Is lumbar spondylosis a cause of urinary retention in elderly women?

Objectives Lumbar spondylosis (LS) is a common spinal degenerative disorder which causes various types of lower urinary tract dysfunction (LUTD). However, it is not certain whether LS may cause urinary retention in elderly women. Methods In a period covering the past 3 years, we retrospectively reviewed: a) urodynamic case records of women with urinary retention (post–void residuals, PVR > 100 ml), b) the records of women with LUTD due to LS (cauda equina syndrome and spinal canal narrowing by MRI), and c) uro–neurological features of women who belonged to both a) and b). Results a) One–hundred women with a mean age of 58 years had urinary retention. The most common underlying disease was multiple system atrophy [19], followed by multiple sclerosis [13] and cervical/thoracic tumours [8]. LS was the fourth most common [5], with the highest age (71 years) of all diseases. b) Nineteen women with LUTD had LS (12, canal narrowing of 50–70%; 7 > 70 %), with a mean PVR volume of 60 ml. A fourth [5] of them had urinary retention, with severe spinal canal narrowing (all 5 > 70%). c) Thus, 5 women belonged to both a) and b). In 4 of these women, LUTD followed or occurred together with typical cauda equina syndrome symptoms such as sciatica and saddle anesthesia. However, one elderly woman presented with painless urinary retention, and absent ankle reflexes were the sole neurological abnormality. The urodynamic abnormalities underlying urinary retention included an underactive detrusor in all 5, bladder sensory impairment in 3, an unrelaxing sphincter in 2, a low compliance detrusor in one, neurogenic sphincter motor unit potentials in 2 of 4 studied, and cholinergic supersensitivity of the detrusor in one of 3 studied. Surgical decompression ameliorated urinary retention in 1 of 2 women who had surgery. Conclusions In our series, only 5 percent of the women with urinary retention had LS, but LS poses a potential risk for retention, particularly in elderly women with severe spinal canal narrowing. Preganglionic somato–autonomic dysfunctions underlie this condition. It may appear as the sole initial complaint in cases in which no other obvious neurological abnormalities are found.     

Deep white matter hyperintensities in patients with bipolar depression,unipolar depression and age-matched control subjects

Objective:  Hyperintensities in the white matter of the brain (DWH) and in the periventricular area (PVH) seen on magnetic resonance imaging (MRI) have been reported to be more frequent in patients with bipolar disorder (BP) than in normal subjects. To examine this further we compared MRI of patients with BP with age-matched patients with major depressive disorder (unipolar depression, UP) and healthy control subjects.
Methods:  T2 weighted axial and coronal brain MRI scans were obtained from 13 patients in the depressive phase of BP, 11 with current UP and 19 age-matched control subjects. The degree of DWH and PVH present in each scan was determined using a standardized scoring method.
Results:  The PVH ratings were similar in the three groups of subjects. However, proportionately more BP patients had higher DWH scores than either UP patients or controls. Although this difference did attain statistical significant, a main effect of age was noted. Further, subjects over the age of 50 were under-represented in the UP group.
Conclusions:  Notwithstanding the small total sample size and relative lack of older subjects in the UP group, the fact that almost twice as many BP patients showed more severe DWH suggests that patients with BP may be more vulnerable to develop these changes than UP patients and healthy controls.     

Peritumoral edema on MRI at initial diagnosis: an independent prognostic factor for glioblastoma?

Background:  Peritumoral brain edema in glioblastoma patients is a frequently encountered phenomenon that strongly contributes to neurological signs and symptoms. The role of peritumoral edema as a prognostic factor is controversial.
Materials and Methods:  This multi-centre clinical retrospective study included 110 patients with histologically proven glioblastoma. The prognostic impact on overall survival of pre-treatment peritumoral edema detected on MRI-scans was evaluated. All patients had preoperative MRI, surgery, histology, and received standard treatment regimens. Edema on MRI-scans was classified as minor (<1 cm), and major (>1 cm).
Results:  Our results confirm that peritumoral edema on preoperative MRI is an independent prognostic factor in addition to postoperative Karnofsky performance score (KPS), age, and type of tumor resection. Patients with major edema had significant shorter overall survival compared to patients with minor edema.
Conclusion:  This easily applicable early radiological characterization may contribute to a more subgroup oriented treatment in glioblastoma patients for future trials, as well as in clinical routine.     

