Short Pancreas in Polysplenia Syndrome

Two cases with the polysplenia syndrome also had a short pancreas. To the best of our knowledge the radiologic characteristics of this anatomic anomaly have not yet been reported. Both cases were asymptomatic with regard to their anomaly-complex. The radiologic findings of the short “pancreas” are similar to the only pathologic description of this association. The awareness of this association led to the diagnosis of the second case after a few months only. A physician performing ERCP in the polysplenia syndrome should keep in mind the possible presence of the “short pancreas” when the whole length of the pancreatic duct is not visualized.

Long-term glutamate supplementation failed to protect against peripheral neurotoxicity of paclitaxel

Toxic peripheral neuropathy is still a significant limiting factor for chemotherapy with paclitaxel (PAC), although glutamate and its closely related amino acid glutamine were claimed to ameliorate PAC neurotoxicity. This pilot trial aimed to evaluate the role of glutamate supplementation for preventing PAC-induced peripheral neuropathy in a randomized, placebo-controlled, double-blinded clinical and electro-diagnostic study. Forty-three ovarian cancer patients were available for analysis following six cycles of the same PAC-containing regimen: 23 had been supplemented by glutamate all along the treatment period, at a daily dose of three times 500 mg (group G), and 20 had received a placebo (group P). Patients were evaluated by neurological examinations, questionnaires and sensory-motor nerve conduction studies. There was no significant difference in the frequency of signs or symptoms between the two groups although neurotoxicity symptoms presented mostly with lower scores of severity in group G. However, this difference reached statistical significance only with regard to reported pain sensation (P = 0.011). Also the frequency of abnormal electro-diagnostic findings showed similarity between the two groups (G: 7/23 = 30.4%; P: 6/20 = 30%). This pilot study leads to the conclusion that glutamate supplementation at the chosen regimen fails to protect against peripheral neurotoxicity of PAC.

Electrogastrography in patients with Parkinson's disease

BACKGROUND

Impaired gastrointestinal motility in Parkinson's disease may affect absorption of levodopa and contribute to the disabling response fluctuations (RF). In this study gastric myoelectric activity was recorded with electrogastrography in patients with PD and correlated with the duration, severity and the presence of RF.

METHOD

Electrogastrography (EGG) was performed in 36 patients with PD of which 22 were men. The mean age was 67 years (48-81), mean duration of disease was 7.07 years (1-20), and mean duration of treatment with levodopa was 5.07 years (1-20). Gastric dysrhythmia was diagnosed when either preprandial or postprandial dysrhythmia for more than 30% of the recording period was detected.

RESULTS

The EGG was abnormal in 24 of 36 patients. Significant association was found between preprandial dysrhythmia and duration of disease (P=0.002); duration of levodopa treatment (P=0.003), severity of 86RF (P=0.001), but not with age (P=0.076). Out of 18 patients with RF, 17 had at least one pattern of dysrhythmia. In 11 out of the 18 patients without RF, the EGG was normal while the remaining seven had at least one pattern of dysrhythmia.

CONCLUSION

Abnormal EGG was quite common in this group of patients with PD, particularly in those with RF. The most common pattern of abnormality was preprandial dysrhythmia, which was positively associated with disease duration and length of levodopa treatment. Although frequently asymptomatic, preprandial dysrhythmia leading to impaired gastric emptying may contribute to irregular absorption of levodopa from the small intestine and contribute to disabling response fluctuations.

Case report: multiple endocrine neoplasia type 2B misdiagnosed as familial dysautonomia

BACKGROUND

Familial dysautonomia (FD) is a rare autosomal recessive disorder of the peripheral nervous system, affecting exclusively Jewish children of Ashkenazi extraction. The typical clinical features consist of somatic abnormalities: failure to thrive, characteristic facies, excessive sweating, labile blood pressure, recurrent aspiration pneumonias, lack of tears, and diminished and later absent deep tendon reflexes with generalized reduction of pain sensation. Oro-dental features include a lack of tongue fungiform papillae, impairment of taste, oro-dental self-mutilation, dental crowding, excessive plaque and calculus accumulation, salivary over production and low caries experience.

