Are we witnessing the disappearance of catatonic schizophrenia?

The decrease in the frequency of diagnosed catatonic subtypes among schizophrenic disorders as a whole during the last 50 years has long been regarded as an established fact. Until now the factors responsible for this development have been under discussion. As it is not clear if there is a true decrease or an ostensible one due to other factors such as changed diagnostic habits or neuroleptic treatment, we examined 174 consecutively admitted schizophrenic patients from three different psychiatric institutions diagnosed according to DSM-IV and Leonhard's criteria. It turned out that-depending on the diagnostic system-the rates of diagnosed catatonias were 10.3% (DSM-IV) and 25.3% (Leonhard's criteria). Comparison of the two original Leonhard cohorts (1938 to 1968, 1969 to 1986) with our own (1994 to 1999) shows a decrease in the frequency of catatonias from 35% to 25%, which-albeit statistically significant-is much less pronounced than in studies that used a narrower definition of catatonia. Here, besides sociocultural developments, the use of neuroleptics seems to effect the decrease in the frequency of catatonias in two ways: on one hand, they cause a decrease of hyperkinesia, excitement, or impulsivity; while on the other hand, they themselves produce motor abnormalities like rigidity, effects that favor the attribution of motoric symptoms to neuroleptics.     

Glucocorticoid inhibition in the treatment of depression: can we think outside the endocrine hypothalamus?

Background: Major depressive disorder affects a substantial percentage of the U.S. population, and can be highly debilitating. Selective serotonin reuptake inhibitors are commonly prescribed to treat depression, but may not be as effective for more severe or persistent depression. Methods: The authors review data concerning the effects of corticosteroid synthesis inhibitors (CSIs) in the management of depressive disorders, present a hypothesis as to their possible mechanisms of action based on recent data suggesting synergistic effects of glucocorticoids on extrahypothalamic corticotropin‐releasing hormone (CRH), and consider alternative hypotheses. Published reports evaluating the efficacy of CSIs in treating depression are reviewed and presented in light of recent findings regarding actions of glucocorticoids on the central CRH system. Results: Results from open label and double‐blind studies by several groups have indicated that CSIs may be efficacious or of adjunctive value in some patients with depression, including those refractory to other agents; however, there is a need for more controlled studies. Several lines of data suggest that the mechanism of action of these agents may not be solely a function of inhibition of adrenal cortisol production. Conclusions: The authors propose that CSIs may be efficacious in part by reducing glucocorticoid enhancement of CRH action in neurons of the central nucleus of the amygdala and other structures outside the endocrine hypothalamus. Possible effects of systemically administered CSIs on glucocorticoid receptor regulation, neuroactive steroids, and classical monoamine systems are also discussed. We conclude that available clinical data suggest a potential role for CSIs in the management of depressive disorders, especially major depression with psychotic features. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Are we overusing the diagnosis of psychogenic non-epileptic events?

In order to determine how often results of video/EEG (V-EEG) studies may change the clinical diagnosis of paroxysmal events, we prospectively studied 100 consecutive patients (75 females, 25 males) admitted for diagnosis of recurrent paroxysmal spells. The presumed diagnosis of the referring physician was obtained. Episodes were classified as epileptic seizures (ES), psychogenic non-epileptic events (PNEE), or physiologic non-epileptic events (PhysNEE). Eighty-seven patients had diagnostic events. A final diagnosis of ES was made in 21 patients, PNEE in 39, PNEE + ES in 20, and PhysNEE in seven. All PhysNEE were unsuspected. ES were misdiagnosed as PNEE more frequently than the reverse (57% vs. 12%, P < 0.001). Among the 64 patients with recorded events who had been suspected of having PNEE, 14 (21.9%) were misdiagnosed: two had PhysNEE and 12 (18.75%) had ES. Among the 23 patients with recorded events who were thought to have ES, 12 (39.1%) were misdiagnosed: seven had PNEE, five PhysNEE. V-EEG changed the clinical diagnosis in 29.8% of the patients with recorded events. Our data suggests that clinicians have become more aware of PNEE since the advent of V-EEG and have little problem recognizing them. However, they may be more prone to make a false-positive diagnosis of PNEE in ES with some atypical features. At this point, efforts should be channeled to better training in the proper recognition of ES that mimic PNEE.     

Are there diurnal variations in the results of the Dix–Hallpike manoeuvre?

This study examines diurnal variation in the result of the Dix-Hallpike manoeuvre when testing for benign paroxysmal positional vertigo in a randomised crossover study of the order of diagnostic testing in a community out-reach clinic for a tertiary neurological centre in Wellington, New Zealand. Study participants were adults referred for physiotherapy treatment. Dix-Hallpike manoeuvres were performed to both ears, and groups were randomly allocated to have a morning, then afternoon, sequence of testing or vice versa. The results of the Dix-Hallpike manoeuvres were digitally recorded and reviewed by a second blinded assessor. A total of 27 of 50 participants (54%) tested positive on at least one of the days, six of 27 (22%) had discordant results. The difference in marginal proportions was 0% (95% confidence interval: -9.6 to 9.6), p=1.0. The time of day is not a factor in false negative Dix-Hallpike manoeuvres, although 22% of those with positive results tested negative on one of the two measurements.     

