The global pandemic has permanently changed the state of practice for pre-DBS neuropsychological evaluations

The evaluation and management of patients with movement disorders has evolved considerably due to the COVID-19 pandemic, including the assessment of candidates for deep brain stimulation (DBS) therapy. Members of the Neuropsychology Focus Group from the Parkinson Study Group Functional Neurosurgical Working Group met virtually to discuss current practices and solutions, build consensus, and to inform the DBS team and community regarding the complexities of performing DBS neuropsychological evaluations during COVID-19. It is our viewpoint that the practice of neuropsychology has adapted successfully to provide tele-neuropsychological pre-DBS evaluations during the global pandemic, thus permanently changing the landscape of neuropsychological services.

In whom does horizontal canal BPPV recur?

PURPOSE

The objective of this study is to examine the rate of horizontal canal BPPV recurrence of the same type and search for predisposing factors.

Meningiomas after Radiotherapy for Tinea Capitis - Still No History

Aims and background

To review the clinical, radiological and histological findings of 19 patients with radiation-induced intracranial meningiomas treated at our neurosurgical department between 1981 and 1996.

Method

The records of 18 patients with intracranial meningiomas who underwent low-dose radiation for tinea capitis in childhood, and of one patient irradiated for pituitary adenoma, were analyzed in respect of the previously reported features of postradiation meningiomas.

Results

The mean age of the patients with low-dose radiation-induced meningiomas was 58 years and the mean shortest onset latency was 48 years. The male to female ratio was 1.1:1. Forty-seven percent of patients presented with mental changes and/or focal neurological signs, 21% with signs of increased intracranial pressure and 26% with seizures. Calvarial location of the meningiomas was found in 54% of patients and in one patient the tumor arose from the skull base. Multiple tumors were present in 15% of patients and 29% of the meningiomas displayed malignant features on histological examination. A significantly lower meningioma recurrence rate was found in our series compared to the recurrence rate in the reported series of postradiation meningiomas. Five patients had a history of a second neoplasm other than meningioma.

Conclusion

Our series of low-dose radiation-induced meningiomas represents one of the largest of its kind in the English literature. The patients did not differ substantially in sex ratio, tumor localization, multiplicity and histological features from the previously reported postradiation meningioma patients, except for the significantly lower tumor recurrence rate. It would seem that over the next years we will be further witnessing the deleterious effects of low-dose radiation administered in childhood.

Clinical Determinants of Long-Term Survival in Patients with Glioblastoma Multiforme

Repeated reports of more than ten years postoperative survival in patients with glioblastoma multiforme (GM) have appeared in the literature over the last decades. Authors have tried to identify the clinical, therapeutic and histological features determining long-term survival. We present two patients in whom, after radical removal of the tumor followed by conventional radiation, there has been no recurrence for at least ten years. The young age of the patients and the radical surgical approach were in accordance with previous reports of long-term survival. Nevertheless, one tumor originated from the thalamus, a location considered to be of unfavorable prognosis. We therefore further discuss the value of clinical signs as determinants in the prognosis of GM.

Parinaud syndrome: Any clinicoradiological correlation?

INTRODUCTION

The significance of MRI findings of patients with Parinaud syndrome (PS) with respect to clinical characteristics is poorly defined. Over the past decades, all patients with PS undergo magnetic resonance imaging which allows a better identification of the lesion localization. We compared the neuro-ophthalmological findings of patients with PS caused by intrinsic (intra-axial) vs extrinsic (pineal gland tumor) brainstem lesions.

METHODS

Medical records of patients with PS evaluated between 2000 and 2016 were retrospectively reviewed.

RESULTS

Twenty-six patients with PS were included. Eight patients had pineal gland tumors and hydrocephalus. Two patients had hydrocephalus due to aqueduct stenosis and fourth ventricle tumor. Sixteen patients suffered from an intrinsic brainstem lesion and seven associated with hydrocephalus. The neuro-ophthalmological findings did not differ between patients with extrinsic and intrinsic brainstem lesions. No correlation was found between the grade of hydrocephalus and number of clinical findings except for more findings in low-grade hydrocephalus in intrinsic (40%) vs extrinsic (0%) lesions (P=.003). Patients with moderate brainstem lesions and hydrocephalus had more clinical findings (65%) than patients with the same grade of brainstem involvement without hydrocephalus (29%) (P=.03). The resolution rate of ophthalmological findings was comparable in all groups of patients.

CONCLUSIONS

Our results did not show differences in neuro-ophthalmological findings between intra- and extra-axial lesions causing PS. However, the presence of hydrocephalus was an important factor influencing clinical findings. The prognosis of PS was less favorable than generally reported.

Headache in stroke according to National Acute Stroke Israeli Survey

OBJECTIVES

Analysis of headache occurrence in a national cohort of patients with acute stroke.