Temporal lobe epilepsy, depression, and hippocampal volume

Objective:   To evaluate the relationship between hippocampal volume loss, depression, and epilepsy.
Background:   There is a significantly increased incidence of depression and suicide in patients with epilepsy. Both epilepsy and depression are associated with reduced hippocampal volumes, but it is uncertain whether patients with both conditions have greater atrophy than those with epilepsy alone. Previous studies used depression measures strongly weighted to current state, and did not necessarily assess the influence of chronic major depressive disorder ("trait"), which could have a greater impact on hippocampal volume.
Methods:   Fifty-five epilepsy patients with complex partial seizures (CPS) confirmed by electroencephalography (EEG) had three-dimensional (3D)-spoiled gradient recall (SPGR) acquisition magnetic resonance imaging (MRI) scans for hippocampal volumetric analysis. Depression screening was performed with the Beck Depression Inventory (BDI, 51 patients) and with the structured clinical inventory for DSM-IV (SCID, 34 patients). For the BDI, a score above 10 was considered mild to moderate, above 20 moderate to severe, and above 30 severe depression. MRI and clinical analysis were performed blinded to other data. Statistical analysis was performed with Systat using Student's t test and analysis of variance (ANOVA).
Results:   There was a significant interaction between depression detected on SCID, side of focus, and left hippocampal volume. Patients with a diagnosis of depression and a right temporal seizure focus had significantly lower left hippocampal volume. A similar trend for an effect of depression on right hippocampal volume in patients with a right temporal focus did not reach statistical significance.
Conclusions:   Our results suggest that patients with right temporal lobe epilepsy and depression have hippocampal atrophy that cannot be explained by epilepsy alone.     

Automated normalized FLAIR imaging in MRI-negative patients with refractory focal epilepsy

Background:   Patients with focal epilepsy that is refractory to medical treatment are often considered candidates for resective surgery. Magnetic resonance imaging (MRI) has a very important role in the presurgical work-up of these patients, but is unremarkable in about one-third of cases. These patients are often deferred from surgery or have a less positive outcome if surgery is eventually undertaken. The aim of this study was to evaluate our recently described voxel-based technique using routine T2-FLAIR (fluid-attenuated inversion-recovery) scans in MRI-negative patients and to compare the results with video-EEG (electroencephalography) telemetry (VT) findings.
Methods:   We identified 70 epilepsy patients with refractory focal seizures who underwent VT and had a normal routine MRI. T2-FLAIR scans were bias-corrected, and intensity and spatially normalized (nFSI) using Statistical Parametric Mapping 5 (SPM5) as previously described. Individual scans were then compared against a set of 25 normal controls using a voxel-based method.
Results:   SPM5 identified 10 patients with suprathreshold clusters (14.3%). In 50% of these there was concordance between the lobe of the most significant cluster and the presumed lobe of seizure onset, as defined by VT. All cases were concordant with respect to lateralization of the putative focus.
Conclusion:   Using nFSI we identified focal structural cerebral abnormalities in 11.4% of patients with refractory focal seizures, and normal conventional MRI, that were fully or partially concordant with scalp VT. This voxel-based analysis of FLAIR scans, which are widely available, could provide a useful tool in the presurgical evaluation of epilepsy patients. Ongoing work is to compare these imaging findings with the results of intracranial EEG and histology of surgical resections.     

