[Contrast Induced Encephalopathy after carotid percutaneous transluminal angioplasty in a patient with end stage renal disease undergoing peritoneal Dialysis]

Introduction. Contrast Induced Encephalopathy (CIE) belongs to Major Adverse Renal and Cardiovascular Events (MARCE) after iodinated contrast medium (IOCM), especially for high-risk patients with several comorbidities such as hypertension, diabetes, heart failure, and Chronic Kidney Disease (CKD). We report a case of CIE in a Peritoneal Dialysis (PD)-patient. Case report. A 78-year-old, affected by diabetes, hypertension, chronic heart failure, and End Stage Renal Disease (ESRD) treated with PD, underwent a carotid Percutaneous Angioplasty (PTA). Immediately after the exam, he developed mental confusion and aphasia. Encephalic CT scan and MRI excluded acute ischemia or hemorrhage but showed cerebral oedema. Mannitol and steroids were administered and additional PD exchange was performed with depurative aim. Within 2 days the patient completely recovered. Discussion. CIE mimics severe neurological diseases. It should be considered as a differential diagnosis if symptoms occur immediately after administration of IOCM, especially in high-risk patients and in case of intra-arterial injection. Clinical presentation includes transient cortical blindness, aphasia, focal neurological defects, and confusion. CIE is often a diagnosis of exclusion, and imaging plays a significant role. Symptoms generally resolve spontaneously within 24-48h, rarely in few days. Symptomatic therapy, including mannitol and steroids could be considered. In literature, CIE is reported only in a few patients affected by ESRD treated with chronic HD, and our is the first available case of a patient treated with chronic PD who developed this rare complication.

[A Rare Cause for Transient Aphasia after Conorary Angiography]

Zusammenfassung. Wir berichten über eine 72-jährige Patientin, die nach einer elektiven Koronarangiografie über plötzlich einsetzende stärkste Kopfschmerzen klagte. Klinisch bestand eine dysphasische Aphasie, die sich rasch progredient zu einer globalen Aphasie und einem deliranten Zustandsbild entwickelte. Nach dem Ausschluss alternativer Differenzialdiagnosen gingen wir von der seltenen Komplikation einer kontrastmittelinduzierten Enzephalopathie nach Koronarangiografie aus.

Metronidazole toxicity presenting with acute onset of aphasia and right sided weakness

We report a 37-year-old man with a history of cirrhosis and methicillin-sensitive staphylococcus aureus (MSSA) bacteremia who presented from a nursing home with 1 week of progressive confusion followed by acute onset of aphasia, forced left eye deviation and right sided weakness. While clinical presentation was concerning for a left middle cerebral artery stroke, MRI was consistent with leukoencephalopathy. The man had been on metronidazole for 2 months for treatment of Clostridium difficile infection. This case exemplifies a stroke mimic to be considered when a patient presents with an acute focal neurological deficit.

Drug-related admissions due to interaction with an old drug, lithium

Lithium is one of the oldest psychotropic drugs with a well-known narrow therapeutic range and the drugs that interact with lithium elimination are well established. However, patients are still admitted to the emergency department with lithium toxicity due to often overlooked interactions with concomitant drugs. We report on two patients, admitted to the emergency department, with lithium toxicity. One patient presented with aphasia and ataxia, showing moderate toxicity. The other was referred due to coma, illustrating severe lithium toxicity. In both cases, a non-steroidal anti-inflammatory drug was the underlying cause. We highlight the mechanism of this drug-drug interaction and underline the need for thoughtful use of other medications in patients taking lithium. Special attention has to be paid for the non-steroidal antiinflammatory drugs due to the low threshold of prescribing them for the control of acute pain and its availability as free over-the-counter drugs.

Reversible posterior leukoencephalopathy syndrome after bevacizumab/FOLFIRI regimen for metastatic colon cancer

OBJECTIVE

To describe a patient with reversible posterior leukoencephalopathy syndrome following the administration of bevacizumab (Avastin), a monoclonal antibody against vascular endothelial growth factor.

