A clinical, MRI and neurophysiological study of acute transverse myelitis

There is paucity of studies correlating the MRI and evoked potential changes in acute transverse myelitis (ATM). We studied ten patients with ATM (age range 14-57 years; 8 men, 2 women) who were subjected to clinical, MRI and neurophysiological evaluation. The latter included median and tibial somatosensory evoked potentials (SEP), motor evoked potentials (MEP) to upper and lower limbs and concentric needle EMG. The outcome was defined on the basis of three month Barthel Index score. All the patients had pronounced lower limb and three had upper limb weakness. Magnetic resonance imaging scans revealed diffuse to hypointense lesions in T1, which became hyperintense in T2 in all except one patient, who had patchy hyperintense lesions in both T1 and T2 sequences suggesting haemorrhage. The signal changes extended at least three segments above the sensory level. Tibial SEP and central motor conduction time to tibialis anterior (CMCT-TA) were abnormal in nine patients each. Median SEP was normal in all, but CMCT to abductor digiti minimi (CMCT-ADM) was abnormal in four patients. The extent of MRI signal alterations and CMCT-TA correlated with the outcome. Seven patients had a poor outcome, in them MRI changes extended 10 spinal segments or more. In these patients, MEP on lumbar stimulation was either unrecordable or of low amplitude and extensive fibrillations were present in the lower limb muscles. From this study, we conclude that in ATM, extensive MRI changes, unrecordable MEP to lower limbs especially on lumbar stimulation and evidence of denervation in leg muscles seem to predict a poor outcome.     

MRI in presumed cervical anterior spinal artery territory infarcts

20 pairs of sera from the National System of Seroepidemiological Surveillance of the triple viral vaccine received in the laboratory with febrile rash diagnosis were studied. By using the hemagglutination inhibition test, it was observed an abnormal answer of antibodies to both rubella and measles through a falling of the antibody titre in one or both diseases, or in one of them with seroconversion to the other one. With the aim of defining the existence of a possible polyclonal activation already described in literature, it was decided to study the antibody response to family Herpesviridae (HSV, EBV, CMV, VZV). 80% of answer to these viruses were found. The results are submitted and discussed.     

Differentiation of recent and old cerebral infarcts by diffusion-weighted MRI

We performed MRI, including diffusion-weighted imaging, in 15 patients with recurrent strokes with acute ischaemia and at least one old lesion according to the clinical history and/or CT. Routine MRI showed similar signal intensity changes in both situations. Diffusion-weighted images, however, were positive in all acute or subacute infarcts. The high signal of acutely disturbed diffusion due to intracellular oedema could also be identified in small brain stem lesions. Spatial resolution was increased by applying separate gradients in each axis instead of creating anisotropy-independent trace images.     

The diagnosis and follow-up evaluation of acute cerebellar ataxia supported by a cerebellar stimulation study]

A 70-year-old woman who has been suffering from diabetes mellitus since 67 years of age rapidly developed severe truncal ataxia. Neurological examination showed severe truncal ataxia, incoordination and decreased deep sensations in the bilateral lower extremities. A CSF study revealed a moderately elevated total protein (125 mg/dl) without any elevation of the cell count. A nerve conduction study supported the diagnosis of polyneuropathy. Lumbar MRI revealed spinal canal stenosis at the L3/L4-L5/S1 intervertebral levels due to disk herniations and ossification of the yellow ligaments. We examined cerebellar stimulation in order to determine whether the ataxia was due to dysfunction of the cerebellum or peripheral nervous system. Conditioning electrical stimulation over the cerebellum did not change the size of motor potentials evoked by magnetic cortical stimulation in the right first dorsal interosseous muscle. Her clinical course was good, and the limb and truncal ataxia became very mild about 4 months after the onset, although there was little change in the decreased deep sensations. The cerebellar stimulation in the second study was normal. We diagnosed her as having acute cerebellar ataxia and thought that the decreased deep sensations were due to diabetic polyneuropathy and lumbosacral radiculopathies. A cerebellar stimulation study was useful for the diagnosis and follow-up evaluation of acute cerebellar ataxia in this patient.     