Higher severity of frontal periventricular white matter and basal ganglia hyperintensities in first-ever lacunar stroke with multiple silent lacunes

Background and purpose:  We investigated whether patients with a lacunar infarct (LI) syndrome exhibiting unique LI or multiple LI on magnetic resonance imaging (MRI) examinations differed in terms of topography and severity of white matter hyperintensities (WMH) ratings.
Methods:  Forty consecutive patients with a first-ever acute LI, who presented a lacunar syndrome according to Miller–Fisher's classification were recruited and were classified into a group presenting isolated LI on MRI ( n  = 17) or multiple LI ( n  = 23).
Results:  Despite equivalent demographic, clinical and cognitive characteristics, patients with multiple LI had increased ratings of WMH in frontal, occipital and subcortical regions. No significant correlations could be evidenced between the number of LI and WMH ratings.
Conclusions:  Present findings provide support to previous hypothesis considering single and multiple LI MRI presentations of lacunar infarct patients as distinct entities.     

One-year MRI scan predicts clinical response to interferon beta in multiple sclerosis

Background and purpose:  To define the predictive value of clinical and magnetic resonance imaging (MRI) characteristics in identifying relapsing-remitting multiple sclerosis (RR-MS) patients with sustained disability progression during interferon beta (IFNB) treatment.
Methods:  All patients receiving treatment with one of the available IFNB formulations for at least 1 year were included in this single-centre, prospective and post-marketing study. Demographic, clinical and MRI data were collected at IFNB start and at 1 year of therapy; patients were followed-up at least yearly. Poor clinical response was defined as the occurrence of a sustained disability progression of ≥1 point in the Expanded Disability Status Scale (EDSS) during the follow-up period.
Results:  Out of 454 RR-MS patients starting IFNB therapy, data coming from 394 patients with a mean follow-up of 4.8 (2.4) years were analysed. Sixty patients were excluded because of too short follow-up. Less than 1/3 (30.4%) of the patients satisfied the criterion of 'poor responders'. Patients presenting new lesions on T2-weighted MRI scan after 1 year of therapy (compared with baseline) had a higher risk of being poor responder to treatment with IFNB during the follow-up period (HR 16.8, 95% CI 7.6–37.1, P  < 0.001). An augmented risk increasing the number of lesions was observed, with a 10-fold increase for each new lesion.
Conclusions:  Developing new T2-hyperintense lesions during IFNB treatment was the best predictor of long-term poor response to therapy. MRI scans performed after 1 year of IFNB treatment may be useful in contributing to early identification of poor responders.     

Digital nerve somatosensory evoked potentials and MRI. Correlation analysis in patients with symptomatic cervical spine disorders

Objectives –  Analysis of the relationship between the symptoms, digital nerve somatosensory evoked potentials (D-SEP) and MRI, in patients with symptomatic cervical spine disorders (CSD).
Materials and methods –  MRI and D-SEP following electrical stimulation of digits I, III and V in 44 patients.
Results –  Symptoms in the fingers correlated significantly with disk herniation at the corresponding cervical level and with spinal cord impingement at one or two adjacent rostral segments on MRI. D-SEP was abnormal in 52% of all patients. Among them, the groups with multiple and single level involved on MRI had 62% and 30% of abnormal somatosensory evoked potentials (SEP), respectively. Digit I-SEP abnormality was more often localized at the root level, while digit V-SEP at the spinal cord level above the dorsal nucleus. D-SEP correlated best with compression of the spinal cord at adjacent upper and especially the most rostral (C3-5) levels on MRI.
Conclusions –  Accurate correlation of D-SEP and symptoms with MRI is essential for correct localization of lesions in patients with CSD.     

The clinical features and outcome of scan-negative and scan-positive cases in suspected cauda equina syndrome: a retrospective study of 276 patients

Background

The majority of patients presenting with suspected clinical cauda equina syndrome (CES) have no identifiable structural cause for their symptoms (‘scan-negative’ CES). Understanding these patients aids clinical differentiation and management in CES.

Methods

A retrospective electronic note review was undertaken of patients presenting with suspected CES, defined as ≥?1 of acute bladder, bowel, sexual dysfunction or saddle numbness, to a regional neurosciences centre. We investigated radiology, clinical features, psychiatric and functional disorder comorbidities and outcome of patients with ‘scan-negative’ CES and patients with MRI confirmed compression of the cauda equina (‘scan-positive’ CES).