DESIGN

Case report/literature review.

SETTING

University hospital.

PATIENT

A 52-year-old man receiving chemotherapy for stage IV rectal carcinoma.

RESULTS

Clinical and radiographic evidence consistent with reversible posterior leukoencephalopathy syndrome was found following the administration of irinotecan hydrochloride, leucovorin calcium, and fluorouracil (FOLFIRI) regimen chemotherapy and bevacizumab.

CONCLUSIONS

Reversible posterior leukoencephalopathy syndrome following treatment with angiogenesis modulators can occur. In addition to raising clinical suspicion in appropriate patients, this report may yield clues to the pathophysiologic underpinnings of reversible posterior leukoencephalopathy syndrome.

Immune reconstitution inflammatory syndrome associated with PML in AIDS: A treatable disorder

An HIV-1-infected patient with progressive multifocal leukoencephalopathy presented clinical deterioration and contrast-enhancing lesions on brain nuclear MR after the initiation of highly active antiretroviral therapy (HAART). Brain biopsy identified an inflammatory reaction compatible with immune reconstitution inflammatory syndrome. Treatment with corticosteroids and transient suppression of HAART led to marked neurologic improvement.

Language lateralization in temporal lobe epilepsy: a comparison between fMRI and the Wada Test

PURPOSE

Recent studies have claimed that language functional magnetic resonance imaging (fMRI) can identify language lateralization in patients with temporal lobe epilepsy (TLE) and that fMRI-based findings are highly concordant with the conventional assessment procedure of speech dominance, the intracarotid amobarbital test (IAT).

METHODS

To establish the power of language fMRI to detect language lateralization during presurgical assessment, we compared the findings of a semantic decision paradigm with the results of a standard IAT in 68 patients with chronic intractable right and left temporal lobe epilepsy (rTLE, n=28; lTLE, n=40) who consecutively underwent a presurgical evaluation program. The patient group also included 14 (20.6%) subjects with atypical (bilateral or right hemisphere) speech. Four raters used a visual analysis procedure to determine the laterality of speech-related activation individually for each patient.

RESULTS

Overall congruence between fMRI-based laterality and the laterality quotient of the IAT was 89.3% in rTLE and 72.5% in lTLE patients. Concordance was best in rTLE patients with left speech. In lTLE patients, language fMRI identified atypical, right hemisphere speech dominance in every case, but missed left hemisphere speech dominance in 17.2%. Frontal activations had higher concordance with the IAT than did activations in temporoparietal or combined regions of interest (ROIs). Because of methodologic problems, recognition of bilateral speech was difficult.

CONCLUSIONS

These data provide evidence that language fMRI as used in the present study has limited correlation with the IAT, especially in patients with lTLE and with mixed speech dominance. Further refinements regarding the paradigms and analysis procedures will be needed to improve the contribution of language fMRI for presurgical assessment.

Speech Preservation during Language-dominant, Left Temporal Lobe Seizures: Report of a Rare, Potentially Misleading Finding

PURPOSE

To evaluate the prevalence and mechanism of ictal speech in patients with language-dominant, left temporal lobe seizures.

METHODS

We retrospectively reviewed the video-EEG telemetry records for the presence of ictal speech in 96 patients with surgically proven left temporal lobe epilepsy and studied the seizure-propagation patterns in three patients who required intracranial EEG recordings for seizure localization.

RESULTS

Ictal speech preservation was observed in five patients. One patient's seizures demonstrated rapid propagation of the ictal discharges to the contralateral temporal area where the seizure evolved, resembling a nondominant temporal lobe seizure. The other two patients had ictal discharges that remained confined to the inferomesial temporal areas, sparing language cortex.

CONCLUSIONS

Preservation of speech in complex partial seizures of language-dominant, left temporal lobe origin is rare. Based on intracranial EEG recordings, the likely mechanism underlying this potentially misleading clinical finding is the preservation of language areas due to limited seizure-propagation patterns.

