Putaminal haemorrhage leading to pure motor hemiplegia

Pure motor hemiplegia (PMH) is commonly attributed to lacunar infarction of internal capsule or basis pontis. We report 7 patients of pure motor hemiplegia as a result of small or moderate size putaminal haemorrhage. All the patients had normal median somatosensory evoked potentials. Central Motor Conduction Time (CMCT) to upper limb was not recordable in all 3 patients with complete hemiplegia. Three of seven patients had complete and four had partial recovery. Anterioposterior extension of small or moderate size putaminal haemorrhage seems to spare the medially located sensory fibres in the internal capsule. On the basis of our results, lateral putaminal haemorrhage should be considered in the differential diagnosis of PMH.     

Pure motor hemiparesis due to hypertensive putaminal haemorrhage

A hypertensive woman presenting as pure motor hemiparesis with rapid and complete recovery from the neurological deficit is described. The probable aetiology was primary hypertensive putaminal haemorrhage, as revealed by CT scan. This rare presentation has been described only once earlier and emphasizes the value of CT scanning as a tool for diagnosis of such cases.     

Serial changes in motor and somatosensory evoked potentials in putaminal haemorrhage

Little is known about evoked potential changes in putaminal haemorrhage. In this study, somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) have been serially evaluated and their role in the prognosis of putaminal haemorrhage is now reported. Nineteen patients with CT- or MRI-proven putaminal haemorrhage were examined after a mean duration of 13 days (range 2–30); there were 4 females and 9 males, ranging in age between 25 and 70 years. The haematomas were of medium size in 13 and large or small in 3 patients each. The changes in the clinical picture and the SEPs and MEPs were evaluated on admission, and after 30 and 90 days. Central motor conduction time (CMCT) could not be recorded in 13, but was prolonged in 2 and normal in 4 patients. Median SEPs revealed the absence of near field potentials in 11 and prolongation of N9–N20 conduction time in 1 patient. In the follow-up period MEP and SEP abnormalities only changed in 5 patients; MEPs changed in 4 and SEPs in 2. The period of normalisation of MEPs ranged between 1 and 6 months. CMCT correlated with motor and N9–N20 conduction time with sensory impairment. Eight patients had poor, 6 partial and 5 complete recovery. Power, sensation, CMCT, and size and location of haematoma made positive contributions to recovery.     

Advanced practice psychiatric mental health nursing, finding our core: the therapeutic relationship in 21st century

TOPIC.  Increasingly, students from various professional backgrounds are enrolling in Psychiatric Mental Health (PMH) Nursing graduate programs, especially at the post-master's level. Faculty must educate these students to provide increasingly complex care while socializing them as PMH advanced practitioners.
PURPOSE .  To present how one online program is addressing these issues by reasserting the centrality of the relationship and by assuring it has at least equal footing with the application of a burgeoning knowledge base of neurobiology of mental illness.
SOURCES .  Published literature from nursing and psychology.
CONCLUSIONS .  The PMH graduate faculty believes that they have developed strategies to meet this challenge and to help build a PMH workforce that will maintain the centrality of the relationship in PMH practice.     

Painful tonic spasms caused by putaminal infarction

Lacunar infarcts in the basal ganglia are known to cause various movement disorders, such as chorea, focal dystonia, and hemichorea-hemiballismus. We report here a case of putaminal lacunar infarction which presented with "painful tonic spasms" of the contralateral limbs. This consisted of paroxysmal brief, painful, flexor contractures of the upper, and occasionally the lower limb. These were not focal seizures but were controlled with carbamazepine, which has been used for the "painful tonic spasms" well-associated with multiple sclerosis. The putaminal infarct we describe is probably related to a lupus anticoagulant and systemic lupus erythematosus.     