METHODS

The data were based on the triennial 2-month period of the National Acute Stroke Israeli (NASIS) Registry. A total of 2166 patients with acute stroke were retrieved: 2001 (92.4%) had ischemic stroke (IS), 150 (6.9%) had intracerebral hemorrhage (ICH), 4 (0.2%) had sinus vein thrombosis (SVT), where as in 11 (0.5) the stroke type was undetermined.

RESULTS

Two hundred and six (9.5%) patients reported headache: in SVT headache was reported by 50% of patients, in ICH by 21.3% while 8.4% of patients with IS (28% with transient ischemic attack [TIA]) complained about headache. In 18.1% of patients with headache, the stroke type was undetermined. Female gender, younger age, previous headache, cerebral hemorrhage, and dizziness/unsteadiness predisposed for headache. The incidence of headache was higher in patients with ICH than in patients with IS regardless of the history of previous headaches. In IS, headache decreased with stroke severity and was more common in the posterior than in the anterior circulation. Patients with lacunar stroke suffered less frequently from headache than patients with non-lacunar stroke. Significantly more patients with carotid dissection presented with headache than without.

CONCLUSIONS

Intracerebral hemorrhage, younger age, female gender, posterior circulation involvement, and headache history are predictors for headache occurrence in acute stroke. Headache incidence in ICH correlates with stroke severity as opposed to IS. Headache in TIA is not unusual. Lacunar strokes are generally not accompanied by headaches. Headache remains the main complaint in SVT and carotid dissection.

Varicella-zoster DNA in saliva of patients with meningoencephalitis: a preliminary study

OBJECTIVES

Since the routine use of polymerase chain reaction testing (PCR) in diagnosing herpes infections, varicella-zoster virus is increasingly recognized as a cause of varicella-zoster meningoencephalitis (VZV ME) among immunocompetent patients. We were interested to determine whether patients with VZV ME had VZV DNA in their saliva during the acute phase of the illness.

MATERIALS AND METHODS

Forty-five consecutive patients who underwent a lumbar puncture for diagnostic purposes were included in the study. The cerebrospinal fluid was examined for the presence of VZV DNA by PCR, and patients with positive findings were treated with acyclovir. The saliva was later analyzed in a blinded fashion for the presence of VZV DNA.

RESULTS

VZV DNA was found in saliva in four of five (80%) patients with PCR confirmed VZV ME (sensitivity 0.8, specificity 0.84, and likelihood ratio 5). This was significantly more than in patients with non-zoster viral ME (0%, P = 0.009), parainfectious headache (12%, P = 0.03) and controls (9.5%, P = 0.007). In immunocompromised patients with systemic lymphoma and AIDS, VZV DNA was present at a similar rate (67%, P = 0.6).

CONCLUSIONS

We have found VZV DNA in saliva of patients with PCR confirmed VZV ME at a higher proportion than in controls and patients with non-VZV viral ME. This finding might be of clinical importance, especially in immunocompetent individuals with suspected VZV ME where the results of genetic and immunological testing are not conclusive.

Clinical and electroencephalographic findings in acutely ill adults with non-convulsive vs convulsive status epilepticus

BACKGROUND

Non-convulsive status epilepticus (NCSE) indicates a change in the mental state with no motor manifestations, being a clinical expression of prolonged epileptiform activity. In contrast to convulsive status epilepticus (CSE), no unified treatment recommendations have been proposed so far. We were interested to review the clinical and encephalographic characteristics in hospitalized patients with NCSE and CSE and compare their treatment and outcome.

PATIENTS AND METHODS

The electroencephalographic recording records of adult patients with electrographic status epilepticus were retrieved. Patients' clinical records were then analyzed.

RESULTS

Fifty-three patients with CSE and 25 patients with NCSE were identified. Background diseases, neuroimaging findings and complications were similar in CSE and NCSE. Anoxia was a more frequent etiological factor only for myoclonic SE. Patients with CSE presented more often with coma. The number of drugs used for treatment was similar, but anesthetics drugs were administered more frequently in patients with CSE. The 30-day mortality rate was higher in myoclonic SE and generalized tonic-clonic SE, but the outcome on discharge in terms of survival and recovery was comparable between CSE and NCSE.

CONCLUSIONS

The results of the present study show that the clinical parameters of NCSE in acutely ill patients do not substantially differ from those of patients with CSE. Moreover, despite more severe mental changes and the need for more anesthetic drugs for treatment of CSE, the final outcome did not differ between both groups. This might indicate that NCSE in acutely ill patients should be regarded as seriously as CSE.

Reevaluation of presentation and course of idiopathic intracranial hypertension--a large cohort comprehensive study

OBJECTIVES

We analyzed the clinical and ophthalmological findings in a large group of patients with idiopathic intracranial hypertension (IIH) trying to find factors that might influence the course of the disease.

MATERIALS AND METHODS

Medical records of patients with IIH were retrospectively reviewed. The patients included were women after menarche and men older than 18 years of age who were followed up for at least 1 year.