Speech Recognition Impairments in Patients with Intractable Right Temporal Lobe Epilepsy

PURPOSE

To evaluate speech recognition in patients with focal intractable epilepsy and surgical resections in the nondominant (right) hemisphere.

METHODS

Speech recognition was tested prospectively, under different listening conditions, in 22 patients with right temporal lobe (11 patients) or extra-temporal lobe epilepsy. All were left-hemisphere dominant for language on preoperative intracarotid sodium amobarbital testing.

RESULTS

All patients demonstrated normal auditory recognition of words and environmental sounds before and after surgery. However, when real-world listening conditions were simulated by using acoustically degraded (filtered) words, patients with temporal lobe epilepsy performed significantly worse than patients with frontal or parietooccipital lobe epilepsy before and after surgery (p<0.0001).

CONCLUSIONS

Patients with intractable right temporal lobe epilepsy are at risk for speech recognition impairments in real-world listening environments, independent of surgery. The impact of speech recognition difficulties on verbal communication, coupled with the prevalence of adverse listening environments, underscores the importance of testing speech recognition under different listening conditions in patients with intractable right temporal lobe epilepsy.

Effects of Illness Duration on Memory Processing of Patients with Temporal Lobe Epilepsy

PURPOSE

To examine the effects of illness duration on the neural processing of memory in patients with temporal lobe epilepsy (TLE) by using functional MRI.

METHODS

Twenty-three TLE patients (16 left, seven right) performed a complex visual scene-encoding task during functional MRI. Region-of-interest (ROI) analyses were used to quantity functional activation in the mesial temporal and frontal lobes. The patients' verbal and visual memory performances were evaluated by standardized neuropsychological tests. Analyses included group comparison and correlations of duration of epilepsy with functional activation and memory performance.

RESULTS

Compared with normal controls, TLE patients demonstrated reduced activation bilaterally in the mesial temporal lobe (p=0.003), and the reduction was more pronounced on the ipsilateral side of the seizure focus. Moreover, a longer duration of illness was associated with fewer voxels activated in both the left (p=0.038) and right (p=0.017) mesial temporal lobe. Furthermore, the duration of illness was found to be significantly and negatively correlated with both verbal (p=0.020) and visual (p=0.000) memory functioning.

CONCLUSIONS

TLE seems to affect the memory processes in the mesial temporal lobes progressively (i.e., the longer the duration of illness, the lower the brain activation). In turn, the reduction of brain activation negatively affects memory functioning. Finally, the reduction is not limited to the side of seizure but also is observed in the contralateral hemisphere.

Etomidate speech and memory test (eSAM): A new drug and improved intracarotid procedure

BACKGROUND

The intracarotid amobarbital procedure (IAP) is an important part of comprehensive investigation of patients who are candidates for surgical treatment of epilepsy. Owing to repeated and lengthy shortages of amobarbital, causing delays in elective surgery, attempts have been made to find a suitable alternative anesthetic. The authors report their experience using etomidate, a widely used agent for the induction of anesthesia.

METHODS

Sixteen consecutive patients requiring IAP to evaluate memory or to lateralize speech underwent the procedure using etomidate. Prior to the procedure a catheter was placed in the internal carotid artery and an angiogram was performed. EEG was recorded and read online by an electroencephalographer. An anesthetist injected the drug, administered by bolus followed by an infusion, which was maintained until each speech measure had been sampled and new memory items had been introduced. The infusion was then stopped and testing continued as in a standard IAP.

RESULTS

In all cases (30 hemispheres) contralateral hemiplegia followed injection. EEG slow waves were observed in every injected hemisphere, with some contralateral slowing anteriorly in 18. Global aphasia with preserved attention and cooperation followed dominant-hemisphere injections. These phenomena remained during infusion, and upon its termination returned gradually to baseline over a period of about 4 minutes.