Transtentorial herniation in patients with hypertensive putaminal haemorrhage is predictive of elevated intracranial pressure following haematoma removal

We investigated surgical outcomes of haematoma evacuation in patients with hypertensive putaminal haemorrhage, with emphasis on the development of postoperative refractory intracranial hypertension. Twenty-two consecutive patients with hypertensive putaminal haemorrhage underwent microsurgical clot removal without decompressive craniectomy. Medical histories, radiographic findings, and surgical notes were reviewed. Twenty patients survived to discharge. Twelve patients with preoperative transtentorial herniation, demonstrating a greater haematoma volume and lower Glasgow Coma Scale (GCS) score, had significantly elevated postoperative intracranial pressure. Five of these patients developed refractory intracranial hypertension (42%), and two of these patients died. Conversely, none of the 10 patients without preoperative transtentorial herniation experienced refractory intracranial hypertension, and they had a better outcome at discharge. The preoperative presence of clinical transtentorial herniation may predict the development of postoperative refractory intracranial hypertension, which may require decompressive craniectomy.     

Imaging of intracranial haemorrhage

Intracranial haemorrhage can be a devastating disorder that requires rapid diagnosis and management. Neuroimaging studies are not only required for diagnosis but also provide important insights into the type of haemorrhage, the underlying aetiology, and the accompanying pathophysiology. Historically, CT has been the diagnostic imaging study of choice; however, there is a growing body of data that suggest that MRI is at least as sensitive as CT to detect haemorrhage in the hyperacute setting, and superior to CT in the subacute and chronic settings. Blood has characteristic appearances on both imaging modalities at each stage (acute, subacute, and chronic) and it is important that physicians are familiar with the appearance of various types of intracranial haemorrhage on CT and MRI and their clinical implications. In addition, new imaging applications, such as magnetic resonance spectroscopy and diffusion tensor imaging, are promising research techniques that have the potential to enhance our understanding of the tissue injury and recovery that result from intracranial haemorrhage.     

Massive spontaneous haemorrhage in a plexiform neurofibroma: A case report and discussion of the literature

Neurofibromatosis Type 1 (NF1) is a neurocutaneous tumour syndrome characterised by mutations in the NF1 gene and resultant neurofibromin protein. The condition is associated with several stigmata of variable penetrance, including various tumours. Massive and fatal haemorrhage arising from plexiform neurofibromas has been described in NF1 patients, though it is a rare clinical entity. The aetiology of massive haemorrhage in NF1 patients appears to be related to vasculopathy, including aneurysms and pseudoaneurysms, often arising within plexiform neurofibromas. There is currently no evidence-based consensus for managing this rare clinical emergency, likely as a result of its low incidence. We describe a case of massive haemorrhage in an NF1 patient managed via embolisation and discuss the literature.     

Cerebral hyperperfusion injury after percutaneous transluminal angioplasty of extracranial arteries

Cerebral hyperperfusion syndrome after carotid endarterectomy (CEA) is a rare but well-known phenomenon. Percutaneous transluminal angioplasty (PTA) is being widely evaluated for treatment of selected stenoses of the extracranial arteries. Its benefits and risks still need to be established. Hyperperfusion injury (HI) after PTA of cerebral arteries has not been reported. We describe two patients with severe HI, one with a small putaminal haemorrhage and the other with diffuse basal subarachnoid haemorrhage. In both cases, a typical clinical hyperperfusion syndrome with headache, confusion, vomiting and seizures occurred. Patient 1 underwent PTA of the left carotid artery, both subclavian arteries and proximal vertebral arteries, patient 2 had carotid angioplasty only. Transcranial Doppler ultrasound displayed markedly elevated blood-flow velocities. HI may occur after PTA of extracranial arteries. The pathogenesis might be similar to reperfusion injury after CEA. Our findings suggest that: (1) HI may occur after PTA; (2) patients should be monitored after PTA for HI; (3) further risk factors for HI need to be identified. Received: 8 May 1996 Received in revised form: 23 July 1996 Accepted: 25 July 1996     

Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache

One third of patients with aneurysmal subarachnoid haemorrhage(ASAH) present with headache only. A prompt diagnosis is crucial, butthese patients must be distinguished from patients withnon-haemorrhagic benign thunderclap headache (BTH). The headachecharacteristics and associated features at onset in subarachnoidhaemorrhage and benign thunderclap headache were studied to delineatethe range of early features in these conditions. In this prospectivestudy, one of two observers interviewed 102 patients with acute severe headache by means of a standard questionnaire. The patients were alerton admission and had no focal deficits. ASAH was subsequently diagnosedin 42 patients, non-aneurysmal perimesencephalic haemorrhage (PMH) in23 patients, and BTH in 37 patients. Headache developed almostinstantaneously in 50% of patients with ASAH, 35% of patients withPMH, and 68% of patients with BTH and within 1 to 5 minutes in 19%,35%, and 19%, respectively. Loss of consciousness was reported in26% of patients with ASAH, 4% of patients with PMH and 16% ofpatients with BTH, and transient focal symptoms in 33%, 9%, and 22%respectively. Seizures and double vision had occurred only in ASAH.Vomiting and physical exertion preceding the onset of headache weremore frequent in patients with ASAH (69% and 50%) and those with PMH(83% and 39%) than in those with BTH (43% and 22%). Headachedeveloped almost instantaneously in only half the patients withaneurysmal rupture and in two thirds of patients with benignthunderclap headache. In patients with acute severe headache, femalesex, the presence of seizures, a history of loss of consciousness orfocal symptoms, vomiting, or exertion increases the probability ofASAH, but these characteristics are of limited value in distinguishingASAH from BTH. Aneurysmal rupture should be considered even if focalsigns are absent and the headache starts within minutes.

     

Lateral hypothalamic relations with medial hypothalamus and limbic areas in geese

Spontaneous unit activity was recorded in the posteromedial hypothalamic (PMH) and preventricular magnocellular (PVM) nuclei, septal area (S) and hippocampal formation (Hp). Modifications of cellular firing induced by lateral hypothalamic area (LHA) stimulation were examined. Both thiopental anaesthetized and chronic non anaesthetized geese were used. Thiopental appeared to significantly decrease the spontaneous discharge frequency of PMH neurons, and to block both orthodromic and antidromic activations elicited by LHA stimulation. The results indicated that LHA has a predominantly inhibitory influence on PMH as well as on PVM and septal area. The study of antidromic evoked responses in the four areas investigated (PMH, PVM, S, Hp) demonstrated that these structures in turn exert a feed-back control onto LHA. These results are compared with previous electrophysiological, anatomical and behavioral feeding data and an attempt is made to establish some comparisons between birds and mammals.     

Deterioration of pre-existing hemiparesis brought about by subsequent ipsilateral lacunar infarction

Mechanisms of post-stroke recovery are still poorly understood. Recent evidence suggests that cortical reorganisation in the unaffected hemisphere plays an important role. A 59 year old man developed a small lacunar infarct in the left corona radiata, which then caused marked deterioration in a pre-existing left hemiparesis that had resulted from an earlier right putaminal haemorrhage. Functional magnetic resonance imaging showed that the paretic left hand grip activated the ipsilateral left motor areas, but not the right hemispheric motor areas. This suggests that partial recovery of the left hemiparesis had been brought about by cortical reorganisation of the left hemisphere and intensification of the uncrossed corticospinal tract. The subsequent small infarct may have damaged the uncrossed tract, thereby causing the pre-existing hemiparesis to deteriorate even further.     

Spastic pure motor monoparesis

Pure motor hemiplegia (PMH) is, in most cases, caused by a lacunar infarction. However, pure motor monoparesis (PMM), i.e., isolated motor involvement with spasticity in one limb, has drawn little attention. We studied prospectively 5 patients with PMM and found that it was always due to a mass lesion in the contralateral superficial cerebral hemisphere. Our observation suggests that PMM should not be regarded as simply a variant of PMH.     