CASE REPORT

A child with multiple endocrine neoplasia type 2B (MEN 2B) received, at the age of 11 months, an incorrect diagnosis of familial dysautonomia (FD). At the age of 6 years, a paediatric dentist experienced with FD noticed a normal number and shape of tongue fungiform papillae, while expecting to find a smooth tongue lacking those structures. The presence of numerous submucosal neuromata initiated a meticulous neurological and endocrine work-up, which established the diagnosis of MEN 2B. This led to an early detection and appropriate treatment of asymptomatic medullary thyroid carcinoma (MTC).

Repeated vs single physical maneuver in benign paroxysmal positional vertigo

OBJECTIVES

To evaluate the effectiveness and possible side effects of a single session of repeated particle repositioning maneuver (PRM) to treat posterior canal benign paroxysmal positional vertigo (BPPV) and the usefulness of post-treatment restrictions.

MATERIALS AND METHODS

A total of 125 consecutive patients with idiopathic BPPV participated in the study. Fifty patients received a single session of repeated PRM only (group I). Results were compared with those of 50 patients with BPPV who received a single PRM (group IIb), and 25 patients who received a single PRM followed by the use of a neck collar and keeping the head upright for 48 h (group IIa).

RESULTS

Forty-six patients (92%) of group I, 40 patients (80%) of group IIb, and 21 patients (84%) of group IIa were completely free of signs and symptoms when re-examined 1 week after treatment. Transient nausea and disequilibrium following treatment were reported equally in all subgroups and well tolerated. Nearly all patients of group IIa considered the post-treatment restrictions very inconvenient.

CONCLUSIONS

A single session of repeated physical procedure seems to be clinically superior to one single maneuver and well tolerated. Additional post-treatment measurements are inconvenient and should be abandoned.

Vestibulo-ocular arreflexia in families with spinocerebellar ataxia type 3 (Machado-Joseph disease)

OBJECTIVE

To identify the presence of vestibulo-ocular arreflexia in patients with Machado-Joseph disease (MJD), which can easily be diagnosed at the bedside.

METHODS

Seven patients with MJD from five unrelated families and 11 patients with sporadic or hereditary cerebellar ataxia other than MJD underwent a detailed neuro-otological and oculomotor examination. Six MJD and five non-MJD patients also underwent electro-oculographic recordings and caloric tests.

RESULTS

Gaze evoked nystagmus, smooth pursuit, and saccade abnormalities were found in both MJD and non-MJD patients. However, in all seven MJD patients but in none of the non-MJD patients, sudden passively induced head thrust to both sides elicited pathological corrective catch-up saccades, indicating bilateral loss of the horizontal vestibulo-ocular reflex. This was further confirmed in six MJD patients who had absent vestibular response to both a standard caloric test and ice water ear irrigation. Nystagmus was induced by standard caloric irrigation in all non-MJD patients examined. There was no correlation between the loss of vestibular function and the severity of cerebellar impairment.

CONCLUSIONS

The presence of vestibulo-ocular arreflexia, as measured by the head thrust test in a patient with dominant cerebellar ataxia, strongly suggests the diagnosis of MJD.

Caffeine-induced headache in children and adolescents

Caffeine is the most widely used behaviourally active substance. Excessive caffeine consumption, mostly in the form of coffee and tea, is a well-recognized cause of headache or migraine, and withdrawal can cause headache. Nevertheless, caffeine abuse headache is not listed as a separate category in the International Headache Society classification, 1988. We report our experience with children and adolescents with daily or near-daily headache and excessive consumption of caffeine in the form of cola drinks. Over a period of 5 years we have encountered, in a tertiary headache clinic in a general hospital, 36 children and adolescents (17 girls and 19 boys) with daily or near-daily headache related to excessive caffeine intake in the form of cola drinks. The mean age of the subjects was 9.2 years (range 6-18) and mean headache duration was 1.8 years (range 0.6-5). All were heavy cola drinks consumers; at least 1.5 L of cola drinks per day (192.88 mg of caffeine daily), and an average of 11 (range 10.5-21) L of cola drinks a week, which amounts to 1414.5 mg of caffeine (range 1350.1-2700.3). Patients were encouraged to achieve gradual withdrawal from cola drinks, which led to complete cessation of all headaches in 33 subjects, whereas one boy and two adolescent girls continued to suffer from migraine without aura not frequent enough to justify prophylactic medication. Children and adolescents with high daily caffeine consumption in the form of cola drinks may suffer from caffeine-induced daily headache. Gradual withdrawal can be achieved without withdrawal headache and with complete disappearance of the induced chronic daily headache.