RESULTS

Eighty-two patients (89% women) with a mean age of 30.2 ± 12.0 years were included. The prevailing complaint was headache and transient visual obscurations followed by tinnitus and double vision. Eighty-two percent of patients were overweight at the time of diagnosis. Overweight patients had higher opening cerebrospinal fluid (CSF) pressure than patients with normal weight did. The grade of papilledema correlated with the CSF opening pressure. Inverse correlation was found between the depression of the visual field sensitivity and the grade of papilledema. The mean follow-up time was 61.3 ± 62.3 months. Eighty-four percent of the patients have improved while in 22% CSF diversion procedures or optic nerve decompression was required. The mean body mass index (BMI) at the end of follow-up decreased significantly. Sixty-seven percent of the patients suffered a recurrence of IIH. The number of recurrences inversely correlated with weight loss. Visual field defects on presentation were encountered more frequently in patients with recurrence. Women with recurrence had a history of more pregnancies.

CONCLUSIONS

Our results confirm the strong association between overweight and IIH. The recurrence rate seemed to be influenced by the obstetrical history and the severity of visual field defects at presentation. In contrast to some previous studies, we have found an interrelation between the CSF opening pressure, grade of papilledema and depression of the visual field sensitivity.

Prevalence of central nervous system diseases--a large retrospective cohort study of adolescents

At age sixteen, most Israeli nationals must undergo medical evaluation for compulsory military duty. All potential conscripts are referred to the Israel Defense Forces (IDF) recruiting office. Therefore, medical screening of a vast number of adolescents is performed, offering a unique opportunity to study the prevalence of neurological diseases in an entire age cohort. Hence, screening is not affected by diagnostic or methodological bias. We performed a retrospective neuroepidemiological large cohort study of adolescents from the database of the Israel Defense Forces recruiting office during the years 1998-2002. The survey included 409 492 adolescents, among them 162 079 (39.5%) females. The most prevalent diagnoses were: headache (754 per 10 000 adolescents), permanent brain damage (197 per 10 000), epilepsy (167 per 10 000) and movement and coordination disorders (36 per 10 000). These were followed by cranial nerve disorders, sleep disorders, cranio-spinal bone defects, and chronic progressive CNS disorders. The relative risk for male adolescents within the specific disease groups was higher for movement-coordination, sleep and cranial nerve disorders. Multivariate analysis revealed gender and severity prevalence and sex-grade, or year-grade interactions in the distinct groups of diseases. This study provides important information on the prevalence of neurological diseases in adolescents and demonstrates some significant epidemiological trends.

Evolving pattern of Guillain-Barre syndrome in a community hospital in Israel

OBJECTIVES

To investigate the frequency of axonal Guillain-Barre syndrome (GBS) in our ward over 6 years (1999-2005).

MATERIALS AND METHODS

Clinical and electrophysiological findings of 40 patients admitted to neurology with abnormalities compatible with acute motor axonal neuropathy (AMAN), acute motor sensory axonal neuropathy (AMSAN) and acute inflammatory demyelinating polyneuropathy (AIDP) were reviewed.

RESULTS

Electrophysiological findings showed that 25 (63%) patients had AIDP, nine (22%) AMAN and six (15%) AMSAN. There were significant differences in disease severity. Most axonal patients (87%) were hospitalized with moderate or severe symptoms (3-4 Hughes grade score) and progressed to severe grade (4-6) in comparison with AIDP patients (64% admitted with mild forms) (1-2 Hughes grade score) and progressed to severe in 44% of cases. Cranial nerve involvement was more frequent in AIDP (56%) in comparison with the axonal type (13%). Raised cerebrospinal fluid protein at the time of hospitalization was observed in 76% of demyelinating and 33% of axonal patients.

CONCLUSIONS

Axonal GBS occurred more frequently in Israel compared with other Western countries.

Low dose methylphenidate improves freezing in advanced Parkinson's disease during off-state

Five men with advanced idiopathic Parkinson's disease (PD) were examined to assess the effect of low dose methylphenidate (MPD) on gait. The patients were tested during "off" state before and two hours after the intake of 10 mg MPD while walking an "8 trajectory". The total walking time, total freezing time, number of freezing episodes and the non-freezing walking time were assessed. The obtained data were compared by the Wilcoxon Signed Rank test with a type I error rate of 0.05. The results showed a statistically significant improvement in all gait parameters after MPD intake. Moreover, a good correlation in the grade of improvement for each individual gait characteristic was found. The study demonstrates that low dose of MPD may improve gait, and especially freezing, in patients with severe PD, without the need for exogenous L-dopa. The mechanism of MPD action in patients with advanced PD is further discussed.

Diagnostic value of vestibular evoked myogenic potentials in cerebellar and lower-brainstem strokes

BACKGROUND

Vestibular evoked myogenic potentials (VEMPs) provide assessment of vestibular function. They consist in picking up compound muscle action potentials in the sternocleidomastoid (SCM) muscles in response to auditory stimulation of the vestibulum. VEMP testing has found application mainly in peripheral vestibular disorders, whereas reports about VEMPs in central vestibular lesions are rather scarce.