Evaluating posterolateral linearization of the putaminal margin with magnetic resonance imaging to diagnose the Parkinson variant of multiple system atrophy.

The objective was to develop a simple method for evaluating putaminal atrophy in patients with the Parkinson variant of multiple system atrophy (MSA-P). We used magnetic resonance imaging to study 9 patients with MSA-P, 24 patients with cerebellar variants of multiple system atrophy (MSA-C), 38 patients with Parkinson's disease (PD), and 27 healthy control subjects. Posterolateral linearization of the putaminal margin was semiquantitatively scored and the putaminal area per intracranial area was calculated as the adjusted putaminal area. There was a negative correlation between the linearization scores and adjusted putaminal areas (r = -0.43, P < 0.001), such that the mean adjusted putaminal area in the group without putaminal linearization (0.0148 +/- 0.0022) was greater than that of the group with linearization (0.0124 +/- 0.0029, P < 0.005). Moreover, the occurrence of putaminal linearization was significantly higher in MSA-P patients (88.8%) than in MSA-C (8.3%), PD (7.9%) and healthy subjects (7.4%; P < 0.005). Putaminal linearization was a highly sensitive (0.89) and specific (0.91) measure for differentiating MSA-P. Our results suggest that evaluating posterolateral putaminal linearization is useful for assessing putaminal atrophy and for differentiating MSA-P from MSA-C, PD, and healthy subjects.     

Apraxia and cerebral haemorrhage: the relationship between haematoma volume and prognosis

In this study, we examined twenty-five patients with left putaminal haemorrhage to investigate the relations between ideational apraxia (IA) and intracerebral haemorrhage. Apraxias were determined at 1 and 6 months after the stroke onset. Extension and volume of haematoma were examined with CT scan within 2 days of stroke onset. IA was present in 10 cases at 1 month and disappeared in 6 cases (transient IA) and persisted in 4 cases(persisted IA) at 6 months from the onset. Although the haematoma volume related to the existence of IA, there was no significant difference between transient and persistent IA. All three patients with the haematoma volume larger than 40 ml in the transient IA group were younger than 50 years old. All cases with persistent IA were older than 50 years old. Consequently, the existence of IA seems to be partially dependent on the haematoma volume which may cause the organic damage of subcortical white matter. However, patient’s age is also important to determine the prognosis of IA. This maybe related to the nature of the haemorrhage and the mode of the onset. These factors remain to be determined.     

Gender differences in positive mental health among individuals with schizophrenia

ObjectiveThis article aims to investigate the gender differences in positive mental health among outpatients with schizophrenia.Methods142 outpatients (aged 21–65 years) with schizophrenia spectrum disorders were recruited from a tertiary psychiatric hospital. They were administered the following instruments: The Positive Mental Health (PMH) instrument, Patient Health Questionnaire (PHQ)-8 and Generalized Anxiety Disorder (GAD)-7, and the Global Assessment of Functioning (GAF) scale. Socio-demographic and clinical characteristics were gathered from interviews with the participants as well as from their medical records. Independent t-tests and chi-square tests were performed to investigate the gender differences in PMH total and domain-specific scores. Association of socio-demographic and clinical characteristics with PMH was furthered explored in men and women independently using multiple linear regression analyses using backward stepwise method.ResultsPMH total score and Emotional Support (ES) and Global Affect (GA) sub-scale scores were significantly higher among women vs men (PMH = 4.41 vs 4.07, p value = 0.01 and domains ES = 4.56 vs 3.84, p value < 0.01 and GA = 4.44 vs 4.02, p value = 0.01), given that the men and women samples did not differ significantly in their socio-demographic and clinical profiles. After adjusting for all covariates, men with no formal/ primary education were significantly associated with lower PMH total score than those with higher (secondary, A level, pre-university) education. Men belonging to Malay ethnic group had significant higher PMH total score compared to men of Chinese ethnicity. Among the women samples, those with depression as measured by PHQ-8 had significantly lower scores in the PMH total score and higher GAF score was associated with significantly higher scores in PMH total score.ConclusionsThis study identified gender differences in PMH of patients with schizophrenia spectrum disorders whereby women had higher PMH total score and domain scores than men. The study also identified factors associated with PMH which can aid in designing gender appropriate mental health interventions.     