CONCLUSIONS

Etomidate is a viable alternative to amobarbital, and its administration by bolus followed by infusion offers an improvement over the traditional intracarotid amobarbital procedure. Cognitive tests can be performed during an assured hemianesthesia of the injected hemisphere.

Progressive multifocal leukoencephalopathy in a patient treated with natalizumab

We describe the clinical course of a patient with multiple sclerosis in whom progressive multifocal leukoencephalopathy (PML), an opportunistic viral infection of the central nervous system, developed during treatment with interferon beta-1a and a selective adhesion-molecule blocker, natalizumab. The first PML lesion apparent on magnetic resonance imaging was indistinguishable from a multiple sclerosis lesion. Despite treatment with corticosteroids, cidofovir, and intravenous immune globulin, PML progressed rapidly, rendering the patient quadriparetic, globally aphasic, and minimally responsive. Three months after natalizumab therapy was discontinued, changes consistent with an immune-reconstitution inflammatory syndrome developed. The patient was treated with systemic cytarabine, and two months later, his condition had improved.

Einseitiges zerebrales Kontrastmittelextravasat nach Koronarangiographie

We report on an 82-year-old woman who suffered a sudden loss of consciousness, right-sided hemiparesis, and aphasia during a coronary angiographic procedure. Computed tomography (CT) of the brain performed immediately revealed an edema and extravascularly localized contrast media in the left hemisphere. Within 6 h, neurological symptoms had disappeared, and a second CT after 48 h revealed normal results. Usually, extravasation of contrast media affects the posterior circulation with cortical blindness. This case demonstrates that contrast media may affect the blood-brain barrier also outside the posterior circulation. If neurological symptoms occur during angiography, contrast media extravasation must be distinguished from embolism or vasospasm induced by the angiographic procedure.

Topiramate and word-finding difficulties in patients with epilepsy

OBJECTIVE

To evaluate the prevalence of word-finding difficulties as a treatment-emergent adverse event in patients with epilepsy taking topiramate and to identify a clinical phenotype at risk.

METHODS

The authors investigated the relationship of word-finding difficulties to topiramate titration schedule, seizure frequency and pattern, and EEG and neuroradiologic findings in 431 consecutively and prospectively collected patients taking topiramate.

RESULTS

Thirty-one patients (7.2%) developed word-finding difficulties. Presence of simple partial seizures (OR = 6.7 p = 0.007) and a left temporal EEG epileptic focus (OR = 5.2 p = 0.021) were significantly associated with word-finding difficulties.

CONCLUSIONS

The presence of word-finding difficulties seems to be a titration schedule independent phenomenon that occurs in a subgroup of patients with a specific biologic vulnerability.

Midazolam challenge reinduces neurological deficits after transient ischemic attack

BACKGROUND AND PURPOSE

A transient ischemic attack (TIA) in the brain is classically considered a syndrome lasting <24 hours. Having previously shown that an experimental challenge with the GABAA agonist midazolam in recovered stroke patients can reinduce the acute clinical state, we determined whether TIA patients would demonstrate a similar effect.

METHODS

Four right-handed patients participated: 3 with clinical TIA presumed to have affected the left hemisphere within the previous 24 to 72 hours and no evidence of a new lesion on diffusion-weighted and fluid-attenuated inversion recovery imaging, and 1 patient with an asymptomatic temporal arteriovenous malformation. The TIA duration ranged from 30 minutes to 3 hours. Each patient underwent baseline testing for motor function and aphasia, after which intravenous midazolam was delivered until mild drowsiness was detected. Patients were tested during the peak drug effect and again after 2 hours when sedation had dissipated.

RESULTS

No patient showed weakness or aphasia at baseline. After administration of midazolam, all 3 TIA patients demonstrated re-emergence of features that characterized their recent transient neurological syndromes (right-sided weakness and/or aphasia) but no left-sided findings. The arteriovenous malformation patient who had never been symptomatic showed no drug effect. Two hours later, all TIA patients returned to their normal clinical state.