MRI assessment of cerebral blood volume in patients with brain infarcts

MRI perfusion studies have focussed mainly on acute ischaemia and characterisation in ischaemia. Our purpose was to analyse regional brain haemodynamic information in acute, subacute, and chronic ischaemia. We performed 16 examinations of 11 patients on a 1.5 T MR images. Conventional and dynamic contrast-enhanced imaging were employed in all examinations. For the dynamic susceptibility sequences, a bolus (0.2 mmol/kg) of gadopentetate dimeglumine was injected. Reconstructed regional relative cerebral blood volume (rCBV) maps, bolus maps, and conventional images were analysed by consensus reading. In all examinations decreases in rCBV were observed in the lesions. The distribution of regional rCBV in lesions was heterogeneous. The rCBV of the periphery of the lesions was higher than that at their center. There was a correlation between the time since onset and abnormalities on the rCBV map and T2-weighted images (T2WI). In the early stage of acute stroke, the abnormalities tended to be larger on the rCBV than on T2WI. Many patterns of bolus passage were observed in ischaemic regions. rCBV maps provide additional haemodynamic information in patients with brain infarcts.     

Mammillary body and cerebellar shrinkage in chronic alcoholics: An MRI and neuropsychological study.

Mammillary body and cerebellar volume loss are common in Korsakoff's syndrome but are more controversial in chronic alcoholics without frank amnesia or ataxia. This study related magnetic resonance imaging (MRI) derived ratings of tissue volume reduction in the mammillary bodies, cerebellar hemispheres, and cerebellar vermis to tests of verbal and nonverbal long-term declarative memory and ataxia. Ss were 33 chronic alcoholic men and 20 healthy male controls. The alcoholics showed tissue shrinkage in all 3 brain regions compared with controls and were impaired on tests of balance but not memory. Memory scores did not correlate with mammillary body or cerebellar ratings, but the correlation between balance scores and cerebellar vermis ratings approached significance. The presence of significant mammillary body shrinkage in 48% of the nonamnesic alcoholics suggests that this tissue volume reduction alone is not sufficient to produce an amnesic syndrome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A study of brain MRI findings and clinical response of bladder emptying failure in brain bladder

In 45 patients (38 males and 7 females; average age: 78 years) with brain bladder, who did not have any peripheral neuropathies and spinal disturbances, cerebral findings of MRI (1.5 T) T2 enhanced image were analyzed in comparison with those of 7 control patients with normal urination after BPH operations. Patients with neurogenic bladder were divided into three groups as follows: 33 patients with a chief complaint of urinary disturbance (Group I), 9 patients with urinary incontinence (Group II) and 3 patients with balanced bladder (Group III). High frequency of lacune (24%) of the globus pallidus and low signalling of the corpus striatum (30%) was found in Group I patients, but low frequency in other Group patients and control patients. Furthermore, pathologic changes with various grade in the globus pallidus were observed in 91% of Group I patients. In the treatment of urinary disturbance, a high improvement rate of micturition disorder (77%) was obtained in patients treated with a combination of dantrolene and TURp (TUIbn for females). However, patients which had clear lacune of the globus pallidus showed the low improvement rate. It should be possible that the globus pallidus contributes to control the movement of the external sphincter and the pelvic base muscles as well as other striated muscles. Moreover, lacune was rarely found in the urination center of the brain-stem on MRI.     

A clinical study in the treatment of acute bacterial infections with fleroxacin

The purpose of this clinical trial is to evaluate the efficacy and safety of fleroxacin and to compare with those of lomefloxacin. A randomized controlled study was carried out to treat sixty patients with urinary tract and respiratory tract bacterial infections, thirty in each group with one of the two drugs, and fifty cases were treated with fleroxacin in an open trial. Altogether there were one hundred and ten cases. Both fleroxacin and lomefloxacin were given orally, the dosage was 200 mg every 12 hours or 400 mg every 24 hours for 7-14 days. The clinical efficacy rate was 93.3%; the culturing rate in the fleroxacin group was 83.3%; the bacterial clearance rate was 92.3%, the incidence of adverse reactions was 9.4%, while in the lomefloxacin group they were 90.0%, 80.0%, 87.5% and 6.7% respectively, with no statistically significant difference between the two groups (P > 0.05). In the open and randomized trials, fleroxacin cured eighty cases of bacterial infections, the overall clinical efficacy rate was 90.0%, the culturing rate in the flero-xacin group was 83.8%, the bacterial clearance rate was 88.2% and the incidence of adverse reactions was 9.6%. It is shown that fleroxacin is an antibiotic of broad-spectrum, high efficacy and safety.     