Results

276 patients were seen over 16 months. There were three main radiologically defined patient groups: (1) ‘scan-positive’ CES (n?=?78, mean age 48 years, 56% female), (2) ‘scan-negative’ CES without central canal stenosis but with lumbosacral nerve root compression not explaining the clinical presentation (n?=?87, mean age 43 years, 68% female) and (3) ‘scan-negative’ CES without neural compromise (n?=?104, mean age 42 years, 70% female). In the two ‘scan-negative’ groups (no neural compromise and nerve root compression), there were higher rates of functional disorders (37% and 29% vs. 9%), functional neurological disorders (12% and 11% vs 0%) and psychiatric comorbidity (53% and 40% vs 20%). On follow-up (mean 13–16 months), only 1 of the 191 patients with ‘scan-negative’ CES was diagnosed with an explanatory neurological disorder (transverse myelitis).

Conclusions

The data support a model in which scan-negative cauda equina syndrome arises as an end pathway of acute pain, sometimes with partly structural findings and vulnerability to functional disorders.

     

Analysis of the upper urinary tract function in multiple sclerosis patients

Aims –  The objective of this study was to analyse the upper urinary tract (UT) function in a group of consecutive multiple sclerosis (MS) patients, who had not previously been treated by urologist.
Materials and methods –  Ninety-two MS patients suffering from lower UT dysfunction were included in the study. The group of patients consisted of 69 women and 23 men. The average Expanded Disability Status Scale (EDSS) score in our group was 4.29 (0–8.5). Functional examination of the kidneys using assessment of creatinine clearance and morphological examination of the kidneys using ultrasound was performed in all patients. Analysis of the upper UT function is presented.
Results –  The average serum creatinine clearance in our group was 132.84 ml/min/1.73 m² (46.8–510). Lower levels than normal were found in three patients (3.3%). Abnormal ultrasound findings were recorded in five patients (5.4%). The creatinine clearance was correlated with the clinical subtype of MS, the severity expressed by EDSS, the urodynamic parameters, the duration of the disease, the duration of the symptoms of lower UT and the EDSS score. We did not find a statistically significant correlation for any of these parameters.
Conclusions –  Our results suggest that impairment of the upper UT function is exceptional in MS patients.     

Aphasic or amnesic status epilepticus detected on PET but not EEG

Purpose:   To describe five patients with ictal aphasia and one patient with ictal amnesia, who had focal positron emission tomography (PET) hypermetabolism but no clear ictal activity on electroencephalography (EEG).
Methods:   ¹⁸F-Fluorodeoxyglucose (FDG)–PET scans with concomitant EEG were obtained in five patients with suspected ictal aphasia or ictal amnesia without ictal activity on EEG. We reviewed medical history, EEG, imaging data, and treatment outcome.
Results:   Brain magnetic resonance imaging (MRI) showed no structural abnormalities in any of the patients. EEG showed left temporal irregular delta activity in three patients, with aphasia and nonspecific abnormalities in two other patients, all without clear ictal pattern. All patients demonstrated focal hypermetabolism on PET scan. The hypermetabolism was in the left frontotemporal region in patients with ictal aphasia and in the bilateral hippocampal region in the patient with amnesia. Three patients who received intravenous benzodiazepines during their episodes had transient clinical improvement. With antiepileptic drug (AED) treatment, symptoms gradually resolved in all patients. Concomitant resolution of PET hypermetabolism was documented in three patients who had follow up scans. One patient with ictal aphasia later developed recurrent episodes, each with recurrent PET hypermetabolism. This patient and one other patient required immune-modulating therapy in addition to AEDs.
Discussion:   FDG-PET imaging should be considered as a diagnostic tool in patients with suspected ictal aphasia or amnesia, who fail to show clear evidence of ictal activity on EEG.     