CONCLUSIONS

Patients who had suffered recent transient cerebral ischemic episodes and were neurologically intact with negative diffusion-weighted imaging showed re-emergence of prior focal deficits after administration of a benzodiazepine in a dose that produces light sedation. These findings suggest that presumed TIA may produce neuronal dysfunction beyond the symptomatic period.

Pica and the elephant's ear

This is a case report of an otherwise healthy 2-year-old boy with a history of pica, associated with iron deficiency anemia. This boy was referred to our department for a neurologic evaluation because of an acute episode of sialorrhea, difficulty in speaking, dysphagia, and repeated swallowing movements. An uncertain episode of a brief-duration still gaze was also reported. In addition, the history revealed that the child had earlier ingested a leaf from a poisonous houseplant called Colocasia esculenta, also known as "elephant's ear." The habit of pica subsided after treatment with iron supplements. A 9-month follow-up period was uneventful. Neurologic manifestations can accompany accidental intoxications of some non-nutrient substances. Thus, pica must be suspected in children with acute behavior alterations.

Reversible aphasic disorder induced by lamotrigine in atypical benign childhood epilepsy

PURPOSE

We studied an eleven year-old girl with atypical, benign partial epilepsy who acutely presented a severe aphasia associated with marked EEG deterioration after lamotrigine administration. A parallel monitoring of language disorders and EEG changes during the gradual withdrawal of lamotrigine was performed in order to evaluate their possible correlation with lamotrigine administration.

METHODS

Detailed neuropsychological and linguistic examinations in association with awake and sleep EEG were periodically performed.

RESULTS

The evolution of the aphasic disorder was closely related to the EEG abnormalities, and disappeared after the withdrawal of lamotrigine.

CONCLUSIONS

We considered the hypothesis that our case could be an expression of a paradoxical reaction to lamotrigine, in which the transitory aphasic disorder was sustained by an epileptiform electric activation.

Gliclazide-induced hepatitis, hemiplegia and dysphasia in a suicide attempt

The drugs used to treat diabetes mellitus are diverse and include several classes. One class is sulfonylureas which primarily cause serum glucose reduction by stimulating the release of preformed insulin from the pancreatic islets. Gliclazide, a second generation sulfonylurea, is used to control glycemic levels in non-insulin-dependent diabetes mellitus. We report a 14 year-old non-diabetic girl who developed hepatitis, hemiplegia and dysphasia after ingestion of an overdose of gliclazide (20 mg/kg/day) in a suicide attempt. Our purpose is to draw attention to the severity of gliclazide-induced neurological signs. To the best of our knowledge, gliclazide-induced hemiplegia and dysphasia have not been previously reported in the literature.

Posterior cerebral artery Wada test: sodium amytal distribution and functional deficits

Inadequate sodium amytal delivery to the posterior hippocampus during the intracarotid Wada test has led to development of selective tests. Our purpose was to show the sodium amytal distribution in the posterior cerebral artery (PCA) Wada test and to relate it to functional deficits during the test. We simultaneously injected 80 mg sodium amytal and 14.8 MBq 99mTc-hexamethylpropyleneamine oxime (HMPAO) into the P2-segment of the PCA in 14 patients with temporal lobe epilepsy. To show the skull, we injected 116 MBq 99mTc-HDP intravenously. Sodium amytal distribution was determined by high-resolution single-photon emission computed tomography (SPECT). In all patients, HMPAO was distributed throughout the parahippocampal gyrus and hippocampus; it was also seen in the occipital lobe in all cases and in the thalamus in 11. Eleven patients were awake and cooperative; one was slightly uncooperative due to speech comprehension difficulties and perseveration. All patients showed contralateral hemianopia during the test. Four patients had nominal dysphasia for 1-3 min. None developed motor deficits or had permanent neurological deficits. Neurological deficits due to inactivation of extrahippocampal areas thus do not grossly interfere with neuropsychological testing during the test.