Incidence and clinical profile of familial forms of Parkinson's disease. A study of 428 index-cases from a department of neurology]

Although the cause of Parkinson's disease remains to be determined, several lines of evidence favor the role of a genetic factor. We therefore studied a series of 428 index-cases of Parkinson's disease that were referred to our Department of Neurology between 1986 and 1993, with the aim to identify secondary family cases. Index-cases were divided into 2 groups. In groups A (279 cases), a retrospective analysis of patients records was performed. In group B (149 cases), a prospective study was carried out by 1992, which allowed a more complete investigation of family history. In group A, 31/279 index-cases (11.1 p. 100) had secondary familial cases of Parkinson's disease. This percentage increased up to 22.8 p. 100 among index-cases in group B (34/149 cases). In most instances, only one secondary case was detected, and very few proponents had 2, or 3 other family cases. No large family with numerous Parkinson's disease cases was disclosed. Age at onset of disease was similar in group A between sporadic and familial index-cases, whereas in group B age at onset was earlier index-cases with positive family history as compared to those without (53.9 +/- 10.4 years versus 59.7 +/- 12.1 years respectively). This may be due to the different sizes of groups A and B, whereas clinical profile analysis did not differentiate index-cases with positive family history from those without family history (sporadic cases). An anticipation of age at onset of illness of 13.9 +/- 12.2 years was found in 9 of the 15 index-cases from group B with first degree parental vertical inheritance, where clinical data were available for the second family case. These findings about age at onset may be at least partly explained by a more accurate estimation of age at onset in index-cases than that in secondary family cases. Further analysis on the possible mode of transmission of the disease among familial cases was consistent with the implication of a genetic factor in the ethiopathogenesis of the disease, with a mendelian autosomal dominant inheritence with reduced penetrance.     

Correlations between clinical examination/MRI/arthroscopy in the acute traumatic knee

Authors study retrospectively 81 cases of isolated recent (less than three months) knee traumas. These include clinical aspects, NMR, arthroscopy. Clinical examinations have been graded: 1. possible lesion; 2. likely lesions; 3. confirmed lesions. Clinical examinations and NMR results are compared to arthroscopy considered as reference. Clinical examination of acute traumatic knee is essential. Nevertheless, its value for detecting precise lesions is poor, except for knee locking well correlated with meniscal tears. Results show that NMR provide better results than clinical examination. NMR is reliable for detecting tears of posterior cruciate ligament, tears of posterior horn of menisci (sensibility: 93%; specificity: 80%). Its results are less effective for appreciation of lesion of anterior cruciate ligament (sensibility: 88%; specificity: 78%) because of partial tears and functional but not morphologic damage. It is the only method able to evidence osteochondral injuries and soft-tissues associated lesions in traumatic knees. Emergency NMR scans show results no differences in results compared with routine examinations. However, one should keep in mind that negative NMR cannot exclude small cartilaginous lesions and partial tears of anterior cruciate ligament. According to these results and the known qualities of NMR (non invasive), we propose that this type of investigation should be more largely included in diagnostic attitude for acute injured knee. Emergency diagnostic arthroscopy could be efficiently replaced by NMR knee examination.     

MRI in acute transverse myelopathy

Cytokines have been widely tested in clinical trials during recent years and beneficial responses have been observed in a variety of malignant, infectious and autoimmune diseases. Interferon-alpha induces remissions in patients with certain hematological malignancies such as hairy cell leukemia and chronic myelogenous leukemia. A proportion of patients with chronic viral hepatitis is cured upon application of interferon-alpha. Treatment with interferon-gamma reduces the number of infections in patients with chronic granulomatous disease. In addition, several chronic infections with intracellular pathogens also respond to treatment with this cytokine. With the exception of some patients with renal cell carcinoma and malignant melanoma, solid tumors are largely resistant to administration of these cytokines. Cytokine treatment has changed the outlook for a small group of patients with selected chronic diseases. However, clinical experience with cytokines is still limited and only interferons have been tested for treatment of a variety of diseases. Thus, it seems reasonable to expect that more cytokine-responsive diseases might be identified by continued research efforts.     

Dacryocystography using CT and MRI. Comparative study apropos of 13 clinical cases

Magnetic Resonance Imaging of a dacryocystography and a watersoluble computed tomographic dacryocystography were compared in 13 prospective cases after facial traumas, infections or without previous history. All had either watering eyes, ephiphora or dacryocystitis. This study demonstrated the superiority of computed tomography which must be used in first intention for complexe problems of the lacrimal drainage system. Only tumoral pathology (very rare) requires Magnetic Resonance Imaging. Combined computed tomography and dacryocystography in the same time provide diagnostic precision and less radiation. Confortable for the patient by helicoidal acquisition, computed tomography is cheaper than a Magnetic Resonance Imaging.     

