Atypical Presentation of Postpartum Cerebral Angiopathy Shown as a Small Penetrating Arterial Territory Infarct with Severe Peri‐Infarct Edema

Postpartum cerebral angiopathy mostly occurs in the large or medium‐sized cerebral arteries. In this case, we aimed to report a case of postpartum cerebral angiopathy presented as an asymmetrical penetrating arterial territory infarct with severe surrounding vasogenic edema. A 26‐year‐old woman admitted because of sudden headache after an attack of seizure. On initial computerized tomography (CT), hypodense lesion in the right basal ganglia was observed. The diffusion‐weighted image on 5th day revealed focal acute ischemic infarction with surrounding extensive vasogenic edema in right basal ganglia. The CT angiography showed multifocal arterial narrowing of intracranial cerebral arteries that completely resolved on the follow‐up study. This case suggested that asymmetrical small penetrating arterial territory infarct can occur as an atypical presentation of postpartum cerebral angiopathy.     

Texas Children's Medication Algorithm Project: update from Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder

OBJECTIVE: To revise and update consensus guidelines for medication treatment algorithms for childhood major depressive disorder based on new scientific evidence and expert clinical consensus when evidence is lacking. METHOD: A consensus conference was held January 13-14, 2005, that included academic clinicians and researchers, practicing clinicians, administrators, consumers, and families. The focus was to review, update, and incorporate the most current data to inform and recommend specific pharmacological approaches and clinical guidance for treatment of major depressive disorder in children and adolescents. RESULTS: Consensually agreed on medication algorithms for major depression (with and without psychosis) and comorbid attention-deficit disorders were updated. These revised algorithms also incorporated approaches to address issues of suicidality, aggression, and irritability. Stages 1, 2, and 3 of the algorithm consist of selective serotonin reuptake inhibitor and norepinephrine serotonin reuptake inhibitor medications whose use is supported by controlled, acute clinical trials and clinical experience. Recent studies provide support that selective serotonin reuptake inhibitors in addition to fluoxetine are still encouraged as first-line interventions. The need for additional assessments, precautions, and monitoring is emphasized, as well as continuation and maintenance treatment. CONCLUSIONS: Evidence and expert clinical consensus support the use of selected antidepressants in the treatment of depression in youths. The use of the recommended antidepressant medications requires appropriate monitoring of suicidality and potential adverse effects and consideration of other evidence-based treatment alternatives such as cognitive behavioral therapies.     

Low resolution electromagnetic tomography analysis of ictal EEG patterns in mesial temporal lobe epilepsy with hippocampal sclerosis

ObjectiveTo investigate the difference in the spatial distribution of scalp initial ictal discharge (IID) patterns in mesial temporal lobe epilepsy with hippocampal sclerosis (HS–MTLE).MethodsScalp ictal EEG data in 22 seizure-free patients after temporal lobectomy with amygdalo-hippocampectomy were classified as follows: a regular 5–9 Hz rhythm with a restricted temporal/subtemporal distribution (type 1, 11 patients), or an irregular 2–5 Hz rhythm with a widespread fronto-temporal distribution (type 2, 11 patients). EEG data were fragmented into segments of 1.28 s, both at ictal onset and at baseline. The LORETA solution of three frequency bands was compared between ictal and baseline using statistical non-parametric mapping (p < 0.01).ResultsThe LORETA solution of 5–9 Hz in type 2 had wider cortical activity in the ipsilateral fronto-temporal area, compared to type 1 with activation of the ipsilateral focal mesial and lateral temporal regions. The LORETA solution of 10–13 Hz in both types showed increased activity in the fronto-temporal area, which was wider in type 2 than type 1. Increased cortical activity of <5 Hz was not observed in type 1, whereas increased cortical activity was observed in the bilateral anterior frontal area in type 2.ConclusionsThe cortical source distribution in HS–MTLE may depend on scalp IID frequency. The neural generators of 5–13 Hz may be important for the formation of the ictal onset zone in both ictal patterns.SignificanceSpatial distributions in HS–MTLE patients differ with scalp IID frequency.     

Pedicular and Extrapedicular Morphometric Analysis in the Korean Population : Computed Tomographic Assessment Relevance to Pedicle and Extrapedicle Screw Fixation in the Thoracic Spine

Objective

To evaluate the anatomical parameters that must be considered when performing thoracic transpedicular or extrapedicular screw fixation.

Methods

We selected 958 vertebrae (1,916 pedicles) from 98 patients for analysis. Eight parameters were measured from CT scans : the transverse outer pedicular diameter, transverse inner pedicular diameter, length, angle, chord length of the pedicles and the transverse width, angle, and chord length of the pedicle-rib units.

Results

The age of the patients ranged from 21 to 82 years (mean : 48.2 years) and there were 57 men and 41 women. The narrowest transverse outer pedicular diameter was at T5 (4.4 mm). The narrowest pedicle length was at T1 (15.9 mm). For pedicle angle, T1 was 31.6 degrees, which was the most convergent angle, and it showed the tendency of the lower the level, the lesser the convergent angle. The chord length showed a horizontal pattern with similar values at all levels. For the PRU width, T5 showed a similar pattern to the pedicle width at 13.4 mm. For the PRU angle, T1 was the largest angle at 46.2 degrees and the tendency was the lower the level, the narrower the angle. For chord length, T1 was the shortest at 46.9 mm and T8 was the longest at 60.1 mm.

Conclusion

When transpedicular screw fixations carried out at the mid-thoracic level, special care must be taken because there is a high chance of danger of medial wall violation. In these circumstances, extrapedicular screw fixation may be considered as an alternative treatment.     

Gender-related difference in left ventricular diastolic elastance during exercise in patients with diabetes mellitus

Background Because the ratio of mitral inflow and annular velocity to stroke volume has been reported as an index of diastolic elastance (Ed), the hypothesis tested in the present study was that Ed during exercise would be more abnormal in female than in male patients with type 2 diabetes. Methods and Results Ed was measured at rest and during graded supine bicycle exercise (25W, 3-min increments) in 53 patients (27 males, mean age 53+/-14 years) with type 2 diabetes and 53 age- and gender-matched controls. The patients with diabetes were divided into 2 groups by gender. Ed was not significantly different at rest between men and women, but was significantly higher during exercise in women than in men (25 W, 0.15+/-0.04 vs 0.20+/-0.07, p=0.009; 50 W, 0.16+/-0.05 vs 0.21+/-0.08, p=0.0175). Conclusion Left ventricular (LV) diastolic elastance is abnormal during exercise, but not at rest, in patients with diabetes without overt heart disease. Female gender was associated with increased LV stiffness during exercise among patients with type 2 diabetes. (Circ J 2008; 72: 1443 - 1448).