[Effects of treatment with OKT3 on brain perfusion in a heart transplant patient with SPET with 99mTc-HMPAO]

A heart transplant patient treated with OKT3 developed a severe headache which worsened and was accompanied by a sudden decrease in the patient's consciousness level and aphasia when the treatment course was completed. CT was performed and was normal. SPET imaging with 99mTc-HMPAO of cerebral blood flow done 16 hours later revealed multiple and clear focal defects in the blood flow. Analysis of cerebral spinal fluid revealed aseptic pleocytosis. Five days after the completion of treatment, the symptoms remitted and a new control SPET 3 weeks later was completely normal. A diagnosis of neurotoxicity secondary to OKT3 administration was established.

[Diagnostic pitfalls in sulfonylurea-induced neuroglycopenic syndrome with hemiparesis, dysphasia and somnolence]

BACKGROUND

The neuroglycopenic syndrome, which is often due to sulfonylurea-induced hypoglycemia, is frequently overlooked or misinterpretated as cerebral ischemia.

PATIENTS

Two women aged 81 and 83 years, respectively, with type II diabetes treated with sulfonylureas presented with hemiparesis, dysphasia and somnolence. Both, general practitioner and emergency room physician first interpretated the symptoms as clinical signs of stroke without determination of blood glucose. After hours of delay due to unnecessary and expensive examinations including cerebral computed tomography the correct diagnosis of hypoglycemia was finally made. After injection of i.v. glucose the symptomatology was completely reversible.

CONCLUSION

In every case of disturbance of consciousness, acute neurologic deficits and psychiatric abnormalities an immediate blood glucose test should be performed to exclude hypoglycemia.

[Reversible neuropsychiatric side effects of lithium with normal serum levels. A case report]

Lithium therapy in patients with manic depressive disorder occasionally causes neuropsychiatric side effects even at therapeutic serum levels. Those lithium-induced symptoms can be polymorphous and may be hard to differentiate from other disorders and from other drugs' side effects. We report the case of a 56-year-old woman with manic-depressive illness, who developed neuropsychiatric side effects from lithium prophylaxis at therapeutic serum levels. The symptoms included disorientation, aphasia, ideatoric apraxia, parkinsonism, restlessness and severe sleep disorder. In contrast to previous reports, the casual role lithium was underscored by symptom increase after lithium re-exposure at therapeutic serum levels. The patient recovered completely after cessation of the lithium prophylaxis.

Severe withdrawal syndrome possibly associated with cessation of a midazolam and fentanyl infusion

A 40-month-old child was sedated with a fentanyl and midazolam infusion for 7 days. After the drugs were discontinued he became unresponsive and globally aphasic, and had marked thrombocytosis. He was hospitalized for 4 weeks, during which time his motor and cognitive status slowly improved, and had almost returned to baseline at time of discharge. Severe neurologic abnormalities have been reported with midazolam and fentanyl, administered separately or together, and seem to be a consequence of a withdrawal syndrome. Of interest, this patient had a reactive thrombocytosis at the time of onset of the withdrawal syndrome, and his decreased platelet count coincided with the return to normal cognitive and motor status. Based on this experience and other reports, we believe midazolam-fentanyl combination should be administered with caution.

Amnesia after unilateral temporal lobectomy: a case report

We report a mixed handed (L > R) patient with exclusive right cerebral language representation who developed a permanent anterograde amnestic syndrome after right anterotemporal lobectomy. Preoperative neuropsychological performance consisted of impaired verbal memory and normal nonverbal memory. Wada memory performance was asymmetrical for objects presented soon after amobarbital injection in conjunction with no memory asymmetry for items presented later in the Wada evaluation. Pre- and postoperative magnetic resonance imaging (MRI) scans showed no structural lesions; however, postoperative MRI hippocampal volume measurements suggested decreased hippocampal volume for the nonresected temporal lobe. These results confirm the risk of anterograde amnesia after unilateral temporal lobectomy and demonstrate that baseline neuropsychological testing may falsely literalize material-specific memory functions in patients with atypical cerebral language dominance.