Outcome after corticoamygdalohippocampectomy in patients with refractory temporal lobe epilepsy and mesial temporal sclerosis without preoperative ictal recording

Purpose:   We report on the surgical outcome obtained in patients with refractory temporal lobe epilepsy with mesial temporal sclerosis (MTS) who were evaluated preoperatively without ictal recording and were submitted to corticoamygdalohippocampectomy.
Methods:   Two hundred twelve patients with refractory temporal lobe epilepsy were evaluated by means of clinical history, neurological examination, interictal electroencephalography (EEG), magnetic resonance imaging (MRI), and neuropsychological testing. MRI disclosed unilateral MTS in all patients. All patients were submitted to corticoamygdalohippocampectomy at the side determined by MRI.
Results:   Interictal EEG showed unilateral temporal lobe spiking in 176 patients; in 36 patients, bilateral discharges were found. Mean follow-up time was 2.7  years. One hundred ninety-four patients (92%) were classified as Engel's class I. Eighteen patients (8%) were rated as Engel's class II. Thirty-two out of 36  patients, in whom bilateral discharges were found, were in Engel's class I. Sixty percent of the patients had an improvement in memory function related to the nonoperated temporal lobe. Fifty-nine percent of the patients had a 10-point increase in general IQ postoperatively. Verbal memory decline was noted in three patients. Pathological examination showed MTS in all patients.
Conclusions:   It is possible to adequately select good surgical candidates for temporal lobe resection using MRI and interictal EEG alone. In patients with MRI-defined MTS, we should expect a 90% postoperative remission rate. Cognitive decline was very rarely seen in this patient population. The finding of MTS on MRI is the single most important prognostic factor for good outcome after temporal lobe surgery.     

Spinocerebellar ataxia type 8 in Scotland: frequency, neurological, neuropsychological and neuropsychiatric findings

Objectives –  The objectives of this study were to: (i) establish whether the spinocerebellar ataxia type 8 (SCA 8) expansion is associated with ataxia in Scotland; (ii) test the hypothesis that SCA 8 is associated with neuropsychological impairment; and (iii) review neuroradiological findings in SCA 8.
Methods –  The methods included: (i) measurement of SCA 8 expansion frequencies in ataxic patients and healthy controls; (ii) comprehensive neuropsychological assessment of patients with SCA 8 and matched controls, neuropsychiatric interview; and (iii) comparison of patient and matched control magnetic resonance imaging (MRI) scans.
Results –  (i) 10/694 (1.4%) unrelated individuals with ataxia had combined CTA/CTG repeat expansions >100 compared to 1/1190 (0.08%) healthy controls ( P  < 0.0005); (ii) neuropsychological assessment revealed a dysexecutive syndrome among SCA 8 patients, not readily explained by motor or mood disturbance; neuropsychiatric symptoms occurred commonly; (iii) cerebellar atrophy was the only salient MRI abnormality in the patient group.
Conclusions –  The SCA 8 expansion is associated with ataxia in Scotland. The disorder is associated with a dysexecutive syndrome.     

Serum S100B protein in early management of patients after mild traumatic brain injury

Background and purpose:  Neuronal protein S100B assays are available now with a perspective of being an early screening tool for serious intracranial injury. The aim of the study was to correlate early S100B measurements and initial CCT findings in the patients sustaining mild traumatic brain injury (MTBI).
Methods:  The prospective study included patients of all ages with a history of MTBI. CCT scans and venous blood sampling for S100B analysis were performed within 6 h after injury. Levels of S100B above 0.1 ng/ml (S100B+) and any CCT detectable trauma-relevant intracranial lesions were considered positive (CCT+).
Results:  A series of 102 patients were involved in the study. CCT+ scans were present in eighteen (17.6%) and CCT- scans in 84 (82.4%) patients. There were 74 (72.5%) patients in S100B+ and 28 (27.5%) in S100B− group. Sensitivity of S100B assay attained 83.3% with a negative predictive value of 89.3%. Three patients from CCT+ group had negative plasma level of S100B. Two of them required surgical treatment.
Discussion:  S100B serum protein marker seems to be an unrealiable screening tool for determination of an intracranial injury risk group due to low sensitivity and negative predictive value seen from samples taken greater than 3 h after an MTBI.     