Can salivary composition and high flow rate explain the low caries rate in children with familial dysautonomia?

PURPOSE

Extremely low caries rate and increased major salivary gland flow rare have been previously reported in children with familial dysautonomia (FD). The purpose of this study was to explore the possibility that, in addition to increased salivary flow, children with FD have alterations in their salivary components, which may suggest an explanauon to their low caries rate.

METHODS

Whole unstimulated and stimulated saliva samples were collected from 13 children with FD who were found to be caries free, and from 28 age- and ethnic-matched healthy children, 15 caries-free children and 13 caries-affected children. The electrolyte and protein content of the unstimulated saliva and the microbial count and buffering capacity of the stimulated saliva were determined.

RESULTS

Children with FD had the highest salivary flow rate and the lowest levels of mutans streptococci and lactobacilli, as well as the lowest concentration of chloride, magnesium, total protein and IgA. Healthy caries-affected children displayed the highest mutans streptococci and lactobacilli levels and lysozyme concentration, concomitantly with the lowest potassium and calcium concentrations.

CONCLUSIONS

The results of this investigation suggest that the caries-free state in FD may be associated with high salivary flow rate, while in healthy children, low caries rate may be associated with high salivary calcium concentration.

Clinical and polysomnographic characteristics of 34 patients with Kleine-Levin syndrome

There is only scant information on sleep characteristics and long-term follow-up in patients with Kleine-Levin syndrome (KLS). This study describes the clinical course, results of polysomnography and long-term follow-up in a relatively large group of patients with KLS. During the years 1982-97, we encountered 34 patients (26 males and eight females) with KLS. We were able to obtain the original polysomnographs from 28 males and four females. In 25 patients, data regarding their present state of health were obtained. Fourteen agreed to be present at a detailed interview and examination while 11 gave the information by phone. The mean age at onset was 15.8 +/- 2.8 years and the mean diagnostic delay, 3.8 +/- 4.2 years. The mean duration of a single hypersomnolent attack was 11.5 +/- 6.6 days. The main abnormal findings extracted out of 35 polysomnographs obtained from 32 patients during and/or in-between attacks included: decreased sleep efficiency, and frequent awakenings from sleep stage 2. All 25 patients reported present perfect health, with no evidence of behavioral or endocrine dysfunction. In adolescents with periodic hypersomnia, the diagnosis of KLS should be explored. Sleep recordings during a hypersomnolent period will often show frequent awakenings from sleep stage 2. The long-term prognosis is excellent.

Abnormal skin wrinkling in the less affected side in hemiparkinsonism-a possible test for sympathetic dysfunction in Parkinson's disease

Some patients with Parkinson's disease (PD) suffer from autonomic dysfunction, even in the early stage of the disease. We examined the skin wrinkling response following immersion of the hands in warm water in 18 patients with hemiparkinsonism. This test evaluates the function of the sympathetic autonomic system. Mean age of the patients was 61 +/- 10 and mean disease duration 5.5 +/- 3.5 years. Both hands of each patient were immersed in warm water for 30 minutes and the number of skin ridges of the fingertip of each finger was counted. The results of each hand were compared to those of nine healthy controls. The mean number of the ridges of the less affected hand was significantly decreased as compared to the affected hand and controls (6.1 +/- 6.8 vs 13.1 +/- 6.8 and 15.3 +/- 8.5, respectively; P < 0.01). These results suggest that autonomic dysfunction is prevalent in the less affected side of patients with PD and can be simply tested by the skin response test.

Seizure frequency and characteristics in children with Down syndrome

Seizures have not historically been considered a major component of Down syndrome. We examined the prevalence of epileptic seizures in 350 children and adolescents with Down syndrome evaluated at a regional center between 1985 and 1997. Results showed that 28 patients (8%) had epileptic seizures: 13 (47%) partial seizures; 9 (32%) infantile spasms, and 6 (21%) generalized tonic-clonic seizures. In the infantile spasm group, there was no relationship between the initial electroencephalogram (EEG) pattern and response to treatment or long-term seizure control, or between type of pharmacologic treatment (valproic acid, adrenocorticotropic hormone or both) and clinical remission, EEG normalization or long-term seizure control. Neurodevelopmental outcome was poor despite good seizure control in the infantile spasm group. This regional study reinforces the relative association of seizures and Down syndrome. A prospective study including a national/international registry with emphasis on developmental assessment and long-term follow up is warranted.

