerative diseases, especially those related with abnormal aggregation of the protein tau.

[Prognostic factors of functional recovery in very elderly stroke patients. A one-year follow-up study]

INTRODUCTION

Although an advanced age is a factor associated to a poorer functional prognosis following a stroke, the capacity for recovery can be determined by other intercurrent clinical, functional and mental factors.

AIM

To evaluate the factors that determine the functional prognosis on discharge of very elderly patients who were admitted to hospital for their functional recovery after suffering a stroke.

PATIENTS AND METHODS

We conducted a longitudinal observational study of 168 patients over 65 years of age, who were hospitalised consecutively over a 15-month period. On admission, data concerning a number of clinical, neurological, functional and mental variables were collected. On being discharged from hospital their functional situation (Barthel index) and institutionalisation were evaluated.

RESULTS

The 48 patients aged 85 and above presented a lower degree of overall and relative functional recovery on discharge from hospital. Nevertheless, 52% had gained more than 20 points on the Barthel index on being discharged with respect to their score when they were admitted; on discharge 44% had recovered over 50% of the functional loss they had suffered following the stroke. On including the other basal variables in a logistic regression analysis, a very advanced age was associated in an independent manner to a greater risk of being institutionalised, but not to a poorer functional prognosis at discharge. Severe functional impairment on admission and post-stroke depression were the factors that were independently associated to moderate-severe disability on admission; in addition, the more severe the neurological consequences were, the lower the level of functional recovery was.

CONCLUSIONS

The capacity for functional recovery in very elderly stroke patients is mainly determined by the degree of functional and neurological repercussion. The functional prognosis should be individualised according to these factors, regardless of the age.

[Unilateral apraxia of eyelid closure in ischemic stroke: role of the right hemisphere in the emotional gesture communication]

INTRODUCTION

Apraxia of eyelid closure (AEC) is an infrequent disorder that is characterised by the inability to close the eyelids on command, although spontaneous blinking and reflex shutting of the eyes is preserved. Very few cases of unilateral AEC have been reported and no long-term follow-ups have been carried out. We report the case of a patient with unilateral AEC that was followed up over a 3-year period and also discuss the role played by the right hemisphere in this disorder. CASE REPORT" We examined the case of a 67-year-old right-handed male who was admitted because of a parietotemporal infarction with extension into the subcortex. A few days after the stroke the patient reported the inability to close his left eye on command, although he was still able to blink spontaneously and the blink and visual threat reflexes were preserved. This deficiency was associated to a dense hemiparesis on the left side and notable aprosodia affecting language. At 3 years' follow-up the AEC had not improved significantly.

CONCLUSIONS

There are data to suggest that the right hemisphere is related to emotional perception and expressiveness, as well as the regulation of language prosody. Likewise, symbolic anthropology stresses the importance of winking as a gesture involved in non-verbal communication. These data suggest that AEC may be a consequence of a dysfunction of the role played by the right hemisphere in emotional expressiveness through gestures. The association with language aprosodia could support this hypothesis.

[Prior authorisation to visit the neurologist from primary care may not be necessary: the findings of a prospective, controlled study]

INTRODUCTION

The system by which approval must be given by the primary care physician before a patient can visit a specialist is known as gatekeeping and is aimed at preventing the mistaken or simple referral of patients to the next stage of health care services. We present a study that compares the final diagnoses of 400 patients who used a direct access model of referral (DAM) with those of 400 patients referred by a primary care physician in a prior authorisation model (PAM).

PATIENTS AND METHODS

We conducted a prospective analysis of two cohorts of patients who visited the same neurologist in a PAM system versus a DAM system. The 800 patients were evaluated following similar diagnostic criteria. The primary objective of the study was to compare the patients who were referred with a final diagnosis of 'non-neurological pathology' in the PAM and the DAM systems. Secondary aims consisted in conducting an analysis of the diagnoses by different pathologies between the two models.