Cauda equina syndrome revealing neuroblastoma

IntroductionNeuroblastoma is the most common solid tumor of childhood. Neurological involvement is rare resulting from cord or nerve compression.Case reportA 7-year-old child was hospitalized for cauda equina syndrome. MRI showed retroperitoneal lesion with dumbbell intradural spreading. Blood and urinary catecholamine level were elevated confirming the diagnosis of neuroblastoma. She was treated with chemotherapy alone with partial neurological recovery.Discussion and conclusionCauda equina compression revealing neuroblastoma is exceptional especially at an early phase in the youngest patients. Treatment is based on surgical resection and/or chemotherapy and/or radiation therapy. Long-term prognosis is sometimes poor with neurological sequels.     

Lumboperitoneal shunt for treatment of dural ectasia in ankylosing spondylitis

Neurological complications of ankylosing spondylitis (AS) are reported in 2.1% of patients. Cauda equina syndrome (CES) is rare and occurs at the ankylosing stage. MRI and CT of the lumbar spine show a cauda equina deformation with dural ectasia and bony erosion. We report three patients with AS presenting with progressive CES. These patients underwent lumboperitoneal shunting (LPS) surgery. The motor deficit improved in all cases. We suggest that CES develops from arterial pulsation of the CSF on a dural sac with reduced elasticity and that LPS reduces these intradural pressure shock waves. A meta-analysis by Ahn et al. [Ahn NU, Ahn UM, Nallamshetty L, et al. Cauda equina syndrome in ankylosing spondylitis (the CES-AS syndrome): meta-analysis of outcomes after medical and surgical treatments. J Spinal Disord 2001;14:427-33] concludes that surgical treatment has a better outcome than conservative or no treatment. Adding our 3 patients to this analysis, it appears that LPS for CES in AS is more efficient than laminectomy. LPS is a routine procedure for a rare indication, which promises improvement or atleast a stabilization of this disabling evolution of the disease.     

Correlation of single photon emission computed tomography with pathology and seizure outcome in children undergoing epilepsy surgery

Introduction:  Single photon emission computed tomography (SPECT) imaging regional cerebral blood flow (rCBF) can help localize the seizure focus in partial epilepsies during presurgical evaluation. Few studies have explored the possible relationship between preoperative SPECT and underlying pathology, or any relationship to postsurgical outcome.
Study group:  Thirty-five children with medically intractable epilepsy undergoing resective surgery between the ages of 11 months and 18 years had presurgical ictal and interictal rCBF and post surgery follow up of 3–6 years.
Results:  Pathological examination revealed 13 to have hippocampal sclerosis (HS): of these 11 had relatively low interictal rCBF perfusion on the side of seizure onset, and eight had hyperfusion ictally. Eight children had morphological evidence of cortical dysplasia: all had a localizing ictal rCBF concordant with the area resected whereas only six demonstrated localized reduction in perfusion on interictal rCBF. All three patients with Rasmussens encephalitis had informative rCBF scans, concordant with the seizure focus. However, infarct, tumours and nonspecific pathology demonstrated poor localization of the seizure focus. No SPECT parameter correlated independently with outcome, although overall the HS group had the best outcome, particularly those with localizing ictal SPECT.
Comment:  Ictal SPECT appears predictive of underlying cortical dysplasia. Although in this small group of HS in children, ictal SPECT added little to interictal SPECT for seizure localization, it may be useful in the prediction of outcome. SPECT adds little to the evaluation of children being considered for hemispherectomy over and above the abnormalities detectable on MRI scan.     

