Natural course and pathogenesis of transient focal neurologic symptoms during pregnancy

OBJECTIVES: To determine the pathogenesis and course of transient focal neurologic symptoms in pregnant women and to identify prognostic variables that will enable targeted workup. DESIGN: Case-control series. SETTING: Tertiary care university hospital. PATIENTS: Pregnant patients with acute transient focal neurologic symptoms. Women with histories of migraine, recurrent thromboembolism, or cerebrovascular disease were excluded. INTERVENTIONS: Diffusion-weighted imaging (DWI), perfusion-weighted imaging, fluid-attenuated inversion recovery (FLAIR) imaging, gradient-recalled echo imaging, and magnetic resonance venography (MRV) and angiography to determine the presence of brain ischemia and venous thrombosis. Patients underwent echocardiography, duplex ultrasonography, and a battery of hypercoagulability tests and were followed up a mean of 12 months after the event. RESULTS: Twenty-eight controls and 14 patients were enrolled from 23 773 pregnancies. Mean age was 31.2 (range, 24-41) years and mean gestational age at symptom onset was 28 (range, 17-44) weeks. No controls reported transient focal neurologic symptoms, migraine aura, or headache. Presenting symptoms included dysphasia (6 patients) and hemisensory (5) and hemimotor (7) syndrome. In 4 patients, these symptoms were preceded by scintillating scotoma; in 9 patients, focal symptoms were followed by a first-ever, throbbing, migraine-like headache. Only 1 patient had evidence of frank infarction on magnetic resonance imaging (MRI); 2 patients had single, small, hyperintense bright foci on FLAIR imaging without accompanying lesions on DWI, and 11 patients had normal MRI and MRV results. Echocardiography, carotid duplex ultrasonography, and hypercoagulability results were negative in all patients. None of the patients had ischemic events and 4 (29%) developed migraines with aura headaches during follow-up. CONCLUSIONS: Focal neurologic symptoms in healthy pregnant women are frequently preceded by aural visual phenomena and can usually be attributed to a first-ever migraine attack. Cerebral ischemia is less common than migraine and can be reliably diagnosed with MRI. Extensive evaluations to assess a putative hypercoagulable state and cardiocerebrovascular pathology may not be warranted in all such patients.     

Ockham's razor or Hickam's dictum: a right atrial mass following excision of left atrial myxoma

We report a case of a 54-year-old man presenting with a rightatrial mass 7 months after undergoing a left atrial myxoma excisionsurgery. The differential diagnosis included recurrent myxomaor thrombus. The patient underwent repeat open sternotomy oncardiopulmonary bypass. Histopathological evaluation of themass revealed an organizing thrombus. This report is, to ourknowledge, the first that demonstrates right atrial thrombusshortly following excision of left atrial myxoma.     

A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation

BACKGROUND: A third version of the Spinal Cord Independence Measure (SCIM III), made up of three subscales, was formulated following comments by experts from several countries and Rasch analysis performed on the previous version. OBJECTIVE: To examine the validity, reliability, and usefulness of SCIM III using Rasch analysis. DESIGN: Multicenter cohort study. SETTING: Thirteen spinal cord units in six countries from North America, Europe, and the Middle-East. SUBJECTS: 425 patients with spinal cord lesions (SCL). INTERVENTIONS: SCIM III assessments by professional staff members. Rasch analysis of admission scores. MAIN OUTCOME MEASURES: SCIM III subscale match between the distribution of item difficulty grades and the patient ability measurements; reliability of patient ability measures; fit of data to Rasch model requirements; unidimensionality of each subscale; hierarchical ordering of categories within items; differential item functioning across classes of patients and across countries. RESULTS: Results supported the compatibility of the SCIM subscales with the stringent Rasch requirements. Average infit mean-square indices were 0.79-1.06; statistically distinct strata of abilities were 3 to 4; most thresholds between adjacent categories were properly ordered; item hierarchy was stable across most of the clinical subgroups and across countries. In a few items, however, misfit or category threshold disordering were found. CONCLUSIONS: The scores of each SCIM III subscale appear as a reliable and useful quantitative representation of a specific construct of independence after SCL. This justifies the use of SCIM in clinical research, including cross-cultural trials. The results also suggest that there is merit in further refining the scale.     

Seasonal variation in the incidence of congenital talipes equinovarus

A review of 77 neonates who presented with congenital talipes equinovarus over a seven-year period revealed an increase in the condition amongst babies born in the winter quarter. This finding was particularly apparent among the less severe cases of club-foot. Possible reasons for this seasonal variation are discussed.     

Late-Onset Granulomatous Reaction to Artecoll

BACKGROUND: Artecoll is permanent filler that is used for the correction of facial wrinkles. It has been used mainly in Europe in the last 9 years. It is a suspension of 25% polymethylmethacrylate microspheres of 30 to 40 microns in diameter and 75% athecollagen. OBJECTIVE: To report a side effect of a late-onset granulomatous reaction to Artecoll. METHODS: We report the case of a 54-year-old woman who presented with longitudinal hard nodules with slight overlying erythema in the glabella and nasolabial folds 14 months after she was treated with Artecoll injections to her glabellar and nasolabial wrinkles. An excisional biopsy of a glabellar nodule was performed. RESULTS: Microscopic examination of hematoxylin and eosin-stained specimen revealed histiocytic granulomas with giant cells and vacuoles, a picture of Artecoll granulomas. Treatment with topical steroids showed no improvement. Intralesional injections of Kenalog caused temporary disappearance of the granulomas. A few months later the nodules reappeared. No further treatment was done. CONCLUSION: Artecoll injection to wrinkles of the face can cause delayed granulomatous reaction. This side effect is not reversible and should be addressed in the informed consent.     

A new method for proton detection of H217O with potential applications for functional MRI

A method is presented for the sensitive detection of minute amounts of H₂¹⁷O. The method is based on the increase of the T₂ of the water protons following an irradiation of the ₁₇O resonance frequency, due to the partial or full decoupling of the ¹H-¹⁷O spin-spin interaction. It is demonstrated that when ¹⁷O concentrations are low, full decoupling is achieved, and at short echo times the increase in the amplitude of the proton echo signal is proportional to the ¹⁷O content of the sample. The potential of the method for indirect ¹⁷O imaging is substantiated by a simple one dimensional projection of cylindrical phantoms containing various ¹⁷O concentrations. Using interleaved sequences with and without ¹⁷O decoupling, errors due to time dependent effects are minimized.     

The treatment dilemma in post-traumatic syringomyelia

Purpose: The aim of the present study was to compare the functional effect of conservative and surgical treatment in post-traumatic syringomyelia. Method: The files of 10 male patients treated for post-traumatic syringomyelia were retrospectively reviewed from 1986 to 1996. Results: The spinal lesion was complete in five patients and incomplete in five. All patients underwent rehabilitation, five of them following surgery. The operative procedures included drainage by syringosubarachnoid shunting (four patients) and decompressive laminectomy (one patient). Rehabilitation alone improved the functional status in all five patients so treated. After surgery, function deteriorated in four of the five operated patients, and rehabilitation failed to restore the preoperative functional status in any of them. Conclusion: In view of the results it is suggested that patients with post-traumatic syringomyelia undergo rehabilitation with very close clinical and magnetic resonance imaging follow-up.