Is blood homocysteine elevated in migraine?

OBJECTIVE

To determine total serum homocysteine levels in a large group of patients with migraine with and without aura.

BACKGROUND

Hypercoagulable state is a known risk factor for stroke in the young. The existence of a hypercoagulable state has been postulated in migraine and homocysteinemia with young-onset stroke. To the best of our knowledge, blood homocysteine has not been studied in a significant number of patients with various forms of migraine.

METHODS

Total serum homocysteine was measured with high-performance liquid chromatography in 78 patients with migraine and in 126 age- and sex-matched healthy volunteers.

RESULTS

Seventy-eight patients aged 18 to 65 years were studied: 22 with migraine with aura and 56 with migraine without aura. Only 1 man had significantly elevated blood homocysteine (38.6 micromol/L), while another had a borderline elevation (15.8 micromol/L) (reference value for both sexes in our laboratory is 4 to 14 micromol/L). Both patients suffered from migraine without aura.

CONCLUSIONS

Blood homocysteine is not elevated in migraine.

[The many faces of syringomyelia]

During July-August 1998, we encountered 4 patients who suffered from syringomyelia. The diagnosis in each case could not be reached on clinical grounds only, since the characteristic thermoanalgesia dissociation was absent in all patients. In each case the spinal MRI showed the typical intraspinal cystic lesion, which finally established the diagnosis and led to appropriate treatment.

Successful withdrawal from analgesic abuse in a group of youngsters with chronic daily headache

Abuse of ergotamine and analgesics is common in adults. It coexists with headache and can also induce headaches. Ten to 15% of patients attending headache clinics and 1% of the general population suffer from chronic daily headache due to medication misuse. Indeed, this phenomenon was recently regarded as an epidemic. Nonetheless, analgesic-induced headache in children and adolescents was first reported in 1998. We report on our experience with children and adolescents with daily or almost-daily headache concomitant with daily or almost-daily analgesic intake. Over a period of 3 years, we evaluated 26 children (19 girls and 7 boys) with chronic daily or near-daily headache related to daily analgesic intake. The mean age of the group was 14.2 years (range, 12-18), and the mean headache history duration was 1.6 years (range, 3 months to 4 1/2 years). The mean number of headache days per month was 28.1 (range, 19-31). All patients had no history of migraine prior to the chronic headache phase according to the International Headache Society criteria. They were using at least one dose of analgesic drug for each headache, whereas 16 were using analgesic drugs daily. The weekly analgesic intake averaged 28.1 tablets (range, 19-41). The majority abused simple analgesics. Twenty-one took acetaminophen alone. Five took a combination; four took a compound containing acetaminophen, caffeine, and codeine; and the fifth patient took a compound containing aspirin, caffeine, and codeine. All patients were informed about the phenomenon of medication-induced headache and were encouraged to achieve drug withdrawal. Withdrawal led to complete cessation of all headaches in 20 patients. In 5 patients, the daily headache resolved; however, they suffered from intermittent episodic migraine attacks, which were frequent enough in 3 to initiate prophylactic medication. One adolescent continued to have daily headache. Analgesic-induced headache does occur in adolescents. Successful withdrawal from the offending analgesics was achieved without hospitalization or significant interference with daily life and with complete disappearance of the induced chronic daily headache in 25 of 26 patients.

Paraneoplastic cerebellar degeneration heralding fallopian tube adenocarcinoma

The objective of this paper is to describe an 81-year-old woman with subacute cerebellar degeneration due to fallopian tube adenocarcinoma. Serum anti-Yo antibodies were used to screen for pelvic malignancy. Their presence led to a meticulous search, which included bilateral salpingoophorectomy. Subsequently an occult fallopian tube adenocarcinoma was discovered. This case report highlights the diagnostic value of antineuroneal antibodies in females with subacute neurologic impairment in the form of paraneoplastic syndrome.

Epidemiology of idiopathic intracranial hypertension in Israel

OBJECTIVES

To determine the incidence, demographic, and clinical features of Pseudo Tumor Cerebri (PTC)/Idiopathic Intracranial Hypertension (IIH) in Israel.

MATERIALS AND METHODS

The chairpersons of all neurology and ophthalmology departments in Israel were asked to complete questionnaires regarding patients diagnosed with PTC/IIH from 1998 through 1999. Each questionnaire contained details regarding patient's age, sex, country of birth, age at diagnosis, weight, height, presence of obesity, and the results of lumbar puncture, brain computed tomography, magnetic resonance imaging, and/or magnetic resonance venography.