RESULTS

No significant differences were found between the referrals that were considered to be non-neurological in the PAM and the DAM systems (27.0% versus 26.3%; p = 0.48). A logistic regression model was performed with 'non-neurological pathology' as the dependent variable and age, sex and type of model (PAM or DAM) as the independent variables, similar results being obtained in both cases.

CONCLUSIONS

Our data suggest that the role played by the primary care physician is not effective when it comes to preventing mistaken referrals to the neurologist in our area. A populational study would be needed to evaluate the rate at which resources are used and the spending on health care in the two models.

[The importance of neurological examinations in the age of the technological revolution]

INTRODUCTION

Neurologic practice and care have been modified in many important ways during the past ten years, to adapt to the explosion of new information and new technology. Students, residents and practicing physicians have been continuing programs to a model that focuses almost exclusively on the applications to neurologic disorders of the new knowledge obtained from biomedical research. On the other hand high demand for outpatient neurologic care prevents adequate patient's evaluation.

CASE REPORTS

Case 1: 65 years old female. Occipital headache diagnosed of tensional origin (normal computerized tomography). Two months later is re-evaluated due to intractable pain and hypoglossal lesion. An amplified computerized tomography revealed a occipital condyle metastasis. Case 2: 21 years old female. Clinical suspicion of demyelinating disease due to repeated facial paresis and sensitive disorder. General exploration and computerized tomography revealed temporo-mandibular joint. Case 3: 60 years old female. Valuation of anticoagulant therapy due to repeated transient ischemic attacks. She suffered from peripheral facial palsy related to auditory cholesteatoma.

CONCLUSIONS

Neurologic education is nowadays orientated to new technologies. On the other hand, excessive demand prevents adequate valuation and a minute exploration is substituted by complementary evaluations. These situations generate diagnostic mistakes or iatrogenic. It would be important a consideration of the neurologic education profiles and fulfillment of consultations time recommendations for outpatients care.

[Transient cerebral oedema associated to hypoglycaemia]

INTRODUCTION

In the adult, hypoglycaemia is documented as a consequence of overdose of insulin or oral hypoglycaemic agents. Neonatal hypoglycaemia is common but rarely symptomatic due to protective mechanisms. Very few reports on hypoglycaemic injury are available in adults and most of them in patients with poor outcome.

CASE REPORT

Woman, 45 years old. She is referred to emergency room due to insulin overdose and coma of unknown duration. Glucose level was 15 mg% without other metabolic anomalies. Computerized tomography revealed brain oedema most obvious in the parieto-occipital lobes. Therapy with manitol and glucose was started with total functional recovery.

CONCLUSIONS

Brain imaging in neonatal hypoglycaemia shows similar findings. In the acute phase oedema in the parieto-occipital cortex and underlying white matter and atrophy or malacic cysts in the chronic phase have been described. Chronic changes are related to long-term sequelae that vary from development delay and epilepsy to persistent vegetative state. In adults lesions involve hippocampus and basal ganglia. The reasons of different sensitivity of these regions are not fully clear. Differences in regional blood flow autoregulation or in excitotoxins receptors of aspartate have been postulated. Hypoglycaemia may induce blood-brain-barrier permeability and subsequently brain oedema.

[The role of slow wave sleep in the homeostatic regulation of sleep]

OBJECTIVES

The homeostatic regulation of sleep is based on the model devised by Borb ly in 1982. During the sleep waking cycle there is an interaction between the natural tendency to sleep, which increase as the vigil is prolonged (S process) and the circadian variation (C process). In this study, we aimed to find how slow activity (0.5 4.5 Hz) during sleep (SWA), mainly registered in phases 3 and 4, may be an indicator of process S.

PATIENTS AND METHODS

We compared two groups of persons: 10 with chronic sleep deprivation (CSD) (less than 6 hours of sleep/day) as compared with 10 persons who slept more than 6 hours per day, using spectral analysis of their delta activity during sleep.

RESULTS

There was a predominance of delta activity in the group of persons with CSD as compared with the control group.