Two mesencephalic lacunar infarcts presenting as Claude's syndrome and pure motor hemiparesis

Two exceptional cases of mesencephalic lacunar infarcts located both in the anterior vascular territory are reported. In patient 1, the infarct selectively involved the red nucleus, thus resulting in a Claude's syndrome. In patient 2, the lesion was limited to the external 2/3 of the cerebral peduncle, and was responsible for a pure motor hemiplegia (PMH). CT scan easily demonstrated the lesion in both cases. Claude's syndrome is very unusual, and PMH has only been reported once before in a mesencephalic infarct. The reasons why these lesions are so uncommon are discussed.     

Circadian fluctuations in onset of perimesencephalic hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) occurs more often during working hours and in the evening, and thus at times of relatively high blood pressure, with an even distribution over the days of the week in most studies. Perimesencephalic hemorrhage (PMH) is a non-aneurysmal subset of subarachnoid hemorrhage (SAH) without known circadian fluctuation. We studied the time and day of onset in a large series of patients with PMH. For all 249 PMH patients included in our SAH-database we analyzed the time (categorized in 2- and 6-h intervals) and day of onset by calculating rate ratios (RRs) with corresponding 95 % confidence intervals (CIs) for time and day, with the afternoon and Saturday as reference. The risk of PMH was lower between 2–4 AM (RR 0.14; 95 % CI 0.03–0.63), 4–6 AM (RR 0.21; 95 % CI 0.06–0.75) and 6–8 AM (RR 0.07; 95 % CI 0.01–0.54). A tendency towards higher risks in the morning and afternoon was observed. Analyzing the time of onset in 6-h intervals also showed a lower risk (RR 0.35; 95 % CI 0.21–0.58) during night hours (12–6 AM). The risk of PMH was evenly distributed over the days of the week. PMH occurs less often during night hours. The pattern of PMH during the day shows similarities to that seen in aSAH, although the differences over the day are not statistically significant, as they are in aSAH. The occurrence of PMH is evenly distributed over the days of the week, as it is in aSAH.     

Putaminal petechial haemorrhage as the cause of chorea: a neuroimaging study

OBJECTIVES—A hyperintense putamen on either CT orMRI as a finding associated with chorea has occasionally been describedand is almost always associated with non-ketotic hyperglycaemia. Thecause of the hyperintensity of the striatum in these images is stillcontroversial. Some reports have found that calcification wasresponsible whereas others have advocated petechial haemorrhage as thecause. The purpose of this study was to determine whether hyperintensestriata are caused by petechial haemorrhage or calcification, with the sequential imaging changes.
SUBJECTS AND METHODS—Five patients presentingwith an acute onset of either hemichorea or generalised chorea andshowed either unilateral or bilateral hyperdense striatum on theinitial CT were assessed. Neuroimaging studies including sequential CTand MRI examinations and detailed biochemical tests were performed.
RESULTS—Three patients had pronouncedhyperglycaemia and the other two patients had no biochemicalabnormalities. In all patients, the first CT scans, performed withintwo weeks of the onset of chorea, showed a high density over thestriatum contralateral to the chorea, which diminished or disappearedtwo months later. T1 weighted imaging disclosed hypersignal intensitiesover the striatum contralateral to the chorea on admission whichdiminished two months later. T2 weighted imaging at two months showedhyposignal intensity changes corresponding to the area with hypersignalchanges on T1 weighted images, implying haemosiderin deposition.
CONCLUSION—Based on the evolution of clinicalmanifestations and the findings of neuroimaging, putaminal petechialhaemorrhage might be a new entity causing either hemichorea orgeneralised chorea.