AIMS OF THE STUDY

Based on the physiological connections between the cerebellum and the vestibular nuclei, we investigated the influence on VEMPs of cerebellar and lower-brainstem strokes. We examined whether or not this method may be suitable as a clinical tool for the evaluation of the extent of cerebellar strokes.

PATIENTS AND METHODS

Nineteen patients with cerebellar ischemic stroke and 15 patients with lower-brainstem ischemic stroke (11 in the pons, four in the medulla) were included. The latencies and amplitudes of P13 and N23 in both groups of patients were compared with those obtained in a control group of 53 normal individuals.

RESULTS

VEMP responses were obtained in all patients and controls. At the group level, mean peak latencies and amplitudes, and the number of subjects with significantly deviant values did not differ between patients and controls. There were no latency or amplitude differences ipsilaterally or contralaterally to the lesion. At the individual level, there was no correlation between laterality of lesion and that of P13 or N23 abnormalities in patients with cerebellar strokes; however, there were two patients (one pontine, one medullar stroke) who presented P13 and N23 latency abnormalities ipsilaterally to the lesion.

CONCLUSION

Cerebellar strokes do not influence VEMPs. Moreover, despite previous reports, we were unable to find at a group level any statistically significant VEMP changes in patients with lower-brainstem strokes as compared with controls. Therefore, VEMPs do not appear a suitable tool for assessment of brainstem integrity in patients with posterior fossa strokes. However, they could constitute a sensitive method for documentation of involvement of the central vestibular pathways in patients with brainstem stroke.

Infectious inflammation of the CNS involves activation of mitogen-activated protein kinase and AKT proteins in CSF in humans

The mitogen-activated protein kinases (MAPKs) and the AKT are interacting proteins that serve as transmitters of numerous extracellular signals to their intracellular targets, thereby regulating many cellular processes, such as proliferation, differentiation, development or stress responses. Whereas a large amount of information about the MAPKs/AKT participation in biological processes is available, less is known about their role in human diseases. We postulated that the MAPKs/AKT could be involved in inflammatory processes of the central nervous system (CNS) in humans and we investigated the CSF of 12 patients with viral infection of the CNS for the presence of the distinct components of these cascades. The cerebrospinal fluid (CSF) of 18 individuals who underwent a lumbar puncture for diagnostic purposes served as controls. Six patients with inflammatory disease of the CNS revealed the presence of activated ERK. In five patients p38MAPK was detected, in three in its activated form. The activity of AKT could be demonstrated in four patients. JNK was not found. None of the control patients showed the presence of MAPK enzymes. The mean CSF cellularity was higher in MAPK-positive than in MAPKnegative patients. There was no difference in mean age or gender between the patients and controls, or between the MAPK- and AKT-positive or -negative patients. Our work demonstrates that the MAPK and AKT cascades might participate in inflammatory processes of the CNS. As selective inhibitors of the MAPKs are available, their application in the future might reduce an inappropriate inflammatory response and thus limit brain damage in severe cases of meningoencephalitis.

Clinical characteristics of patients with ischemic ocular nerve palsies and lacunar brain infarcts: a retrospective comparative study

BACKGROUND

Ischemic ocular motor nerve palsies (IOMP) and lacunar brain infarcts share a similar pathological mechanism. The clinical characteristics of patients as well as the protective role of aspirin should therefore be similar in both conditions.

METHODS

The medical records of 107 consecutive patients with IOMP and 160 patients with lacunar cerebrovascular accidents (CVA) were reviewed and analyzed with respect to patient characteristics, vascular risk factors, and aspirin intake. The data on patients with and without aspirin were compared within each group as well as between both groups.

RESULTS

Hyperlipidemia, smoking, high carotid stenosis (>70%) and the presence of more than one vascular risk factor in an individual patient were found to be more common in patients with lacunar brain infarcts regardless of aspirin intake. Absence of vascular risk factors was encountered more in IOMP patients. The recurrence of lacunar CVA was significantly higher than recurrence of IOMP. A history of Bell's palsy was more common in IOMP patients than in patients with lacunar CVA. Within the IOMP group, the prevalence of vascular risk factors did not differ between the aspirin and non-aspirin group. Ischemic heart disease (IHD), CVA and recurrence were found more often in the aspirin group. Within the CVA group hypertension, IHD, cardiac arrhythmia and recurrence rate were more common in the aspirin group whereas smoking was found to be more common in the non-aspirin group of patients.

CONCLUSIONS

Arteriosclerosis is the main cause of lacunar CVA and IOMP. However, IOMP depends less on the presence of vascular risk factors than does lacunar CVA. Furthermore, aspirin - at least at low doses - does not seem to have a protective effect on either of these conditions, but more extensive prospective studies of homogeneous groups of patients are needed to clarify the preventive role of antiplatelet agents in IOMP.