RESULTS

Ninety-one patients with PTC/IIH were diagnosed during the years 1998 to 1999. Eighty-five (93.4%) patients were females and six (6.6%) patients were males. The calculated incidence of PTC/IIH in the Israeli general population was 0.57 to 0.94 per 100,000 persons, with incidences of 1.82 per 100,000 for women and 0.034 per 100,000 for men. The incidence for women during the childbirth years was 4.02 per 100,000. The female to male ratio was higher than previously reported for Western countries.

CONCLUSIONS

Although the population of Israel is a mixture of people originating from Eastern and Western countries, the incidence of PTC/IIH was found to be similar to that of Western countries. This finding is an additional support to the notion that PTC/IIH is more common in obese populations.

Do men with pseudomotor cerebri share the same characteristics as women? A retrospective review of 141 cases

OBJECTIVE

To determine whether males with pseudotumor cerebri (PTC) differ from females by clinical presentation, risk factors, and outcome.

METHODS

The medical records of patients diagnosed with PTC or idiopathic intracranial hypertension (IIH) in two major university hospitals were obtained. Diagnostic criteria, clinical features, presence of obesity, mode of treatment, and outcome were tabulated.

RESULTS

A total of 134 patients (18 males and 116 females) fulfilled the Dandy diagnostic criteria for PTC. Females and males shared similar clinical features and outcome. There was a substantial difference between the groups regarding body weight. The majority of females (77.8%) were considered significantly overweight, compared to 25% of the males.

CONCLUSION

Pseudotumor cerebri in males is relatively rare. The clinical features are identical to those found in females. The fact that the majority of the male patients had a normal body weight may indicate that increased body weight does not play a major role in causing PTC in men, whereas it is an established major risk factor in women.

Vestibular findings in professional divers

The purpose of the present study was to investigate possible inner ear changes related to professional diving, by the documentation of auditory and vestibular function in 13 asymptomatic professional divers and 12 nondiver controls. A higher average pure tone hearing threshold, although of no clinical significance, was found in the study group (8.53 +/- 4.85 versus 6.67 +/- 3.54 dB hearing level, p = .04). In the vestibular evaluation, the smooth harmonic acceleration test phase leads for 0.01, 0.02, and 0.04 Hz were significantly lower in the divers (0.01 Hz, 38.46 degrees +/- 7.15 degrees versus 45.83 degrees +/- 9.02 degrees, p = .02; 0.02 Hz, 21.08 degrees +/- 5.19 +/- versus 25.17 degrees +/- 5.78 degrees, p = .05: 0.04 Hz, 12.38 degrees +/- 3.69 degrees versus 14.25 degrees +/- 3.14 degrees, p = .05). We suggest that the lower smooth harmonic acceleration phase values found in the professional divers, reflecting longer vestibulo-ocular reflex primary time constants and enhancement of the velocity storage mechanism, are the result of a habituation process that augments the low-frequency response of the canal-ocular system.

The use of baclofen in cluster headache

Cluster headache is a rare, clinically well-characterized disabling disorder that occurs in both episodic and chronic forms. The very painful short-lived unilateral headache attacks are associated with autonomic dysfunction. A large number of drugs such as ergotamines, steroids, methysergide, lithium carbonate, verapamil, valproate, capsaicin, leuprolide, clonidine, methylergovine maleate, methylphenidate, and melatonin are considered beneficial for prophylaxis. Nevertheless, this extremely painful condition is occasionally refractory to conventional treatment. The antispastic agent baclofen has been shown to possess an antinociceptive activity. Its efficacy in neuralgias, central pain following spinal lesions, painful strokes, migraine, and medication misuse chronic daily headache suggests that it may be useful for prevention of cluster headache attacks. Therefore, we treated 16 symptomatic patients with cluster headache with daily baclofen, 15 to 30 mg, in three divided doses for the cluster period and 2 weeks after. Within a week, 12 patients reported the cessation of attacks. One was substantially better and became attack free by the end of the following week. In the remaining three patients, the attacks worsened and corticosteroids were prescribed. One of these was also given verapamil. Three of the 16 patients had an additional cluster period, which cleared with a second course of baclofen. In this pilot study, baclofen seemed to be effective, safe, and well tolerated for cluster headache, and seemed to retain its efficacy on repeated clusters.