CONCLUSIONS

An increase in SWA was accompanied by an increased tendency to sleep and may therefore be considered to be a marker for this. This marker allows conditions associated with hypersomnolence due to alteration of process S to be identified.

[Nonconvulsive status epilepticus: experience in 33 patients]

BACKGROUND

To review the nonconvulsive status epilepticus diagnosed in a general hospital in order to identify its frequency, electroclinical characteristics and response to medical treatment. PATIENTS ANTS AND METHODS: A retrospective study of 33 cases of nonconvulsive status epilepticus was undertaken. The diagnosis was based on clinical and EEG manifestations. Data regarding their clinical presentation, previous epilepsy, etiology of the status, its medical management and outcome were analysed.

RESULTS

The 33 patients comprising the study included 20 men and 13 women. The medium age was 49.8 years. A previous history of epilepsy was present in 51.5% of them. Most of the patients presented impaired consciousness (39.4%) or confusional state (36%). The mean duration of the disorder did not exceed 24 hours (64.5%). There were five cases of absence status and 28 of complex partial status, two of them with secondary generalization. A precipitating factor was found in 80% of the patients and the cerebrovascular etiology was the most frequent. There was a good response to phenytoin (80%), although in the first month death was the final outcome for 25% of them.

CONCLUSIONS

Nonconvulsive status epilepticus is an underdiagnosed medical emergency because of its different manifestations, similar to confusional or psyquiatric states. The precipitating factor determines its outcome. A high index of suspicion is needed in order to make a faster diagnosis and treatment.

[MELAS syndrome masquerading as herpes encephalitis: genetic diagnosis]

INTRODUCTION

MELAS syndrome (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke like episodes) is a mitochondrial disease related to the mitochondrial DNA mutation. The tRNALeu(UUR) mutation at the base pair 3234 is associated to 80% of cases of MELAS syndrome. The onset with the stroke like episodes is often before the age 40. Herpes simplex encephalitis (HSE) presents as acute episodes of focal neurologic deficit that are often related to the temporal lobe. Occasionally MELAS syndrome and HSE may have a similar clinical presentation.

CLINICAL CASE

A 33-year-old woman presented with seizures and a right parietotemporal syndrome of acute onset. The differential diagnosis between HSE and MELAS syndrome was established. MELAS syndrome was suspected based on her phenotype. The diagnosis of MELAS syndrome was confirmed by the presence of the mitochondrial tRNALeu(UUR) mutation at the base pair 3243.

CONCLUSION

The clinical presentation of the MELAS syndrome may mimic that of the HSE, and antiviral treatment should be given until the diagnosis of MELAS syndrome is definitive. The study of the mitochondrial DNA helps diagnosing in a non invasive way many patients with MELAS syndrome.

[Idiopathic spinal cord herniation. Presentation of a new case and review of the literature]

INTRODUCTION

Idiopathic herniation of the spinal cord is a rarely diagnosed condition. It is important since this cause of paraparesis is potentially curable if diagnosis is made early. Our aim is to report a new case, review the relevant literature, describe the radiological findings and consider the etiopathogenic findings.

CLINICAL CASE

We report the case of a 56 year old man with increasing difficulty in walking attributed to stenosis of the lumbar spinal canal, which did not improve after laminectomy. On examination he had sensory and motor deficits compatible with the Brown-Séquard syndrome. Dorsal MR showed ventral displacement of the thoracic spinal cord with disappearance of the anterior subarachnoid space together with a posterior arachnoid cyst at the same site. A further operation was done at the same place and the cyst removed. However, it was impossible to free the spinal cord since there was severe spinal arachnoiditis. The patient made little improvement.

CONCLUSIONS

Herniation of the spinal cord is a rarely diagnosed condition. After careful study of the literature it seems that all patients present in a similar manner. Clinically there is a disorder of gait compatible with the Brown-Séquard syndrome. On MR there is sudden ventral displacement of the thoracic spinal cord, associated in some cases with an arachnoid cyst. When surgery is effective there is great improvement, so this diagnosis should be remembered in all cases of progressive paraparesis.