Polysomnography in patients with intracranial tumors before and after operation

OBJECTIVE

To evaluate the breathing and sleep patterns in patients with brain tumors before and after operation, and assess their relation to the location and size of the tumor, as well as to the post-operative outcome.

METHODS

Polysomnographic studies were performed in 11 patients with intracranial tumors (nine supra- and two infratentorial) before and after surgery.

RESULTS

Pre-operatively, the mean apnea-hypopnea index (AHI) was 23.3. Six patients demonstrated signs of obstructive sleep apnea (SA) and one had mixed obstructive and central type SA. After operation, the mean AHI decreased to 8.1(P < 0.05). The duration of random eye movement sleep stage increased after tumor removal (P < 0.04). No relation was found between the characteristics of the tumor, nor the post-operative outcome and SA.

CONCLUSIONS

Patients with brain tumors often suffer from SA and this can further worsen their symptoms related to increased intracranial pressure. Removal of the tumor results in a substantial decrease in sleep-related disturbances and may thus play a role in clinical recovery.

Neurological features of West Nile virus infection during the 2000 outbreak in a regional hospital in Israel

During the summer of 2000, 35 patients with West Nile Virus Fever were admitted to our hospital. Of these, the 26 (21 adults, mean age 56 (19-86) and 5 children (aged 9-15)) presented have neurological involvement, 33% with meningitis, 52% with meningoencephalitis, 10% with encephalitis and 5% with acute polyneuropathy. Presenting clinical features were fever in 95% of cases, headache in 90%, nausea/vomiting in 52%, confusion in 48%, somnolence in 38%, neck stiffness in 33%, a skin rash in 19%, diarrhea in 14%, cervical pain in 14%, seizure in 9%, photophobia in 9% and limb weakness in 4%. Leucopenia was not found. Two patients diagnosed with meningoencephalitis died. Three patients had signs of an acute polyneuropathy, this being the only complaint of one patient. The EEG was abnormal in all cases of meningitis or meningoencephalitis, except in three cases. Outbreaks of West Nile Virus Fever are emerging as a worldwide disease with high rates of neurological involvement and death. It should be considered in cases presenting with aseptic meningoencephalitis, meningitis and acute polyneuropathy, especially during the summer months and in areas along bird migration pathways.

Comparison of glatiramer acetate (Copaxone) and interferon beta-1b (Betaferon) in multiple sclerosis patients: an open-label 2-year follow-up

OBJECTIVE

To compare the clinical efficacy, as expressed by relapse rate and disability accumulation, and safety profile of glatiramer acetate (Copaxone; COP-1) and Interferon beta-1b (Betaferon; IFN beta - 1b) administered to multiple sclerosis patients during a 2-year follow-up on an open-label parallel design, as compared to their clinical condition in the 2-year period prior to treatment.

BACKGROUND

Copaxone and IFN beta - 1b have been recently introduced for the treatment of relapsing forms of MS. Both medications have been proven to have a relatively safe profile and are used extensively world-wide.

METHODS

58 consecutive patients with relapsing forms of MS were enrolled from the MS out-patient clinic, during three months. After being informed in detail of the two approved treatment options existing at the time in Israel, the patients chose by themselves to receive either: (a) Copaxone 20 mg subcutaneously (sc) daily (Copaxone dly, 20 patients), or (b) Copaxone 20 mg sc alternate-day (Copaxone alt, 18 patients) or (c) IFN beta-1b 8 MIU sc in alternate day (20 patients). Mean relapse rate/year and mean EDSS/year were calculated for each group of patients during the 2 years prior to the onset of treatment, and during the year prior to the onset of treatment. Statistical significance was observed in the relapse rate in the year prior to the onset of treatment between the IFN beta -1b group and the two Copaxone groups (p = 0.05). This statistical difference has no effect on the overall data of the 2 years prior to starting the treatment and on the results. No statistical significance was observed in the total number of relapses, and on the 2-year relapse rate, prior to the onset of treatment. Mean relapse rate/year and mean EDSS/year were calculated for each group during the first and second year of treatment. Wilcoxon analysis for clinical data and chi-square for adverse events were applied.

