Early somatosensory evoked potentials in ischemic cerebrovascular diseases--I: Methodology, patients, normal group and review of the literature

Somatosensory evoked potentials (SEP) were examined in 140 patients suffering from cerebro-vascular ischemic disease. Patients were classified in 1. asymptomatic stenosis/occlusion, 2. complicated migraine, 3. transient ischemic attacks (TIA), 4. reversible ischemic neurologic deficit (RIND), 5. completed stroke and 6. Multiinfarct-dementia. Normal SEP values were obtained from 26 age-correlated normal persons without a history of neurologic or psychiatric disease. The findings were correlated to clinical data, EEG, Single-Photon Emission and Transmission Computertomography (SPECT, TCT). SEP were done by stimulation of the median nerve. We evaluated central conduction time (CCT), amplitude ratio (AR) and number of phases (PHAS) of cortical potentials within 50 ms. Also quotient of amplitude ratio left stimulation side to right stimulation side (AR l/r) was calculated. EEG were recorded by 19 electrodes according to the 10-20 scheme, focal signs and diffuse changes were evaluated. In TCT the location of hypodense lesions was evaluated. SPECT was performed by application of J123 IMP and Tc99 HMPAO as a tracer. Focal decrease of tracer uptake compared to the compartment was evaluated. Results of animal experiments and clinical studies are discussed in respect of patients and methods.     

Early somatosensory evoked potentials in ischemic diseases--II: Normal values and findings in asymptomatic vascular stenoses/occlusions, complicated migraine, transitory ischemic attacks, reversible ischemic neurologic deficit, complete stroke and multi-infarct dementia

Somatosensory evoked potentials (SEP) were investigated in 140 patients suffering from cerebro-vascular ischemic disease (CVD). Data were compared to age-correlated normal persons (n = 26; male 16, mean age 55.6 years SD 10.9). Patients with asymptomatic vascular diseases (n = 10; male 7, mean age 63.8 years SD 10.4) showed bilateral prolonged CCT (left side p less than 0.05). Patients with TIA (n = 44; male 21, 58.3 years SD 12.3), complicated migraine (n = 3, all female, 24, 40, 63 years) and RIND (n = 17; male 10, 56.5 years SD 16.8) showed no abnormalities of CCT and AR as compared to normals. Abnormalities of PHAS were only seen in patients with RIND of the right carotic supply. In patients suffering from completed stroke (n = 40; male 29, mean age 56.9 years SD 14.4) bilateral prolongation of CCT was seen in those with ischemia of the right carotic supply; those with ischemia of the left carotic supply showed a significant asymmetry of CCT and deviation of AR l/r. In two patients with infarction of the pons an increase of CCT and decrease of AR at the side of the lesion was found. Patients with MID (n = 27; male 20, 69.7 years SD 10.3) showed significant bilateral prolongation of CCT, increase of AR (at the side of stimulation) and deviation of AR l/r (1.63).     

Intracranial tumors simulating the presentation of cerebrovascular syndromes: Early detection with cerebral computed tomography (CCT)

One hundred thirty consecutive patients in whom the initial diagnosis of cerebrovascular disease was made on clinical basis were evaluated by cerebral computed tomographic (CCT) scan. Three of 20 patients with transient ischemic attacks were found to have an abnormality on CCT scan. Of 30 patients with an initial diagnosis of stroke-in-evolution, 13 were found to have a clinically unsuspected lesion by CCT scan. Of 60 patients with completed stroke, CCT scan made possible differentiation of intracerebral hematoma, hemorrhagic and nonhemorrhagic infarction, and excluded intracranial tumors. Of 20 patients believed to have symptoms of cerebral arteriosclerosis, six had nonvascular lesions and eight had a cerebral atrophic process. This study demonstrates the efficacy of this safe and noninvasive procedure in evaluating patients with cerebrovascular disease.     

