Rare cause of subarachnoid hemorrhage: spinal meningeal carcinomatosis. Case report

Subarachnoid hemorrhage (SAH) of spinal origin is a rare entity accounting for approximately 1% of all cases of SAH. Its most frequent causes are trauma and vascular malformations. Although primary spinal tumors, especially ependymomas, are also relatively common causes, SAH secondary to a metastatic spinal tumor arising from outside the central nervous system is an extremely rare condition; only one case has been reported in the literature. The authors present a case of spinal meningeal carcinomatosis secondary to cutaneous malignant melanoma in which the patient presented with only symptoms of SAH. Although very rare, this case underscores several factors. 1) Spinal SAH due to spinal metastases should be considered in the differential diagnosis of patients with previously known malignancy. 2) Spinal SAH may manifest without paraparesis or sensory deficit. 3) Magnetic resonance imaging of the spinal cord may be important to determine the source of SAH in patients in whom four-vessel cerebral angiography demonstrates no abnormal findings.     

The acute effect of trimetazidine on the high frequency fatigue in the isolated Rat diaphragm muscle

The objective of this study was to determine the acute effect of trimetazidine (TMZ) on the pre-fatigue, fatigue and post-fatigue contractile characteristics and tension-frequency relationships of isolated rat diaphragm muscle. Muscle strips were taken from the ventral-costal aspects of the diaphragm muscle of rats killed by decapitation. The muscle strips were suspended in organ baths containing Krebs solution, with a gas mixture of 95% O2 and 5% CO2 at 37 degrees C and pH 7.35-7.45. After determining the thermoregulation and optimum muscle length the muscles were subjected to direct supramaximal stimulation with 0.05 Hz frequency square pulses for periods of 0.5 msec to obtain control values. After adding 5 x 10(-6) and 5 x 10(-5) M trimetazidine solution to the respective bath media, the contractile parameters of the muscles were recorded. The contractile parameters were also recorded for both the trimetazidine and trimetazidine-free media after application of the high frequency fatigue protocols. Later, the tension-frequency relationship was determined by applying stimulating pulses of 10, 20, 50 and 100 Hz to the muscle strips. Whilst the twitch tension obtained from the 5 x 10(-6) and 5 x 10(-5) M trimetazidine media showed numerical increases compared to that of the controls, these were not statistically significant (p>0.05). The contraction time exhibited a dose dependent increase (p<0.001), whilst the contraction and relaxation rates did not differ significantly. The isometric contraction forces obtained with the different stimulating frequencies showed a significant increase in the tetanic contraction only at 100 Hz (p<0.05). A comparison of the pre- and post-fatigue twitch tensions in the trimetazidine media showed the post- fatigue twitch tensions to be significantly higher than those of the pre-fatigue contraction forces (p<0.05). In the 5 x 10(-6) and 5 x 10(-5) M trimetazidine media the increases in the post-fatigue contraction force were 22 and 30%, respectively. These results demonstrated that in isolated rat diaphragm muscle, TMZ significantly limited the mechanical performance decrease during fatigue. It is our opinion that trimetazidine contributed to the observed fatigue tolerance by eliminating the factors of fatigue, due to preservation of intracellular calcium homeostasis, provision of the ATP energy levels needed by ATPase dependent pumps and especially by keeping the intracellular pH within certain limits.     

Spinal dural arteriovenous fistula and venous aneurysm: an unusual association

OBJECTIVE: Although spinal intradural arteriovenous malformations have frequently been associated with venous aneurysms, spinal dural arteriovenous fistulas typically are not. We describe a case of conus medullaris compression by a large saccular venous aneurysm of a spinal dural arteriovenous fistula. As these lesions are slow-flow arteriovenous shunts, development of a venous aneurysm is an unexpected condition. Pathogenesis of these aneurysms is briefly discussed. METHODS: A 61-year-old man presented with progressive spastic paraparesis of 1-year duration. Spinal magnetic resonance (MR) suggested abnormal serpiginous vessels and a partially thrombosed aneurysm at the level of conus medullaris. Spinal angiography was performed but some lower thoracal and upper lumbar segments could not be catheterized because of severe atherosclerosis. As a result, vascular anomaly could not be demonstrated angiographically, but surgical exploration was found to be necessary because of positive clinical and MR findings. RESULTS: An arteriovenous fistula that entered the spinal canal beneath the L1 pedicle on the left was identified. It was easily coagulated and cut. The partially thrombosed aneurysm within the conus medullaris was also resected. CONCLUSIONS: Our case illustrates two important points related to patients harboring spinal dural arteriovenous fistulas (AVF): First, clinical suspicion and MR findings are important in diagnosis of these lesions and surgical exploration is indicated despite negative or nondiagnostic angiographic results in such cases. Second, venous aneurysms may be associated with spinal dural AVFs, and although spinal dural AVFs are low-flow lesions, the development of the venous aneurysm is probably a result of high venous pressure.     