Unilateral lenticular infarcts: radiological and clinical syndromes, aetiology, and prognosis

OBJECTIVES: To analyse the clinical features induced by lenticular infarction found in 20 patients, and to analyse the radiological and clinical correlations. METHODS: Eight women and 12 men, mean age 73 years, were included in this study, which was carried out from 1 January 1994 to 30 November 1996. They were characterised by the onset of a lenticular infarction, shown by CT and MRI. A complete neurological and neurocognitive examination, and photon emission computed tomography (SPECT), were performed in all the patients and there was a long clinical follow up. RESULTS: Two distinct clinical syndromes were identified corresponding to the two anatomical areas of the lenticular nucleus: behavioural and cognitive disorders were associated with infarcts within the globus pallidus, whereas both motor disorders (dystonia) and cognitive disorders were associated with infarcts within the putamen. Outcome was excellent in all the patients for motor function, but slight cognitive disorders, problems with short term memory, and dysphasia persisted for several months. The size of the lesion did not explain these symptoms. By contrast, the slight reduction in cerebral blood flow found in the adjacent frontotemporal area may explain them by a deafferentation or a diaschisis phenomenon. CONCLUSION: It is possible to identify the clinical symptoms of a single lesion in the pallidus nucleus and in the putaminal nucleus, in which behavioural, cognitive, and movements disorders are important. After an acute and spectacular onset, outcome is in general excellent. A disease of the small arteries must be involved.     

Therapeutic use of botulinum A toxin in neurology

The highly potent neurotoxins produced by Clostridium botulinum lead to botulism when ingested in appreciable amounts. However, botulinum toxin injections delivered intramuscularly in very small quantities can produce a therapeutically intended focal paresis while producing only negligible local or systemic side effects. Over the past several years, various neurological disorders, especially those involving increased muscle tone and/or abnormal movements, have been successfully treated with local botulinum A toxin injections. The success of this method has led to a general change in the management of blepharospasm, torticollis spasmodicus, hemifacial spasm, and other disorders. Treatment is usually effective for 4 to 12 weeks; if symptoms recur, the injections can be repeated over a period of several years, usually with the same success. Side effects depend on the site of the injections, and are rare at the optimal dosage and always reversible. For optimum therapeutic results, this treatment must be restricted to specialized centers.     

MRI and clinical features in amyotrophic lateral sclerosis

MRI of the brain and spinal cord was performed in 21 patients with amyotrophic lateral sclerosis (ALS), 8 normal volunteers and 16 neurological disease controls. High signal was seen in the intracranial corticospinal tract in 16 of the 21 patients on T2-weighted and in 10 on proton density (PD)-weighted images. In one patient, the high signal on T2-weighted images became less marked with progression of the disease. Low signal intensity was seen in the motor cortex in 12 of the 21 patients. High signal in the anterolateral column of the spinal cord on T1 weighted images was seen in 14, and high signal in the lateral corticospinal tract on T2 weighted images was seen in 7 of the 21 patients. The relationship between the abnormal images and upper motor neurone signs remained unclear. High signal intensity was seen in the corticospinal tract in the brain on T2-weighted images in two normal volunteers and four disease controls, and on PD weighted images in three disease controls. Low signal intensity in the motor cortex on T2 weighted images was seen in three normal volunteers and four disease controls. However, high signal intensity was seen in the intracranial corticospinal tract on T1 weighted images in five patients with ALS who showed pronounced upper motor neurone signs including spastic paraparesis, but not in controls. Thus, abnormalities on MRI in the brain and spinal cord should be considered in the diagnosis of ALS, and high signal intensity of the intracranial corticospinal tract on T1-weighted images may reflect the severe pathological changes of the upper motor neurones in ALS.     

Antineuronal antibodies in acute cerebellar ataxia following Epstein-Barr virus infection

A 29-year-old man developed acute cerebellar ataxia following Epstein-Barr virus infection. Serum IgG and IgM antibodies reacted with both nuclear and cytoplasmic elements of neurons. Western blot revealed IgG binding to the 34- and 29-kd bands and IgM binding to the 44-, 37-, and 29-kd bands. The IgM reactivity gradually reduced. There was no identifiable neoplasm and the ataxia gradually improved. These findings suggest a role for autoimmune mechanisms in the pathogenesis of acute cerebellar ataxia.