[Reversible dementia in neurology outpatient clinics]

INTRODUCTION

The dementias are one of the commonest conditions seen in Neurology Clinics. Potentially reversible causes are described amongst the various aetiologies although there are doubts as to whether the use of indiscriminate testing to detect them is worthwhile.

OBJECTIVE

In a group of demented persons to determine how many had a potentially reversible condition and how many improved, in a prospective, descriptive study in a Neurology Outpatient Clinic.

PATIENTS AND METHODS

Using the Mini-Mental State Examination of Folstein and the DSM-III-R criteria for dementia, 121 demented patients were selected. An ordinary biochemical study was made (vitamin B12, thyroid hormones), serology (lues) and neuroimaging (cerebral CT), and when a potentially reversible condition was found, each case was treated. The patients treated were followed-up periodically for an average of 9.6 months (range 2 to 24 months).

RESULTS

A potentially reversible condition was seen in 19.8% of the patients. On prospective evaluation only 3.3% had reversible symptoms and in no case were these completely reversed. Improvement was seen in conditions of depressive pseudo-dementia.

CONCLUSIONS

Since some causes of dementia are reversible, the neurologist is obliged to investigate and seek these possible aetiologies. This study should be individualized according to clinical criteria to improve profitability of the complementary tests. Our results suggest that there are doubts as to the usefulness of indiscriminate investigation of possible reversible causes of the cases of dementia referred to Outpatient neurologists.

[Hypnic headache: a new case]

INTRODUCTION

Hypnic headache is a condition characterized by nocturnal episodes of headache which periodically waken the sleeping patient. They usually occur in persons over 55 years of age and are thought to be due to some type of disturbance of biological rhythm.

CLINICAL CASE

A 70 year old woman, with no relevant past history, complained that during the previous 12-14 months she had been woken from sleep by episodes of headache. The headache was diffuse, non-pulsatile and very intense. The duration was variable, from 15 to 45 minutes and usually disappeared without requiring analgesics. The pain was not associated with autonomic or ocular disorders, nausea, vomitting or focal neurological signs. Both general and neurological examinations were completely normal. No alterations were seen on cranial CT. Treatment with lithium was started and there was marked improvement in the frequency of headaches.

CONCLUSIONS

Hypnic headache is an unusual disorder characterized by episodes of holocranial, or rarely hemicranial, headache of moderate-severe intensity and periodic occurrence. Typically the headache wakes the patient whilst he is asleep ('alarm clock') and there are no autonomic or neurological alterations of any type associated with the episode. The condition usually affects persons over 55 years of age, and it has been related to changes in biological rhythms. This presumed alteration of biological pacemakers has been based on the periodicity of the episodes and the response to lithium.

[Spinal tumors in infancy. A report of 48 cases]

INTRODUCTION

Spinal tumours in infancy are an infrequent oncological disorder. The clinical features, usually of insidious onset, are alterations in gait and a painful spine.

OBJECTIVE

To analyze the different histological types of spinal tumours seen in infancy and their form of presentation in our series.

PATIENTS AND METHODS

We reviewed the clinical histories of 48 patients with intraspinal tumours, aged under 15 years, whose reports of histological diagnosis had been sent to our centre.

RESULTS

Of the patients studied, 17 were girls (35.4%) and 31 boys (64.6%) with an average age of 7.7 years. The histological diagnoses made most frequently were astrocytomas (22.9%) and lipomas (18.8%) followed by metastases (12.5%), ependymomas (8.3%) and Edwing's sarcoma (8.3%). The clinical features were present prior to diagnosis for between 1 and 6 months in 13 patients, and for less than one month in 9 patients. The presenting symptoms were alterations in gait and back pain in most patients. Exploratory tests were related to the involvement of long vias and second motor-neurone lesions. The main topographical findings were: in the axial plane the lesions were extradural (23 patients) and in the sagittal plane there was dorsal involvement (34 patients).