Risk factors for cerebrovascular deaths in patients operated and irradiated for pituitary tumors

Vascular mortality, especially cerebrovascular disease (CVD), are the most pronounced cause of mortality in women with hypopituitarism. In a cohort of 342 patients operated and irradiated for pituitary tumors, 31 died from CVD (CVD patients) between 1952 and 1996. The study assessed whether the radiation regimens and duration of symptoms of hypopituitarism before operation differed between the 31 CVD patients and the 62 matched patients from the same cohort who had not died from CVD (control patients). Furthermore, the infarction/hemorrhage ratio, type of clinical stroke syndrome, and time to death after stroke were investigated in the CVD patients and in matched controls from the general population who had died from CVD (population controls). No significant differences in maximum or centrally absorbed dose, maximum or central biological equivalent dose, field size, or number of fraction were recorded between CVD and control patients. A significant difference in the duration of symptoms of hypopituitarism before operation was recorded, but only in women (P = 0.01). There were no significant differences in the infarction/hemorrhage ratio (P > 0.3) of lacunar or posterior circulation syndrome compared with middle cerebral artery syndrome with cortical features (P = 0.22) or the proportion of patients who died within the first month after stroke onset (60% vs. 59%, respectively) between CVD patients and population controls. In conclusion, no significant effect on CVD deaths could be detected for any radiation parameter. A long history of unsubstituted pituitary insufficiency may be a contributing factor to the very high CVD mortality among women. There were no indications of significant differences in type of stroke, clinical stroke syndromes, or stroke fatality between the CVD patients and the population controls.     

Correlation of the organic psychosyndrome in the aged with technical findings--value of EEG and CCT in psychiatric diseases in the aged

The Psychogeriatric Department of the Bezirkskrankenhaus Regensburg is an open ward of acute cases with intensive care facilities; it exists since 2 years. There are 39 beds, admission rate is about 20-25 patients per month; patients both male and female suffer from neuropsychiatric disorders and concomitant internal diseases. There is a technical examination of all patients by EEG, CCT, cranial x-ray, and in most cases also by Doppler-sonography. The statistical evaluation aims at an attribution of neurological and psychiatric disorders resp. to technical findings. The study comprises 207 in-patients with organic brain syndromes or functional psychiatric-endogenous or psychogenic disorders. There is a better concordance in the differential diagnosis between organic brain syndrome and functional psychiatric disorders resp. and EEG than CCT, it is a statistically significant difference. Most of the psychogeriatric patients demonstrate a marked atrophy of the brain in CCT, and relation to clinical diagnosis is rare, while--apart from some exceptional cases--there is a good concordance between EEG and the clinical diagnosis "organically disturbed" or "organically normal". Though CCT being the appropriate technical method of diagnosis in cerebrovascular stroke, EEG sometimes demonstrates the localisation of an infarction at an earlier stage. EEG and CCT are indispensible in the psychogeriatric diagnostics, EEG has shown to be superior to CCT in the differential diagnosis "organic brain syndrome" vs. "functional psychiatric disorder".     

Cerebral SPECT with 99mTc-HMPAO in extracranial carotid pathology: evaluation of changes in the ischemic area after carotid endarterectomy.

The authors report their experience in studying patients undergoing carotid endarterectomy with simple photon emission computed tomography (SPECT). This technique made it possible to identify areas of preoperative cerebral hypoperfusion in 54.8% of the patients which had a good correlation with neurological symptoms. To distinguish gradual changes in the ischemic lesions, a method of assessing the surface of the hypoperfused areas was adopted. In addition, SPECT made it possible to detect a greater number of hypoperfused areas even in sites other than those revealed by CT. Moreover, there was good correlations between the SPECT data and the grade and site of the carotid lesion and the data provided by some intraoperative monitoring procedures. The Authors therefore propose the use of SPECT in the evaluation of patients with cerebrovascular insufficiency following a carotid disease.     

A clinical study in elderly patients with Parkinson's disease using MRI and SPECT--Parkinson's disease and the lacunar state]