Sulfasalazine induced seizures and dysphasia

We describe the case of a 46-year-old woman with rheumatoid arthritis who developed a severe reaction to sulfasalazine, characterized by dysphasia, seizures, rash and the development of strongly positive pANCA (perinuclear antineutrophil cytoplasmic antibodies). Her condition improved spontaneously upon withdrawal of sulfasalazine. Dysphasia has not been reported as a side effect of sulfasalazine.

Acute systemic vanadate poisoning presenting as cerebrovascular ischemia with prolonged reversible neurological deficits (PRIND)

A 22-year-old woman is reported who attempted suicide by oral ingestion of approximately 10-15 g ammonium metavanadate (NH4VO3). A few hours later she developed gastrointestinal symptoms followed by a transient right sensomotor hemiparesis and aphasic disturbances. Brain MRI and SPECT with 99mTc-HMPAO revealed a lesion in the left parietal cortex. Plasmapheresis, ascorbic acid and desferoxamine led to a complete clinical recovery within a few days.

Neurological reactions in HIV-infected patients treated with trichosanthin

Trichosanthin is a ribosome-inactivating protein that is being studied as a possible treatment for patients infected with human immunodeficiency virus (HIV). We report the clinical and pathological features in two patients who experienced neurological reactions to trichosanthin. Both patients were neurologically asymptomatic prior to treatment but developed coma and multifocal neurological deficits after treatment. Neuropathological examination revealed regions of severe, multifocal necrosis with histiocytic infiltrates. These reactions to trichosanthin may be mediated by soluble factors released by HIV-infected macrophages.

Botulinum toxin treatment of spasmodic torticollis

We reviewed the efficacy and adverse effects of repeated botulinum toxin injections into hyperactive neck muscles of 107 successive patients with spasmodic torticollis. They received 510 injection treatments over a median period of 15 months (range 3-42 months). One patient failed to benefit at all, but 101 (95%) patients reported considerable (moderate or excellent) benefit from at least one treatment. On a global subjective response rating, 93% of 429 treatments resulted in some improvement and 76% in moderate or excellent improvement. Pain reduction followed 89% of 190 treatments with moderate or excellent reduction after 66%. Median duration of benefit was 9 weeks. All torticollis types responded equally well and injections into two (or more) involved neck muscles were more effective than injection into a single muscle. The most frequent adverse effect was dysphagia, occurring after 44% of all treatments, but this was severe after only 2%. Antibodies to botulinum toxin were detected in the serum of three out of the five patients in whom loss of treatment efficacy occurred. We conclude that botulinum toxin treatment is the most effective available therapy for spasmodic torticollis and practical advice is provided for anyone wishing to set up the technique.

Anosognosia during Wada testing

Anosognosia, the verbally explicit denial of hemiplegia, is more often reported after right- than left-hemisphere lesions. However, this asymmetric incidence of anosognosia may be artifactual and related to the aphasia that often accompanies left-hemisphere lesions. Anosognosia has been attributed to psychological denial and the emotional changes associated with hemispheric dysfunction. Eight consecutive patients undergoing intracarotid barbiturate (methohexital) injections as part of their presurgical evaluations for intractable epilepsy were assessed for anosognosia after their hemiplegia and aphasia had cleared. After their left-hemisphere anesthesia, all subjects recalled both their motor and language deficits. However, after right-hemisphere anesthesia, none of the eight patients recalled their hemiplegia. These results suggest that anosognosia is more often associated with right- rather than left-hemisphere dysfunction and that it cannot be attributed to either psychological denial or the emotional changes associated with hemispheric dysfunction.