CONCLUSIONS

Insidious, progressive alterations in gait together with continuous, nocturnal back pain are valuable data when a serious spinal disorder is to be suspected. Early diagnosis should be based on neuroimaging tests, essentially MR, in the patients in whom spinal cord involvement is considered.

[Vascular malformations of the central nervous system in children]

OBJECTIVE

To present the experience of vascular malformations (VM) of the central nervous system (CNS) in children obtained in our centre. Since these lesions do not often present clinically in childhood, there are few series described in the literature.

PATIENTS AND METHODS

We made a retrospective review of the clinical histories of patients with VM of the CNS shown on MR, angiography and/or morbid anatomy, who were aged 15 years or under. Patients with Sturge-Weber or Von Hippel-Lindau syndromes were excluded.

RESULTS

We describe 32 patients with VM of the CNS. Twenty four had arteriovenous malformations (AVM), 5 had cavernous malformations (CM), 2 had malformations of Galeno's vein (MGV) and one patient had a congenital fusiform arterial aneurysm. Twenty two children (68%) presented clinically with hemorrhages. This was the form of presentation in 20 patients with AVM. In 4 of the 5 patients with CM the first sign was epileptic crisis. The two patients with MGV presented with macrocephaly, in one neonate it was associated with heart failure and in on older baby with hydrocephaly. The patient with a congenital arterial aneurysm presented with paroxystic episodes of facial pain.

CONCLUSIONS

The AVM are the VM which most frequently cause symptoms in childhood.

[Guidelines for headaches and dizziness for general physicians: analysis of their impact on visit frequency to outpatient neurological ambulatory services]

BACKGROUND

The work of neurologists in the Public Health Service is absolutely determined by the demand of the general physicians, who have occasionally been considered to be not too selective. For this reason we have tried to change this demand.

METHODS

In our outpatient clinic we have developed some guidelines for the general physicians to orientate them in the selection of patients referred with neurological disease. In this study the impact of the implementation of headache and dizziness guidelines on the annual frequentation from 1993 to 1997 is analysed. We also reviewed 200 cases of patients referred in 1996-1997 and assessed their adequacy to the guidelines, and inquired the general physicians after their demand and percentage of patients with neurologic disease that they referred to the neurologist.

RESULTS

There were no significant changes on the demand of consultations on headache or dizziness. We found that 39% of patients referred with headache and 23% of those with dizziness didn't adequate to the guidelines. General physicians referred only 3.3% of the patients seen by them with headache, and 3.7% of those with dizziness.

CONCLUSIONS

Sending guidelines to the general physicians has not demonstrated to be effective on improving their selection of patients, and a better implementation of guidelines should be studied, admitting that the care demand of headache and dizziness is high, and that general physicians make an important selective effort.

[Cervical radiculopathy as a form of presentation of non-Hodgkin's lymphoma]

INTRODUCTION

Neurological involvement in no-Hodgkin lymphoma is usually a serious problem leading to subacute compression of the spinal cord secondary to invasion of the spinal extradural space. This condition may be the presenting form of the illness, although relatively infrequently. Onset with involvement of the cauda equina or as an isolated radiculopathy is even rarer and has mainly been described at lumbar level.

CLINICAL CASE

We present the case of a 27 year old man with no significant previous clinical history who had progressive, insidious onset of moderate-serious senso-motor radiculopathy at C8. On MR there was an infiltrating mass affecting the nerve root and reaching the spinal extradural space. Following decompression laminectomy the patient's leg recovered and on histology there was a large cell B lymphoma. The other complementary tests showed disseminated disease, although analysis of the cerebro-spinal fluid (including cytology) was normal. HIV seriology was also normal.

CONCLUSION

Although isolated nerve root involvement is unusual in the presentation of lymphoma it should be considered to be part of the differential diagnosis of nerve root syndromes in young patients with no history of trauma or degenerative lesions.