Parkinson's disease (PD) is often associated with dementia in elderly patients, and sometimes PD coexists with senile dementia of the Alzheimer type (SDAT) or cerebrovascular disease (CVD) in the elderly. However, since there are few previous clinical studies on the coincidence of, or relationship between PD and CVD, the authors evaluated these aspects in 34 elderly patients with PD using MRI and SPECT. All the patients were over 70 years old. The diagnosis of PD was based on the presence of three symptoms (resting tremor, cogwheel rigidity and bradikinesia) which are characteristic of PD, and the effectiveness of L-DOPA therapy. We therefore believe that patients with vascular Parkinsonism were excluded from our study. In 34 cases, 24 (71%) had MRI evidence of CVD (mainly the lacunar state). In the 10 cases who had no CVD, 2 (20%) had severe dementia and the decrease of regional cerebral blood flow (rCBF) in the temporal and parietal lobes bilaterally correlated with the SPECT findings commonly found in SDAT. A comparison of the rCBF and the results of Hasegawa's dementia score (HDS) (verbal intelligence score) was made between the patients with PD associated with CVD and the patients with PD who had no CVD and no SPECT findings which correlated with SDAT. The rCBF in the frontal lobes and the results of the HDS of the former group were significantly lower than those of the latter. As mentioned above, elderly patients with PD often had CVD, leading to dementia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Headache in patients with systemic lupus erythematosus: analysis of clinical EEG and neuroimaging studies

The aim of the study was to evaluate the prevalence of headache in patients with systemic lupus erythematosus (SLE), its classification and estimation if they are the symptoms of central nervous system (CNS) involvement in patients with SLE causing any pathologies in EEG and neuroimaging methods like SPECT and MRI. We examined 83 patients with systemic lupus erythematosus (81 females and 2 males) aged between 19 and 71 years. All patients had neurological examination and EEG complemented with SPECt and MRI in some cases. 65 patients reported headache, 45 of them complained of idiopathic headache and 20--symptomatic one. The group with symptomatic headache had more frequently paroxymal changes in EEG while changes in background activity were more often notified in patients with idiopathic headache. Both SPECT and MRI showed more cerebral pathologies in patients with idiopathic headache. In SPECT the most common were multiple perfusion deficits and in MRI small hyperintensive lesions in white matter of cerebral hemispheres. Headache is the most common neurological complaint in SLE. Headache associated with pathological results of EEG or neuroimaging methods indicate the presence of central nervous involvement in patient with SLE.     

The place of EEG mapping in cerebral ischemia

70 patients with Completed stroke were studied and the findings of routine EEG, EEG mapping and CT were compared. It could be shown, that the EEG mapping revealed significantly more often focal changes corresponding with the clinical signs (83%) than the routine EEG (57%). Hypodense lesions in CT were seen in 54 patients. Identical results of EEG mapping and CT were found in 50 patients, EEG mapping and routine EEG were identical in 46 patients. The EEG mapping provided additional lateralisation in 12 patients with negative CT findings and in 21 patients with negative routine EEG. In patients with hypodense lesions in CT the EEG mapping revealed significantly more often focal changes (85%) than the routine EEG (59)%).     

Efficacy of a "standard" seizure workup in the emergency department

In many institutions it is the "standard of care" to obtain serum chemistries and anticonvulsant levels as part of the emergency department evaluation of seizure patients. To determine the efficacy of such a workup in the ED, 163 seizure patients presenting to an inner-city teaching hospital were studied in a standardized, prospective manner. After the clinical examination all patients had CBC, serum electrolyte, BUN, creatinine, glucose, calcium, magnesium, and if indicated, anticonvulsant drug level determinations performed. Any patient presenting with a first-time seizure (in patients greater than 6 years old), recent head trauma, focal neurologic deficit, or focal seizure activity had cranial computerized tomography (CCT). After obtaining historical and physical examination and before receiving laboratory results, as many as five likely etiologies were listed and assigned probability ratings. After review of the laboratory data (and CCT scan, if obtained), final etiologies again were listed and assigned percentages of likelihood. Significant abnormalities (ie, those that changed diagnosis, management, or disposition) were found in 104 patients; 96 had subtherapeutic anticonvulsant levels, five had abnormal CCT scans, two had hypoglycemia, and one had hyperglycemia as the cause of seizure. The clinical examination successfully predicted those abnormalities in all but two cases (one each of hyperglycemia and subdural hematoma). We contend tha routine serum chemistries in patients presenting to the ED are of extremely low yield, and that the clinical examination can predict accurately the need to obtain these studies. CCT scanning is useful in selected patients, and was found to be abnormal in five of 19 (25%) patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

A comparison of EEG mapping with and without visual artefact control in focal cerebral lesions]