RESULTS

The three groups were statistically comparable concerning mean relapse/year in the 2 years before the trial started and no statistical significance was observed among the three groups. A statistically significant reduction in the mean relapse rate in the 2 years after onset of treatment was observed in the three group of patients: Copaxone daily (dly) 1.1 +/- 0.6 (p = 0.0001); Copaxone alternate (alt) 0.9 +/- 0.6 (p = 0.0004) and IFN beta -1b 1.2 +/- 0.7 (p = 0.0001). Disability as expressed by EDSS score prior to the onset of treatment and after 2 years of treatment showed deterioration in the three groups although more significant in the Copaxone groups: Copaxone dly 3.3 +/- 1.4 to 3.8 +/- 1.6 (p = 0.007); Copaxone alt 2.4 +/- 1.1 to 2.8 +/- 1.3 (p=0.04); IFN beta - 1b 3.1 +/- 1.3 to 3.3 +/- 2.0 (N.S.). The most common adverse events reported were: (1) flu-like symptoms 7 pts (35%) in the IFN beta -1b group; 10 pts (26%) of the two Copaxone groups; (2) increased spasticity of lower limbs 3 pts (15%), only in the IFN beta -1b group; (3) site injection reaction (SIR): 16 SIR (80%) in the IFN beta -1b group; 12 SIR (67%) in the Copaxone alt group; 14 SIR (70%) in the Copaxone dly group; and (4) systemic reaction 3 pts (15%) in the IFN beta -1b group; 4 pts (22%) in the Copaxone alt group; 6 pts (30%) in the Copaxone dly group. Premature termination occurred in five patients treated with Copaxone (3 in the alternate group and 2 in the daily group).

CONCLUSION

The present study, despite the limitations of an open-label study, shows that Copaxone dly, Copaxone alt and IFN beta -1b treatment seem to be equally effective for the control of exacerbations in MS. The adverse event profile, as reported by the patients, was also similar. However, the adverse events profile registered indicated that Copaxone is somewhat less detrimental, whereas disability as measured by EDSS accumulation showed that the interferon beta - 1b patients demonstrated a slower progression of the disability.

Visual vertigo: symptom assessment, spatial orientation and postural control

Certain patients with balance disorders report a 'visual vertigo' in which their symptoms are provoked or aggravated by specific visual contexts (e.g. supermarkets, driving or movement of objects). In order to determine the causes of visual vertigo (VV), we assessed symptoms, anxiety and the influence of disorienting visual stimuli in 21 such patients. In 17 out of 21 patients, a peripheral vestibular disorder was diagnosed. Sixteen bilateral labyrinthine-defective subjects (LDS) and 25 normal subjects served as controls. Questionnaire assessment showed that the levels of trait anxiety and childhood motion sickness in the three subject groups were not significantly different. Reporting of autonomic symptoms and somatic anxiety was higher than normal in both patient groups but not significantly different between LDS and VV patients. Handicap levels were not different in the two patient groups, but the reporting of vestibular symptoms was higher in the VV than in the LDS group. The experimental stimuli required subjects to set the subjective visual vertical in three visual conditions: total darkness, in front of a tilted luminous frame (rod and frame test) and in front of a large disc rotating in the frontal plane (rod and disc test). Body sway was also measured in four visual conditions: eyes closed, eyes open, facing the tilted frame and during disc rotation. In psychophysical and postural tests, both LDS and VV patients showed: (i) a significant increase in the tilt of the visual vertical both with the static tilted frame and with the rotating disc; and (ii) an increased postural deviation whilst facing the tilted frame and the rotating disc. The ratio between sway path with eyes closed and eyes open (i.e. the stabilizing effect of vision) was increased in the LDS, but not in VV patients, compared with normal subjects. In contrast, the ratio between sway path during disc rotation and sway path during eyes open (i.e. the destabilizing effect of a moving visual stimulus) was increased in the VV patients but not in LDS. Taken together, these data show that VV patients have abnormally large perceptual and postural responses to disorienting visual environments. VV is not related to trait anxiety or a past history of motion sickness. The results indicate that VV emerges in vestibular patients if they have increased visual dependence and difficulty in resolving conflict between visual and vestibulo-proprioceptive inputs. It is argued that treating these patients with visual motion desensitization, e.g. repeated optokinetic stimulation, should be beneficial.

Labyrinthine involvement in Behçet's syndrome

We report the neuro-otological findings in 26 consecutive patients with definite and probable Behçet's syndrome unselected for audiovestibular complaints. Auditory and/or vestibular abnormalities were found in 19 (73 per cent) patients, with auditory involvement in 14 (54 per cent) and vestibular in 10 (38.5 per cent) of patients. Peripheral involvement was more common than central involvement for both auditory and vestibular lesions. Bilateral cochlear hearing impairment was the most common audiological finding, whereas unilateral peripheral dysfunction was the prevailing vestibular abnormality. No correlation has been found between audiovestibular lesions and other organ lesions, disease duration or age or sex of the patients. Moreover, there was a lack of interdependence between cochlear and vestibular labyrinthine lesions. We conclude that a full neuro-otological assessment in patients under investigation for Behçet's syndrome may reveal labyrinth involvement in a substantial proportion of patients. In view of the absence of a specific diagnostic test for Behçet's syndrome, audiovestibular lesions may provide further diagnostic support for this disorder.

Electroencephalographic abnormalities in aseptic meningitis and noninfectious headache. A comparative study

BACKGROUND

The finding of abnormalities on electroencephalogram (EEG) during the course of aseptic meningitis is often considered to be indicative of parenchymal brain involvement, even in absence of clinical signs of encephalitis.