Neurological complications of essential thrombocytosis (ET)

OBJECTIVE

To evaluate the prevalence of neurological abnormalities in patients with ET and attempt to identify risk factors for neurological complications.

METHOD

Ninety-five patient charts were reviewed from January 1983-July 1999. Seventy patients fulfilled the Polycythemia Vera Study Group criteria for diagnosing ET.

RESULTS

Eighteen patients (25.7%) had episodes of neurological impairment, 52 (74.3%) had none. Neurological features-- occlusive cerebrovascular event-9; chronic headache-3 and dizziness-3, mononeuritis multiplex, sinus vein thrombosis and epilepsy-1 each. The interval between diagnosis of ET and occurrence of neurological events ranged from time of presentation (10 patients) to 13 years (1 patient) with a high predominance of females, 88.8% and 55%, respectively.

CONCLUSIONS

Neurological complications occurred at presentation or during follow-up in approximately 25% of patients with ET. Our observation suggests that further investigation focusing on the possible mechanisms for neurological deficits in females with ET should be considered.

Can police car colored flash light induce encephalographic discharges and seizures?

AIM

To explore the epileptogenic potential of a newly introduced police car flash light device (930 Heliobe Lightbar).

METHODS

A 930 Heliobe Lightbar was installed in the EEG laboratory. Thirty patients with known epilepsy, 30 otherwise healthy subjects with chronic headache, and 15 healthy volunteers were examined. All the subjects signed an informed consent and underwent an EEG during which photostimulation was performed first with the standard stroboscope, and later with the Police lightbar.

RESULTS

In all 75 examinees the lightbar did not induce clinical or electrographic seizures. In a single patient with epilepsy, the lightbar enhanced epileptiform activity induced by standard photic stimulation.

CONCLUSION

The new Police light bar was found to be non-epileptogenic.

[Pitfalls in the diagnosis of benign paroxysmal positional vertigo]

Benign paroxysmal positional vertigo (BPPV) is a common but often unrecognized cause of treatable vertigo. Possible causes of misdiagnosis of BPPV were studied by review of the records of 191 patients referred to our neurology clinic; 36 were identified as having BPPV not previously diagnosed. On referral the patients carried the following diagnoses: unspecified dizziness/vertigo (33%), transient ischemic attacks (28%), cervicogenic vertigo (19%), psychogenic dizziness/vertigo (11%), and others (8%). The paroxysmal nature of the vertigo and position-precipitating factors were not spontaneously reported by 31%. Atypical, even bizarre, symptoms including dizzy sensations were reported by 19%, and neck pain and headache were cardinal symptoms that accompanied vertigo. The Dix-Hallpike maneuver, which is essential for the diagnosis of BPPV, was not performed in any of the patients prior to referral. 30 (83%) experienced complete resolution of signs and symptoms after the first physical treatment session. We conclude that non-paroxysmal, non-positional vertigo does not rule out BPPV. Atypical and even bizarre complaints of dizziness, as well as neck pain and headache could be cardinal symptoms of BPPV. The Dix-Hallpike maneuver is mandatory in those complaining of dizziness and vertigo.

Kleine Levin syndrome (KLS) in young females

During the years 1982-1998, we encountered 7 adolescents and one young woman suffering from KLS. In 4 patients, hypersomnolence was accompanied by hyperphagia and hypersexuality, while in the remaining 4, recurrent hypersomnia was the only symptom. Mean age at onset of hypersomnolent attacks was 15.1+/-3.5 yrs. The mean duration of a hypersomnolent attack was 9.9+/-5.4 days, and the number of attacks per patient was 6.2+/-3.4. Polysomnographic recordings from 3 patients inbetween attacks, and from one patient during an attack, showed relatively normal sleep structure with decreased sleep efficiency due to numerous awakenings from sleep stage 2. Besides the recurrent hypersomnia, all patients enjoyed good health, with no evidence of behavioral or endocrine dysfunction. Similarly aged males with KLS from our clinic and previously reported females, had similar clinical features.

Bipolar affective disorder heralding cerebral demyelination in adreno-myelo-leukodystrophy

A young male with adrenomyeloleukodystrophy (AMLD), diagnosed at the age of 25 years, presented with signs of bipolar affective disorder (BPD) concomitant with radiological findings of central demyelination. There was a marked deterioration of the earlier relatively benign neurological dysfunction, leading to fatal bulbar syndrome. The association of BPD with central demyelination in AMLD is in agreement with previously reported cases of this and other types of multifocal central demyelination diseases.