In 163 patients with focal cerebral lesions, 43 of them with completed stroke, 43 patients with TIA, 33 patients with ICH and 29 patients with malignant and 15 patients with benign tumors EEG mapping and CT was performed. The results of EEG mapping obtained using automated artifact detection were compared to those achieved by means of visual control of raw EEG. Furthermore the impact of long (850 +/- 250s) or short (32s) analysis time was studied. Eliminating artifacts by means of visual control of raw EEG significantly more positive results were obtained than using automated artifact detection. That was found in patients with as well as in patients without lesions in CT. In relation to etiology a significant difference was found only in cerebrovascular diseases but not in the other patients-groups. Corresponding results were found in 75% of the patients. The visual control provided additional lateralization especially in patients with CS (37%) and TIA (26%). A longer duration of analysed EEG epochs did not increase the number of focal changes in EEG mapping.     

EEG and SPECT in cerebral manifestations of AIDS

The purpose of the presented study was to determine the diagnostic value of correlated EEG and SPECT findings in patients with CNS-manifestations of AIDS. Ten HIV 1 infected patients had been examined. Diagnoses: meningitis (2 x), lymphoma (2 x), necrotizing encephalitis (1 x), toxoplasmosis (7 x) (Some patients had more than one diagnosis). Unenhanced and Gd-DTPA enhanced MR, 99mTc-HM-PAO SPECT and clinical EEG were compared. In 9/10 patients MR demonstrated intracranial lesions. In one patient with necrotizing encephalitis (not detected by MR), SPECT revealed an inhomogeneous cerebral perfusion. Only lymphoma was hyperperfused. Toxoplasmic lesions-when detectable by SPECT-were hypoperfused. Reduced rCBF was also seen in brain regions not affected directly, but functionally associated to altered areas. EEG revealed diffuse signs such as slowing in patients with brain atrophy, but also in those patients with lesions of basal ganglia and thalamus. Focal signs in the EEG were in concordance with imaging findings in only 2/10 patients. In 4/10 patients foci even adjacent to the cortex - as shown by MR - remained undetected by EEG. One patient with an active toxoplasmosis had sharp waves over the affected region. The parallel application of the three methods as suggested in this paper appears useful not only for scientific purposes. In most cases, this procedure provides relevant diagnostic information. It is recommended for AIDS-patients with CNS manifestations of unknown etiology.     

Evaluation of the hemorheological and neurosonographic relationship in patients with cerebrovascular diseases

During the last fifteen years some of our priority scientific topics of research were hemorheological and neurosonographic investigations in 229 patients with different forms of cerebrovascular diseases (CVD): 75 patients with asymptomatic CVD (ACVD), 65 patients with transient ischemic attacks (TIAs) and 89 patients with chronic unilateral cerebral infarctions (UCI). The findings were compared with 70 healthy persons. The main estimated hemorheological parameters were hematocrit (Hct), apparent whole blood viscosity (WBV), plasma viscosity (PV) and fibrinogen (Fib). They were correlated with the following sonographic parameters, obtained by extracranial and transcranial Doppler sonography: blood flow velocities (BFV) and peripheral resistance index of Pourcelot (RP) of the major arteries of the head and the basal cerebral arteries and vasomotor reactivity indices (VMRI) of the middle cerebral arteries (MCA). Among the hemorheological variables the correlations of Hct with the velocity sonographic parameters predominated in all groups. Significant positive correlations between Hct, WBV and the RP of the internal carotid artery and MCA were found in patients with CVD. In UCI the increase in Hct and Fib was associated with a decrease in BFV of the collateral circulation where aging and high mean blood pressure were additional risk factors for impairment of the cerebral hemodynamics. Plasma viscosity was found to correlate with cerebral VMRI of MCA in patients with UCI. The clinical impact of these findings and their relation to the therapeutic strategy in CVD are discussed.     