OBJECTIVE

To investigate if patients with aseptic nonherpetic meningitis who have abnormal EEG recordings during the acute stage of the disease differ in clinical characteristics or cerebrospinal fluid findings from patients with aseptic meningitis and normal EEG recordings.

METHODS

The EEG records of 82 patients with aseptic meningitis were reviewed. A comparative group consisted of 41 age-matched patients with severe headaches without evidence of meningeal inflammation.

RESULTS

Significantly more patients with aseptic meningitis (28%) demonstrated abnormalities on EEG than controls (12%) (P =.048). Patients with aseptic meningitis and abnormal EEG findings (n = 23) did not differ in age, duration of symptoms, clinical course, cerebrospinal fluid cell count, or protein level from those with normal EEG findings (n = 59). However, all patients with aseptic meningitis who were confused (n = 5) also revealed EEG abnormalities (P<.00012). Patients with headache with normal EEG recordings did not differ from those with abnormal EEGs in age, sex, or duration of symptoms. Nevertheless, patients with common migraine (n = 9) showed abnormalities on EEG (P =.06) more frequently.

CONCLUSIONS

The finding of an abnormal EEG in patients with aseptic meningitis, clear mental state and absence of focal neurological signs should not be used as proof of encephalitis. Because pathological examination is usually not performed, it remains unclear if EEG abnormalities in patients with aseptic meningitis indicate a silent parenchymal inflammation, or reflect an infectious encephalopathy.

Body packer: cocaine intoxication, causing death, masked by concomitant administration of major tranquilizers

Cocaine, derived from the leaves of the shrub Erythroxylon coca, which grows on the slopes of the Andes, remains one of the most widely abused illicit drugs (Johnson et al., 1993). Its abuse appears to be increasing and as a result, so is its trafficking across borders, with ever-increasing sophistication of concealment (Rouse, 1992). Over the past few years, cases of cocaine intoxication have been reported, resulting from ruptured packets of cocaine that have been swallowed, or inserted into the vagina or rectum by couriers (drug smugglers), so called 'body packers' or 'mules' (Westli and Mittleman, 1981; Ricaurte and Langston, 1995). Cocaine is a powerful sympathomimetic and central nervous system stimulant, an overdose of which causes primarily cardiac, neurological and psychiatric effects (Ricaurte and Langston, 1995). Acute toxicity is dose-related and is characterized in the first place by its sympathomimetic effects, which include tachycardia, hypertension and hyperthermia arrythmias, followed by seizures. Brainstem depression and cardio-respiratory collapse, stroke, coma, intracranial vasculitis, myocardial infarction and sudden death have all been reported in cocaine abuse (Ricaurte and Langston, 1995). We present a fatal case with neurological and psychiatric symptoms, but without the usual cardiac and systemic signs.

Hartshill spinal fixation in vertebral metastasis

Spinal fusion by Hartshill rectangle frame was used in 10 patients with spinal cord compression secondary to vertebral metastasis in the thoracic and lumbar spine, occupying mainly the posterior elements. All patients presented with pain, bone collapse, and neurologic deficit. The procedure is built on a system of sublaminar wires passed under two to three lamina above and below the decompressed area and tightened to a prebent metal frame. This procedure was relatively simple, and the immediate stabilization achieved in our patients was good. All patients experienced immediate pain relief. While only two patients were able to walk before surgery, seven were able to do so at follow-up. During a follow-up period of at least 2 years in two patients, or until death in the other eight patients, one patient had a broken wire that did not affect the correction achieved at surgery. Partial loss of correction in the sagittal plane was found in two patients who had metastasis in the lumbar spine and in another patient who had metastasis in the ninth thoracic vertebra.

Revival of non-surgical management of neonatal depressed skull fractures

The management of depressed skull fractures in the newborn infant can be controversial. We report on a neonate, born by Caesarean section with difficult head extraction, complicated by a parietal depressed fracture. This 'ping-pong' fracture was treated by elevation with an obstetrical vacuum extractor. No complications occurred. The possible treatment modalities for neonatal depressed fractures, being conservative or operative, will be discussed.

Neurosurgical intervention for cervical disk disease in dystonic cerebral palsy

We report five young patients with athetoid-spastic cerebral palsy who had deteriorated neurologically. Magnetic resonance imaging (MRI) was used to investigate suspected compressive cervical spine lesion. Cervical spondylosis with disk protrusions was found in all patients. Four patients underwent surgery by an anterior approach with insertion of a bone graft resulting in substantial clinical improvement. The other patient, diagnosed 8 years after onset of symptoms, was treated conservatively. The availability of MRI makes early recognition of cervical cord compression possible, allowing effective surgical intervention in this special group of patients.