Idiopathic intracranial hypertension and anticardiolipin antibodies

The association of idiopathic intracranial hypertension (IIH) or pseudotumour cerebri (PTC) with anticardiolipin antibodies (aCL-Abs) has been only acknowledged recently. However, its true incidence is as yet unknown. In this retrospective study, the co-occurrence of IIH and aCL-Abs was looked for among a relatively large group of patients diagnosed with IIH or PTC in the neuro-ophthalmology clinic during the years of 1992-8. All patients underwent routine blood tests and the presence of activated protein C resistance and protein S and protein C deficiency were recorded. ACL-Abs were determined in all patients. The co-occurrence of IIH and aCL-Abs was found in three out of 37 patients (8.1%), which is higher than the incidence of aCL-Abs in the general population but considerably lower than that reported in two previously published studies. The aCL-Ab positive patients in our series were significantly older and thinner than those in whom antibodies were undetected. In conclusion, it seems that patients with this association should be considered as a unique subgroup of IIH.

Baclofen in cluster headache

Cluster headache is a rare, severe, clinically well-characterized disorder that occurs in both episodic and chronic forms. The painful short-lived attacks occur unilaterally and are associated with signs and symptoms of autonomic involvement. They are difficult to treat, and reported prophylactic therapies include ergotamine, steroids, methysergide, lithium carbonate, verapamil, valproate, capsaicin, leuprolide, clonidine, methylergonovine maleate, and melatonin. Baclofen, an antispastic agent, has been shown to have an antinociceptive action. Its efficacy in the treatment of neuralgias, central pain following spinal lesions or painful strokes, migraine, and medication misuse chronic daily headache suggested that it may prevent cluster headache attacks. Nine cluster headache patients received baclofen, 15 to 30 mg, in three divided doses. Within a week, six of nine patients reported the cessation of attacks. One was substantially better and became attack free by the end of the following week. In the remaining two patients, the attacks worsened and corticosteroids were prescribed. In this pilot study, baclofen seemed to be effective and well tolerated for the prevention of cluster headache.

[Can police car flashing lights induce a risk of encephalographic epileptic discharges and seizures?]

The new police car flashing-light device (930 Heliobe Lightbar) has recently been implicated as potentially epileptogenic. We exposed 30 epileptic patients, 30 nonepileptic patients who suffered from headache and 15 normal volunteers to this light source. All had routine EEGs with standard intermittent photic stimulation, followed by 3-minute stimulation with the Lightbar. In none were either seizures or EEG changes induced. In 1 epileptic spike-and-wave activity induced by standard photic stimulation was enhanced with the Lightbar. We could not confirm that the Lightbar is epileptogenic.

Melkersson-Rosenthal syndrome treated by methylprednisolone

Melkersson-Rosenthal syndrome is an uncommon disorder of uncertain etiology. Different therapeutic regimens have been attempted but with limited success. We report a 24-year-old woman with recurrent facial and lip swelling, lingua plicata, and peripheral facial-nerve palsy who benefited from a short course of high-dose i.v. methylprednisolone.

Abnormal liver test results in myotonic dystrophy

Myotonic dystrophy (DM) is an autosomal dominant multisystem disorder. Little evidence suggests the existence of liver damage in a small number of patients. We have prospectively evaluated liver and gallbladder function in 53 patients with DM in relation to clinical and genetic parameters. None of the patients had an enlarged liver, signs of cirrhosis, or portal hypertension. All were free of medication, and none were pregnant or had a history of alcohol abuse. In 35 (66%) patients, serum activity of at least one of six liver enzymes assayed was abnormal. An elevated level of alkaline phosphatase was found in 50.9%, of gamma-glutamyltransferase in 52.8%, of 5' nucleotidase in 43.4%, of serum aspartate aminotransferase in 35.8%, of serum alanine aminotransferase in 33.9%, and of lactate dehydrogenase in 37.7%. Liver function test results did not correlate with severity of muscle weakness, disease duration, or serum levels of creatine kinase, glucose, or lipids. Motility of gallbladder and abdominal ultrasonography were normal. Cytosine-thymidine-guanine repeat expansion by southern blot did not correlate with liver enzyme abnormalities. We conclude that elevation of liver enzymes is frequent in DM and should be included as an additional laboratory finding of the disease.