Pulmonary complications in patients with antibody deficiency

ObjectiveThe aim of this study was to evaluate pulmonary complications in patients with primary antibody deficiency (X-linked agammaglobulinaemia [XLA] and common variable immunodeficiency [CVID]).MethodsThirty patients over six years of age regularly followed in a reference out-patient clinic on primary immunodeficiency were studied. All of them have been treated with intravenous immunoglobulin (IVIG) replacement therapy. Pulmonary complications were evaluated analysing clinical data (medical records review), lung function test (spirometry) and pulmonary imaging (chest computed tomography [CCT]).ResultsPatients with normal CCT (N=14) and those with abnormal CCT (N=16) have shown no differences regarding the age at onset of symptoms, age of diagnosis, and duration of IVIG treatment. The mean number of pneumonia episodes before IVIG replacement was significantly higher among patients with abnormal CCT (4 vs 7 episodes, p=0.008). CCT abnormalities observed in 16 patients were: bronchiectasis (12/16); peribronchial thickening (3/16); air trapping (5/16); lung volume reduction (4/16); atelectasis (2/16), follicular bronchiolitis and ground-glass abnormality (2/16) and parenchyma nodule (1/16). Lung function tests showed ventilatory disturbance in 18/30: obstructive pattern in 38.8%, restrictive pattern in 44.4%, and mix pattern in 16.7%. There were no significant differences in lung function between those with and without CCT abnormalities. Negative significant correlations were observed between lung function and number of episodes of pneumonia. Chronic persistent cough was associated with a reduction in lung function.ConclusionsPulmonary complications are not rare in patients with antibody deficiencies and they must be monitored.     

Kayser-Fleischer ring in Wilson's disease: A cohort study

AimsTo evaluate Wilson's disease (WD) features in Sardinian patients with Kayser–Fleischer (KF) ring and to evaluate correlations between modifications in KF and anti-copper therapy and systemic WD evolution.Patients and methodsSixty-seven WD patients (35 m/32 f; mean age 41 years) were retrospectively studied. At diagnosis and during follow up comprehensive ophthalmologic and neurologic examinations, brain RMN and ECD SPECT, detailed objective laboratory studies and hepatic histological examination were performed on all patients for analysis. All patients were given anti-copper therapy with d-Penicillamine in mono-therapy or in combination with Zinc Salts.ResultsAt diagnosis, KF was observed in 27% of patients with equal distribution in all age groups. Significant correlations between KF at diagnosis, neuro-psychiatric manifestations and pathologic features in brain RMN and in brain ECD SPECT were found at diagnosis. During follow up, a decrease in, or regression of KF was seen in 14% of patients. Anti-copper therapy leads to KF regression and prevents the appearance of KF. No significant correlations were observed between KF regression and clinical neurological or neuro-imaging improvement nor between KF modifications and clinical hepatic improvement.ConclusionsOur study highlights the peculiar features of Sardinian WD patients: low representation of KF, its equal distribution in all age groups, significant correlation between KF at diagnosis and clinical neurological manifestations, pathologic brain RMN and brain ECD-SPECT are highlighted by our study. Anti-copper therapy induces KF regression and prevents its onset. Therefore, KF ring does appear to be a predictive factor in the neurological and hepatic evolution of WD.     

改良颅内外血管吻合术治疗缺血性脑血管病五例

目的 评价改良颅内外血管吻合术治疗缺血性脑血管病的疗效。方法 对5例颈动脉闭塞患者行改良颅内外血管吻合术，分析术前、术后的脑血流动力学改变及临床症状，并进行7-12个月的随访。结果 5例患者临床症状有所改善，在随访期间无卒中发生，单光子发射电子计算机断层扫描(SPECT)行局部脑血流量(rCBF)测定，显示脑血流量较术前有所增加。结论 颅内外血管吻合术可有效地改善脑局部血流动力学状况及临床症状，预防完全性卒中的发生，远期疗效尚需进一步证实。     

99m-Tc-HMPAO-SPECT in diagnosis of early cerebral vasculitis

The objective of this study was to evaluate whether mild neurological symptoms suggestive of neuropsychiatric involvement may be associated with cerebral perfusion defects as detected by functional brain imaging with 99m-Tc-HMPAO-SPECT (single photon emission computed tomography). SPECT analysis for the early detection of central nervous system (CNS) involvement was evaluated in 40 consecutive patients with systemic vasculitis or with Sneddon's syndrome. Of these, 18 patients showed overt neuropsychiatric symptoms, so-called major symptoms (e.g. motoric or sensible defects); 6 had mild symptoms like headache or cognitive disorders, so-called minor symptoms; 16 patients did not present with any of these symptoms. SPECT abnormalities were detected in 16 of the 18 patients with overt neuropsychiatric symptoms (89%). Five of the 6 patients with minor symptoms (83%) and 5 of the 16 patients without neurological symptoms (31 %) also had SPECT abnormalities. There was no relation to disease activity or duration. We concluded that the high sensitivity of SPECT (87.5%) in detecting perfusion abnormalities among the evaluated group of patients indicates its suitability for early diagnosis of vasculitic CNS involvement.     