Indication to surgical management of cerebellar hemorrhage

Few reports have compared patients operated for cerebellar infarcts with those operated for cerebellar hemorrhage. Considering our previous paper about patients with massive cerebellar infarcts, we report on our surgical experience with five patients with cerebellar hemorrhage. The indication for operation was decreased consciousness with signs of brainstem compression. In all patients hydrocephalus was absent or mild, as opposed to patients with cerebellar infarcts. Suboccipital craniotomy with hematoma evacuation was therefore the surgical procedure of choice. The outcome was worse than in patients with cerebellar infarcts. We conclude that depressed mental state in cerebellar hemorrhage is mainly due to pressure of the cerebellum on the activating reticular system of the brainstem. The surgical approach to patients with bleeding in the cerebellum differ somewhat from that of patients with cerebellar infarcts in timing and kind of first choice procedure.

Quantified EEG in patients with vertigo of central or peripheral origin

Computerized EEG frequency analysis was performed in 18 patients with peripheral vestibular dysfunction (PVD), 17 patients with central vestibular dysfunction (CVD) and 22 aged matched controls. Increase in the relative theta activity in the centrotemporal region was found in patients with PVD. The decrease of centroparietal beta activity in both groups of patients, as compared to controls, did not reach statistical significance. We conclude that quantified EEG may be a sensitive method to show changes of cortical electrical activity in patients with vertigo, reflecting the imbalance in afferent vestibular input to the cortex.

Effect of very high single dose of cisplatinum and of radiation on the brain of the rabbit

The importance of chemotherapy and radiotherapy for treating brain tumors, is well established. In a previous study, a rabbit's brain was treated with doses of up to 12 mg kg-1 of cisplatinum and 4000 cGy, without any morphological or pathological changes. The purpose of this study is to establish the effect of very high single doses of cisplatinum and radiation on the rabbit's brain, applied in 12, 16 and 18 mg kg-1, and 5000, 7500 and 8000 cGy, respectively. The general clinical and neurological condition of the rabbits was unaffected, but areas of alopecia and scalp ulcers appeared. Although these are very high doses of chemotherapy and radiotherapy, the histopathological and morphological examination of the rabbit's brain remained normal.

Effect of high simple dose of cisplatinum and of radiation on the brain of rabbit

In former studies of intracarotid and intravenous administration of cisplatinum, separate and combined with brain irradiation, we found no cerebral damage. In this study, gradually increasing high doses (above the therapeutic ones) of cisplatinum were administered intravenously to one series of rabbits and increasing high amounts of irradiation (above the therapeutic amounts) were given to another series. Although the rabbits that received highest doses of irradiation developed areas of alopecia and skin ulcers on the head, the general clinical and histopathologic examination of the rabbits' brains in both series was normal. The purpose of this study was to establish the effects of high doses of intravenous cisplatinum and irradiation on the rabbits brains.

Symptomatic patients after craniectomy

Various surgical procedures in neurosurgery end with cranial vault defects. It is generally believed that the reason for repair of the skull defect is cosmetic or protective. There is evidence, however, that in selected cases neurologic deterioration can be reversed by cranioplasty. In the sinking scalp flap syndrome the deterioration has been thought to be related to the concavity of the skin flap and underlying brain tissue secondary to atmospheric pressure and also to the in-and-out displacement of the brain through the skull defect. Five cases of symptomatic patients after craniectomy are reported, of which all had a neurologic deterioration that was improved by cranioplasty.

Posterior fossa lesions associated with neuropsychiatric symptomatology

We reviewed 7 cases with posterior fossa structural abnormalities (3 tumors, 2 megacisterna magna and 2 Dandy-Walker syndrome) presenting with neuropsychiatric symptomatology. Derangement in the balance of dopamine, serotonin and noradrenergic networks has been implicated in the pathogenesis of schizophrenia, affective and even personality disorders. Disruption of the cerebellar output to mesial dopaminergic areas, locus coeruleus and raphe nuclei, or deafferentation of the thalamolimbic circuits by a cerebellar lesion may lead to behavioral changes. Seven patients (pts) (comprising 4 men and 3 women with mean age 22 years) were diagnosed as suffering from psychosis (2 pts), major depression (1 pt), personality disorders (2 pts) and somatoform disorders (2 pts) (DSM-IV criteria). Brain CT scan (7 pts) and MRI (4 pts) revealed tumors of the posterior fossa (2 pts), megacisterna magna (2 pts) and Dandy-Walker variant (2 pts). In one patient a IVth ventricle tumor was removed in childhood.

Effect of the combination of cisplatinum and radiation in the rabbit's brain

The effect of cisplatinum as a potential radiosensitizer in brain tumors is controversial. We examined the effect of the combination of cisplatinum with radiation compared to radiation alone in rabbits' brain. All rabbits were irradiated and cisplatinum was injected intravenously into part of them. Therapeutic doses of cisplatinum and irradiation were given. The rabbits were euthanised at different intervals according to protocol. The general clinical and neurological condition of the rabbits was unaffected, and histopathological examination of the rabbit's brain was normal. The purpose of this study was to establish the effect of cisplatinum followed by cranial irradiation in therapeutic doses to the normal rabbit's brain.