Vitamin B12 deficiency: a clinical and electrophysiological profile

OBJECTIVE

The present study was conducted to evaluate the clinical and electrophysiological profile of vitamin B12 deficiency syndrome and whether a correlation exists between the disease process and the various electrophysiological parameters.

METHODS

40 patients with vitamin B12 deficiency neurological syndromes with low serum vitamin B12 and high homocysteine levels were subjected to a detailed motor and sensory nerve conduction studies and pattern reversal VER (P100), SSEP (P37) after stimulation of the posterior tibial nerve and median nerve (N 20) were obtained bilaterally. MR cervical spine was done in all the patients and MR brain in those who presented with neuro-psychiatric symptoms. The patients were followed up at three months, six months and one year after treatment.

RESULTS

On the basis of clinico-electrophysiological profile, 31 patients had myeloneuropathy, 5 isolated myelopathy, 4 isolated neuropathy. Four of the patients with myeloneuropathy, had concomitant dementia. MR imaging revealed abnormality in 12.5% of cases. Prolongation of P37 latency was observed in 39 (97.5%) patients, N 20 latency in 22 (55%), and P100 latency in 19 (47.5%) patients. Peripheral neuropathy was seen in 18 patients; optic neuropathy in 8; and combination of peripheral and optic neuropathy in 9 patients. The peripheral neuropathy was axonal in 19, and demyelinating in 6 patients. There was a significant correlation of the duration of the disease with N 20 latency (P < 0.04). Serum vitamin B12 level correlated well with the latencies of P37 (P < 0.005) and sural SNAP (P < 0.006). On treatment, normalization of P100, MRI signal, N 20 and partial recovery of P37 latencies was seen at 6 months, 9 months and one year respectively.

CONCLUSION

Differential recovery of central and peripheral syndromes was seen. This correlated with the underlying demyelinating and axonal processes, which was well reflected by the electrophysiological studies, and has an important bearing on the outcome.

Brachial plexopathy: a clinical and electrophysiological study

BACKGROUND

A retrospective study to evaluate the clinical and electrophysiological profile of brachial plexus lesions in a tertiary care center of India.

METHODS

Thirty eight patients with brachial plexopathy (idiopathic or traumatic) with detailed electrophysiological studies were sampled. This included detailed motor and sensory nerve conduction studies of the conventional median, ulnar and radial nerves of the upper limbs, CMAP from deltoid, biceps and triceps on stimulating the ERB's point, needle EMG in the appropriate muscles and paraspinal muscles. The electrophysiological studies were performed on both sides irrespective of the clinical involvement and were recorded within 1.61 +/- 2.89 months in idiopathic group and 2.11 +/- 2.65 months in traumatic plexopathy group. The severity of involvement was assessed on MRC scale. ADL scale was used to assess the disability at presentation and subsequent follow up.

RESULTS

12 patients (11 male and 01 female) had idiopathic brachial plexopathy and 26 patients (all male) had traumatic brachial plexopathy. In the idiopathic group the lesion was localized to upper trunk in 58.3% of patients and middle trunk (posterior cord) in 41.66% and none had lower trunk or diffuse involvement. 25% had bilateral involvement. Two patients (16.6%) with idiopathic plexitis had recurrence involving the opposite side during the follow up. In the traumatic group the lesion was localized to the upper trunk in 11.53%, middle trunk (posterior cord) in 57.69% and 30.76% of patients had diffuse involvement. All the patients in traumatic plexopathy group had severe disability while in idiopathic group 91.66% had severe disability and 8.33% had moderate disability. Low amplitude CMAP and F wave abnormality were seen in 16.6% of patients in idiopathic group. On needle EMG 83.3% had fasciculation or fibrillations while none had paraspinal EMG abnormality. In traumatic group low to absent CMAP was seen in 69.2% and 76.92% had F wave abnormality. SNAPs were not recordable in 53.8%. On Needle EMG all the patients showed fasciculation or fibrillations and only 6 (23.0%) had paraspinal muscle fibrillations. Root avulsion could be documented in only four of these cases on MR imaging.

CONCLUSIONS

Recovery in the traumatic group correlated well with the electrophysiological abnormalities while no such correlation was evident in the idiopathic group.

Creutzfeldt-Jakob disease : report of 10 cases from North India

Creutzfeldt-Jakob disease (CJD) is increasingly being reported over the last three decades as a result of heightened awareness of the disease. Various studies have reported annual incidence of 0.5-1.5 cases of CJD per million of general population. In India, the disease is still under reported. Over the period spanning from 1968-1997, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore recorded 69 cases of CJD from different parts of India in the CJD registry. This paper describes the clinical experience with cases of CJD managed at the Department of Neurology, G.B. Pant Hospital, New Delhi from 1990-1998. In this series, the mean age of the patients was 53.80 (+/- 7.32) years and there were 5 females and 5 males. Myoclonus was present in all the cases and abnormal behaviour with or without other features was the presenting complaint in 7 of the 10 patients, while one patient of CJD had cerebellar ataxia as the presenting feature. One patient with occipital variant of CJD presented with acute onset cortical blindness and myoclonic jerks. One of the patients had acute psychosis precipitated by emotional stress at the onset. Extrapyramidal features were noted in 7 of the 10 patients before death. The mean duration of symptoms from the onset of disease to death was 6.6 (+/- 6.11) months. Classical EEG changes were observed in all the patients, except in one possible case of occipital variant of CJD, where we did not have access to EEG record. Brain biopsy could be undertaken in 3 patients, and in 2 patients the features of subacute spongiform encephalopathy (SSE) were noted.

A double-blind evaluation of alprazolam and imipramine in the treatment of major depression

This report describes the results of a multicentre collaborative study comparing the safety and efficacy of alprazolam with imipramine in patients suffering from major depressive disorder. Two hundred and eight patients diagnosed as major depression as per DSM-III criteria were randomly allocated to alprazolam (N= 105) or imipramine (N = 103) in a double-blind fashion. Detailed assessments were carried out for a period of six weeks. Results revealed that alprazolam was as effective as imipramine as an antidepressant. Side effects were less frequently reported with alprazolam.

Paramedian diencephalic syndrome. Report of 3 cases

We report three patients who lapsed into coma and subsequently manifested hypersomnolence, amnesia and vertical gaze paresis. Computed tomography revealed bilateral paramedian thalamic infarcts. This clinical symptomatology comprises the paramedian diencephalic syndrome.