Effect of normal ageing on the sites of aortic bifurcation and inferior vena cava confluence: a CT study

The object of this retrospective study was to determine the sites of abdominal aortic bifurcation and inferior vena cava confluence in relation to age and sex. The study group comprised 180 subjects (90 males and 90 females) divided into 9 groups by age (in decades). The positions of the aortic bifurcation and the inferior vena cava confluence were evaluated by CT, and linear regression models were fitted to the data. The positions of the aortic bifurcation and venous confluence showed a highly significant downward shift with increasing age (p = 0.0001). The shift was more pronounced in women. The mean site of the aortic bifurcation for the whole group was at lower L4 (range, upper L3 to upper S1); in males, it was at upper L4 (range, upper L3 to upper L5), and in females at lower L4 (range, upper L3 to upper S1). The mean site of the venous confluence for the whole group was at disc L4-L5 (range, lower L3 to upper S1); in males, it was at disc L4-L5 (range, upper L4 to disc L5-S1), and in females at disc L4-L5 (range, lower L3 to upper S1). Thus, the aorta and the inferior vena cava can extend as low as the level of S1. These data are of relevance in laparoscopic procedures, especially in laparoscopic lumbar discectomy.

A cephalometric evaluation of craniofacial morphology in familial dysautonomia

OBJECTIVE

The purpose of this study was to delineate the craniofacial and dentoalveolar morphology of patients with familial dysautonomia (FD) in order to contribute to the understanding of the association between progressive sensory and autonomic neuropathy and the characteristic appearance of the dysautonomic face.

PATIENTS

The study group comprised 32 patients with FD (15 females and 17 males; mean age 10.8 years, SD 3.5 years, range 5.8-19.8 years).

DESIGN

Lateral cephalograms from each patient were traced twice. The means of the two measurements were compared with homologous cephalometric normal values of ethnic-specific and classical norms from the literature.

RESULTS

In some parameters, the craniofacial morphology of the FD group was significantly different from the classical norms. There was a pronounced retrognathism in the mandible and a steep mandibular plane angle. The skeletal features of FD patients more closely resembled those of their ethnic group, although they were more retrognathic, and the mandibular growth axis was more horizontal. The incisors of these patients were more retropositioned and retroclined than were those of their healthy counterparts.

CONCLUSIONS

The results suggest an insufficiency of the expected dentoalveolar compensatory mechanism that usually helps to bridge skeletal discrepancies. It is postulated that the neuropathy is probably the important factor in the lack of this compensatory mechanism.

3-Methyl glutaconic aciduria in Iraqi Jewish children may be misdiagnosed as cerebral palsy

It is generally accepted that patients with cerebral palsy suffer from a static encephalopathy causing a non-progressive disorder of posture and/or movement. We describe 7 patients from 5 families who were initially diagnosed with cerebral palsy. Eventually, excessive excretion of urinary 3-methyl glutaconic acid (3-MGA) was found. The data of our 7 patients are quite similar to the clinical description of Costeff et al (1989): Jewish-Iraqi origin (7/7), consanguinity (2/7), involuntary movements (5/7), ataxia (6/7), pyramidal involvement (6/7) and optic atrophy (6/7). The cognitive functions were intact in 5/7 and 2/7 showed mild to moderate mental retardation. The mean delay in the definitive diagnosis was 9 years. Cerebral palsy-like symptoms accompanied by optic atrophy and extrapyramidal signs should call for extensive metabolic evaluation including the determination of urinary 3-MGA.

Reversible cortical atrophy and cognitive decline induced by valproic acid

An 18-year-old male suffered from familial progressive myoclonic epilepsy from the age of 7 years. In addition to seizures, there was a marked decline in school performance. At the age of 14 years, sodium valproate was started as add-on therapy; 2 weeks later he was hospitalized in a stuporous state. The serum level of valproate was within the therapeutic range. Cognitive evaluation disclosed moderate mental retardation. No metabolic abnormalities were detected. Valproate was discontinued and during the 4 following months, a slow but significant improvement was documented in cognitive functions. Repeated assessment was within the range of mild mental retardation. Initially, magnetic resonance imaging (MRI) showed mild cortical atrophy. A subsequent MRI study performed 2 years later was normal.