A giant renal cyst in a 89-year-old patient with a malign clinic

International Urology and Nephrology -     

Clinical predictors of therapeutic response to clozapine in a sample of Turkish patients with treatment-resistant schizophrenia

BACKGROUND: Several lines of evidence suggest that clozapine is more effective than both first- and second-generation antipsychotic drugs in treatment-resistant schizophrenia (TRS). However, clinicians appear to be hesitant to prescribe this drug. It would therefore be extremely valuable if predictors of response to clozapine could be identified. The aim of this study was to evaluate the predictive factors of clinical responses to clozapine in a group of Turkish patients with TRS. METHODS: This was a 16-week uncontrolled open study carried out among 97 TRS patients (80 males and 17 females; DSM-IV diagnosis). All patients fulfilled the criteria for refractory schizophrenia according to the UK guidelines for the National Institute of Clinical Excellence (NICE). After all previous antipsychotic medications had run their course, the patients were started on clozapine according to a standardized titration and dosage schedule. Psychopathology was evaluated before the initiation of clozapine therapy and once every 4 weeks using the Brief Psychiatric Rating Scale (BPRS), the Scale for the Assessment for Positive Symptoms, and the Scale for the Assessment of Negative Symptoms. RESULTS: Of the TRS patients on clozapine, 55.7% achieved a clinical response, defined as at least a 20% decrease in BPRS. We observed a favorable effect of clozapine on both positive and negative symptoms. Logistic regression analysis showed that a good clozapine response was more likely when schizophrenia began at a later age, when negative symptoms were severe, and when patients had an early response at 4 weeks. CONCLUSION: A combination of demographic, baseline clinical, and acute treatment response variables may accurately predict response to clozapine in TRS. Priority should be given to initiating clozapine at the earliest phase of TRS, especially for patients with evident negative symptoms.     

Arthroscopic shoulder assessment in Turkish amateur boxers

The most common injuries reported in the literature regarding the sport of boxing are to the brain, eyes, kidneys and hands. Shoulder injuries have not been fully reported in the literature until recently, as a result we aimed to present our arthroscopic findings in amateur boxers. Ten amateur boxers with complaints of pain in the shoulder region and decreased performance during sportsplay were enrolled. They were evaluated by physical examination, radiology and arthroscopy. There were no clinical findings of instability. One patient was found to have subacromial impingement; six had crepitation at various degrees during shoulder movements. At arthroscopy, all patients had a variety of pathological findings. Five patients had Grade 1, three had Grade 2, and two had Grade 3 chondropathy. Various degrees of fraying of the anterosuperior and posterosuperior regions of the glenoid labrum were noted in all cases. Three patients had superior labrum anterior and posterior lesions, one patient had a posterior labroligamentous lesion, and one had chondral erosion in the anterosuperior portion of the humeral head. In conclusions, although the injury mechanism of the shoulder during boxing is unknown, this study shows that shoulder complaints in boxers should be considered as possible indicators of serious intra-articular lesions.     

Nightmare disorder, dream anxiety, and subjective sleep quality in patients with borderline personality disorder

Aims:  The aims of the present study were to examine the rate of nightmare disorder (ND) and to determine the levels of dream anxiety and subjective sleep quality in patients with borderline personality disorder (BPD). Another aim was to determine whether dream anxiety was associated with childhood trauma, dissociative experiences, and subjective sleep disturbance in BPD patients. Finally, the hypothesis as to whether BPD patients with ND exhibited a more severe clinical profile than those without ND, was also tested.
Methods:  A total of 88 borderline patients and 100 age- and sex-matched healthy control subjects were assessed using the Structured Clinical Interview for DSM-III-R Personality Disorders, Structured Clinical Interview for DSM-IV Axis I Disorders, Van Dream Anxiety Scale, Pittsburgh Sleep Quality Index, Dissociative Experiences Scale, and Traumatic Experiences Checklist. Subjects with codiagnoses that could affect sleep were not included.
Results:  BPD patients suffered a significantly greater rate of nightmares, elevated levels of dream anxiety, and disturbed sleep quality than did controls. In the borderline group, heightened dream anxiety was correlated with higher rates of early traumatic experiences and dissociative symptoms, and impaired sleep quality. Furthermore, borderline patients with ND exhibited greater psychopathology as compared to those without ND in terms of several clinical characteristics.
Conclusions:  The present study provides support for a strong association between BPD, distressing nightmares, and subjective sleep quality. Recognition and management of dream and sleep disturbances in BPD patients might lead to improvements in their global clinical picture.