Extent of initial injury determines language lateralization in mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS)

Purpose :  To assess the prevalence and attributes of atypical language lateralization (ALL) in patients with left mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE-HS).
Methods :  We recruited consecutive patients with left MTLE-HS, who had undergone resective surgery and had pathologically proven HS. Based on the Wada test, language lateralization was classified into typical (left hemispheric) or atypical (right hemispheric or codominant). We assessed the attributes of patients with ALL using univariate and multivariate analyses.
Results :  Of 124 patients with left MTLE-HS, 23 (18.5%) had ALL. ALL occurred more frequently in patients with severe initial precipitating injury (IPI), early onset of epilepsy, and a short latent period between IPI and onset of habitual seizures. ALL was more common in patients with bitemporal and extratemporal interictal epileptiform discharges (IEDs) on electroencephalogram (EEG) and extratemporal changes on magnetic resonance imaging (MRI). On multivariate analyses, the age at onset of habitual seizures <6 years, atypical IPI, nonunilateral temporal IEDs, and extratemporal MRI abnormalities independently predicted ALL. The likelihood of ALL was very low (∼1%) when all of these four risk factors were absent, whereas it was very high (>95%), if any three or all four of them were present.
Conclusions :  ALL occurs in one-fifth of patients with left MTLE-HS. ALL is more frequent in those with structural or functional extrahippocampal involvement and early onset of epilepsy interrupting the development of normal language networks. Because ALL is uncommon in those with damage/dysfunction restricted to the hippocampus, the hippocampus itself may have only a limited role in determining language lateralization.     

Outcome after hemispherectomy in hemiplegic adult patients with refractory epilepsy associated with early middle cerebral artery infarcts

Purpose:   To study the outcome after hemispherectomy (HP) in a homogeneous adult patient population with refractory hemispheric epilepsy.
Methods:   Fourteen adult patients submitted to HP were studied. Patients had to be at least 18 years old, and have refractory epilepsy, clearly focal lateralized seizures and unilateral porencephalus consistent with early middle cerebral artery infarct on magnetic resonance imaging (MRI). All patients were submitted to functional hemispherectomy. We analyzed age of seizure onset, age by the time of surgery, gender, seizure type and frequency, interictal and ictal electroencephalography (EEG) findings, MRI and IQ scores preoperatively; seizure frequency, drug regimen, and IQ outcome were studied postoperatively.
Results:   Mean follow-up was 64 months. All patients had frequent daily seizures preoperatively. All patients had unilateral simple partial motor seizures (SPS); 11 patients had secondarily generalized tonic–clonic (GTC) seizures and five patients had complex partial seizures (CPS), preoperatively. All patients had hemiplegia and hemianopsia. Twelve patients had unilateral EEG findings, and in two epileptic discharges were seen exclusively over the apparently normal hemisphere. Twelve patients were seizure-free after surgery and two patients had at least 90% improvement in seizure frequency. Pre- and postoperative mean general IQ was 84 and 88, respectively. Five of the twelve Engel I patients were receiving no drugs at last follow-up. There was no mortality or major morbidity.
Conclusions:   Our results suggest that well-selected adult patients might also get good results after HP. Although good results were obtained in our adult series, the same procedure yielded a much more striking result if performed earlier in life.     

The classic lacunar syndromes: clinical and neuroimaging correlates

Background:  Although lacunar syndromes (LSs) are aimed to be linked to lacunar infarcts, the relation between both is still not very well defined.
Purpose:  The present retrospective study tries to define more specifically the clinical and the neuroimaging characteristics of the five most classic LSs.
Patients and methods:  Out of a series of 1617 consecutive stroke patients, admitted to the Ghent University Hospital, 293 presented a classic LS. Magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) was performed within 5 days after stroke onset in 227 patients. An acute territorial infarct was demonstrated in 54 patients. The study population finally consisted of 173 patients with a classic LS in whom the responsible lacune was demonstrated or in the absence of another type of infarct.
Results:  The responsible lacune was demonstrated with DWI in 104 patients. Pure motor stroke (MS) correlated significantly with the presence of the responsible lacune in the internal capsule ( P  = 0.000147) and with the stroke severity ( P  = 0.00724). No significant correlation was observed between the location of the lacunes and the other LS's.
Conclusion:  Pure MS has to be considered as the most specific lacunar syndrome.