Review of the benefits of treating hypertension.

The main points covered in this review are as follows: 1. Hypertension is a major determinant of cardiovascular disease (CVD). As such it is a major cause of mortality, potential years of life lost, morbidity and long-term disability. 2. The incidence of CVD is directly related to BP. It is likely that this extends over the full range of BP although some writers believe that a J-curve of risk exists for CHD. 3. The relationship between long-term disability from CVD and BP requires further study. 4. Because of regression dilution bias, the gradient in risk of stroke and CHD with BP has been underestimated in the past. Recent research suggests that the risk of stroke increases at least tenfold and CHD sixfold over a range of usual DBP of 30 mmHg (equivalent to approximately 50 mmHg baseline DBP). 5. The population attributable risk (PAR) of CVD related to general elevation of BP in the population from a mean daily excess of sodium intake of 100 mmol/day is at least 30%. In typical industrialised countries the PAR for stroke and CHD from clinical hypertension is 36% and 22%, respectively. These estimates of PAR provide a guide to the maximum benefit that could result from either restriction of sodium intake in the whole population or ideal management of all persons with hypertension. In practice such targets are unlikely to be realised. 6. Recent analyses of clinical trials of treatment of hypertension suggest that the risk of stroke is reduced at all levels of initial BP to the extent predicted from observational studies.(ABSTRACT TRUNCATED AT 250 WORDS)     

Asymptomatic cerebrovascular lesions detected by magnetic resonance imaging in patients with systemic lupus erythematosus lacking a history of neuropsychiatric events.

OBJECTIVE: To clarify the extent of asymptomatic cerebrovascular involvement in systemic lupus erythematosus (SLE). PATIENTS AND METHODS: Cerebral magnetic resonance imaging (MRI) findings and ultrasonography findings of 100 patients with SLE lacking present or past clinical neurologic deficits were compared with 66 age-matched volunteers to determine the combined intima-media thickness (IMT) of the common carotid artery, and tests for anti-cardiolipin antibodies (aCL). RESULTS: Thirty-eight patients, but only 2 controls, showed imaging abnormalities. Among 23 SLE patients with cerebrovascular lesions by MRI who underwent single-photon emission computed tomography (SPECT), 14 showed hypoperfusion of the lesion. The IMT value and prevalence of aCL did not differ between the 55 SLE patients tested and controls. SLE disease activity index (SLEDAI) as assessed by a quantitative clinical index was significantly greater in patients with brain lesions than in those without. CONCLUSION: The prevalence of asymptomatic brain lesions in SLE patients is highs and shows a relationship to disease activity.     

Diagnosis of hepatic hemangioma with 99mTc-labeled red cells: single photon emission computed tomography (SPECT) versus planar imaging

This paper reports the results of a prospective study carried out to demonstrate the most important advantages of 99mTc-blood pool single emission computed tomography (SPECT) versus the established method of planar scintigraphy (PS) in the non-invasive diagnosis of liver hemangiomas. The study group comprised 40 patients in whom positive evidence of 56 hemangiomas, detected incidentally in the course of screening examinations, was established via SPECT and PS. The sensitivity of SPECT was 51/56 (91%), of PS 22/56 (39.3%); for lesions smaller than 30 mm in diameter, the sensitivity of SPECT was 31/38 (81.6%), of PS 6/38 (15.8%). All lesions with diameters of more than 30 mm were detected by both PS and SPECT. However, the SPECT method proved to be clearly superior in the identification of lesions which were smaller than 30 mm and located in unfavourable topographical sites (dorsal or subphrenic). The study proves that SPECT with 99mTc-labeled erythrocytes is the ideal complement to ultrasonography in the detection of liver hemangionas; its major advantage over TCT (transmission computed tomography) is its safe application in cases with contrast agent intolerance and hyperthyroid patients. Moreover, liver biopsies are dangerous and ill-suited for the verification of diagnosis.