Cyclosporine neurotoxicity in heart transplantation

The neurotoxic potential of cyclosporine in previous clinical experience has not been considered a significant problem. Recently a significant incidence of severe neurotoxicity has been related to cyclosporine therapy in liver transplant recipients. In our heart transplant program we have observed an unexpectedly high incidence of serious neurologic toxicity, presumably caused by use of cyclosporine. Coma, cerebral hemorrhage, hemiparesis and dysphasia, confusion, and visual hallucinations were reported in four patients. Cyclosporine discontinuation or dose reduction eliminated the neurologic effects in all but one patient. Cyclosporine neurotoxic effects should be suspected in heart transplant recipients with central nervous system syndromes.

Focal encephalopathy after cisplatin therapy

Focal encephalopathy after cisplatin therapy, although described previously, is a rare adverse effect. Recently, four patients who received cisplatin therapy at our institution developed focal encephalopathy which manifested itself as cortical blindness, aphasia with seizures, aphasia with hemianopia and a focal seizure, respectively, shortly after the administration of cisplatin. Each episode occurred while the patients were febrile with neutropenia although no evidence of central nervous system infection was found. The neurological symptoms occurred after at least two courses of cisplatin therapy (minimum total cisplatin dose, 300 mg/m2) and three of the four patients also were noted to have hypomagnesaemia. In each case, the neurological deficit resolved and two patients received further cisplatin therapy without a recurrence of the neurological symptoms. Our experience suggests that focal encephalopathy that is associated with cisplatin therapy may resolve completely with supportive measures alone and need not preclude further therapy with cisplatin.

Cerebral infarct precipitated by praziquantel in neurocysticercosis--a cautionary note

A patient who developed a cerebral infarct during the course of praziquantel therapy for neurocysticercosis is described. Destruction of a large number of cysts by praziquantel followed by a massive inflammatory response was likely to have precipitated the event. Caution on the use of this drug in patients with heavy parasite loads is emphasized.

Aphasia, apraxia and neurogenic stuttering as complications of metrizamide myelography (speech deficits following myelography)

Aphasia following metrizamide myelography has been reported infrequently. During a seven-month period, we examined two patients who developed Broca's aphasia, apraxia of speech, oral-buccal-facial apraxia and neurogenic stuttering after intrathecal metrizamide administration. In each case, focal neurologic deficits were accompanied by clinical, electroencephalographic and radiologic signs of generalized neurologic disease. Serial speech and language evaluations initially revealed severe deficits that were largely resolved by the third day post-myelography. Out-patient follow-up examinations demonstrated persistence of mild speech and language abnormalities in each case. Our findings suggest that metrizamide may cause longlasting neurologic dysfunction.

Severe central nervous system toxicity from high-dose cytarabine: expressive aphasia occurring after the second day of treatment

A patient with acute erythroleukemia secondary to polycythemia vera was treated iv with high-dose cytarabine at a dose of 3 g/m2 every 12 hours. After the fourth dose, he developed an expressive (Broca's type) aphasia and somnolence, which progressed until after the treatment was stopped at the seventh dose. The somnolence cleared partially during the next 2 weeks but recurred after cytarabine was restarted at a dose of 100 mg/m2 daily for 7 days. The patient died 5 days later of refractory extreme thrombocytopenia and bleeding. The normal spinal fluid obtained during life and the postmortem findings were consistent with previously reported findings with central nervous system toxicity from high-dose cytarabine. Three unusual aspects of this case are early onset of symptoms, expressive aphasia as the dominant manifestation, and exacerbation of symptoms with standard doses (100 mg/m2/day).

Transient expressive (nonfluent) dysphasia after metrizamide myelography

Four (3.4%) of 117 patients undergoing metrizamide myelography experienced transient expressive dysphasia 7-8 hr after myelography and lasting up to 36 hr. All four patients had lumbar myelograms obtained with 15 ml of 190 mg l/ml (2850 mg l). Metrizamide was injected via lumbar puncture with a 20 gauge spinal needle under fluoroscopic control. Neurologic complications after metrizamide have been reported, but so far have appeared to be transient. It is likely that the transient expressive dysphasia experienced by the four patients reported here was a neurotoxic reaction, rather than a seizure phenomenon.