Patient and family perceptions of the neuropsychological evaluation: how are we doing?

To assess perceptions of the neuropsychological evaluation, 349 patients and 218 significant others presenting to an academic medical center neuropsychology service were surveyed over a two year period. Thirty-seven percent of the patient surveys (n = 129) and 37% of the significant other surveys (n = 80) were returned. Overall, both patients and significant others reported being satisfied with the interview, testing, and feedback sessions. Responders were generally receptive to the recommendations made, but were more inclined to have followed recommendations regarding patient safety (63.6%) than coping or support (31.8%). Some barriers to compliance with recommendations were identified.     

Amygdala activation in the processing of neutral faces in social anxiety disorder: is neutral really neutral?

Previous research has suggested that Social Anxiety Disorder (SAD) is associated with a tendency to interpret ambiguous social stimuli in a threatening manner. The present study used event-related functional magnetic resonance imaging to examine patterns of neural activation in response to the processing of neutral facial expressions in individuals diagnosed with SAD and healthy controls (CTLs). The SAD participants exhibited a different pattern of amygdala activation in response to neutral faces than did the CTL participants, suggesting a neural basis for the biased processing of ambiguous social information in SAD individuals.     

Lumbar puncture and the risk of herniation: when should we first perform CT?

Death following lumbar puncture (LP) is feared by physicians. Many opinions are found in literature on the question whether computed cranial tomography (CT) should be performed before LP, to prevent herniation. These opinions are mainly based on retrospective studies and pathophysiological reasoning. In this review the difficulties in the decision whether we should perform CT before LP are discussed. It is explained that the concept of “raised intracranial pressure” is confusing, and that the less ambiguous terms “brain shift” and “raised CSF pressure” should be used instead. Brain shift is a contraindication to LP, whether CSF pressure is raised or not, and whether papilloedema is present or not. Subsequently, recommendations are offered for indications to perform CT before LP, grouped according to the safety and clinical utility of LP. Received: 28 May 2001, Accepted: 24 July 2001     

Changing the mind? Not really—activity and connectivity in the caudate correlates with changes of choice

Changes in preference are inherently subjective and internal psychological events. We have identified brain events that presage ultimate (rather than intervening) choices, and signal the finality of a choice. At the first exposure to a pair of faces, caudate activity reflected the face of final choice, even if an initial choice was different. Furthermore, the orbitofrontal cortex and hippocampus exhibited correlations only when the subject had made a choice that would not change.     

Alpha-fetoprotein secretion in a craniopharyngioma. Are craniopharyngiomas part of the germ cell tumor family?

A 14-months-old girl was admitted to our hospital because of excessive irritability and abnormal eye movements over the last two months. Brain CT and MRI revealed a suprasellar cystic and partially solid mass with calcifications. The laboratory investigation revealed increased serum levels of AFP. These findings were suggestive for a brain germ cell tumor. Therefore, systemic chemotherapy was started. After two courses there was a reduction in the levels of AFP but the tumor size remained unchanged. Subtotal tumor excision was performed that revealed the presence of a craniopharyngioma. One month later there was enlargement of the cystic part of the tumor, while serum AFP was elevated. The child received again systemic chemotherapy and placement of a reservoir into the cystic part of the tumor. Analysis of the intracystic flouid revealed the presence of beta-HCG and AFP. Following that the patient received brachytherapy with intracavity yttrium placement. Three months later repeated MRI showed a decrease in the size of the cystic part, while the solid part remained unchanged. Thus, the solid part was treated by radiosurgery. One year later the patient was stable but with complete loss of vision. These observations support the theory of a germ cell tumor family, in which craniopharyngioma and germ cell tumor present the two sides of the same entity, while between them a wide variety of tumors, with variable type of secretion of AFP and/or beta-HCG, may exist.     

Long-Term Outcome and Economic Burden of Aneurysmal Subarachnoid Hemorrhage: Are we Only Seeing the Tip of the Iceberg?

Neurocritical Care -     

Reporting success rates in the treatment of vestibular schwannomas: Are we accounting for the natural history?

Stereotactic radiosurgery is generally accepted as one of the best treatment options for vestibular schwannomas. We question whether growth control is an accurate measure of success in vestibular schwannoma treatment. We aim to clarify the success rate of stereotactic radiosurgery and adjust the reported results to the benign natural history of untreated tumors. All articles were taken from a PubMed search of the English literature from the years 2000–2011. Inclusion criteria were articles containing the number of patients treated, radiation technique, average tumor size, follow-up time, and percentage of tumors growing during follow-up. Data were extracted from 19 articles. Success rates were adjusted using published data that 17% to 30% of vestibular schwannomas grow. The average reported success rate for stereotactic radiosurgery across all articles was 95.5%. When considering 17% or 30% natural growth without intervention, the adjusted success rates became 78.2% and 86.9% respectively. These rates were obtained by applying the natural history growth percentages to any tumors not reported to be growing before radiosurgical intervention. Success in the treatment of vestibular schwannomas with stereotactic radiosurgery is often defined as lack of further growth. Recent data on the natural growth history of vestibular schwannomas raise the question of whether this is the best definition of success. We have identified a lack of continuity regarding the reporting of success and emphasize the importance of the clarification of the success of radiosurgery to make informed decisions regarding the best treatment options for vestibular schwannoma.