Light-induced amaurosis fugax

PURPOSE

To describe an important symptom of bilateral amaurosis precipitated by exposure to bright light.

METHODS

Case report. Clinical analysis of transient, painless, asymmetrical visual loss occurring in bright light in a 54-year-old man.

RESULTS

Carotid ultrasound showed bilateral carotid disease. Carotid angiography demonstrated occlusion of the left internal carotid artery and severe stenosis of the right internal carotid artery and both external carotid arteries. Visual symptoms and an abnormal photostress test completely remitted after a right carotid endarterectomy.

CONCLUSION

Light-induced amaurosis is an unfamiliar manifestation of ocular ischemic syndrome occurring with severe, often bilateral, carotid artery disease. Its recognition is important because the complaint is associated with severe carotid occlusive disease and recognition is necessary for timely surgical intervention because of the major risk for stroke.

Acute multifocal placoid pigment epitheliopathy and central nervous system involvement: nine new cases and a review of the literature

OBJECTIVE

The authors describe nine new cases of acute multifocal placoid pigment epitheliopathy (AMPPE) with associated central nervous system (CNS) involvement and permanent visual sequelae. The study includes a review of the literature and discussion of evaluation, management, and treatment options.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Nine patients were identified with AMPPE and CNS involvement in addition to 22 patients reviewed in the literature.

MAIN OUTCOME MEASURES

A review of nine patients with AMPPE and CNS involvement was performed. Charts were reviewed for age, gender, preceding viral prodromes, visual acuity, ophthalmologic examination findings, CNS findings, and treatment.

RESULTS

Thirty-one patients (nine new patients) were diagnosed with AMPPE and various degrees of CNS involvement. Ages ranged from 8 to 54 years, with an average of 27 years. Twenty-one males (68%) and 10 females (32%) were identified. Eleven patients (35%) had antecedent viral illnesses. Visual acuity was variable and ranged from 20/20 to count fingers. The spectrum of CNS findings ranged from headaches to sagittal sinus thrombosis.

CONCLUSIONS

Acute multifocal placoid pigment epitheliopathy can be associated with CNS abnormalities and permanent visual deficits. Neuroimaging, lumbar puncture, and cerebral angiography analysis provide useful diagnostic tools when CNS involvement is suspected. Intravenous corticosteroids and collaboration with neurovascular colleagues should be considered in these situations. In cases complicated by CNS arteritis, immunosuppressive agents can be a beneficial adjunct to corticosteroids.

Retinol-binding protein in idiopathic intracranial hypertension (IIH)

OBJECTIVE

We postulated that an alteration in endogenous vitamin A (retinol) metabolism plays a causal role in the pathogenesis of idiopathic intracranial hypertension (IIH).

MATERIALS AND METHODS

Serum retinol was determined by a fluorometric method from 40 control subjects and 58 patients with idiopathic intracranial hypertension (IIH). Retinol binding protein (RBP) was also assayed by quantitative radial immunodiffusion in 17 control subjects and 30 patients with IIH.

RESULTS

Mean retinol values were higher in the IIH group compared with the control group, but did not reach a significant level. However, seven of 30 patients with IIH had high RBP levels, but none of the control subjects did.

CONCLUSION

This data suggests that IIH is associated with an abnormality in vitamin A metabolism that is linked to its transport system.

MRI in Lhermitte-Duclos disease

Lhermitte-Duclos disease (LDD) is a disorder sometimes referred to as a dysplastic gangliocytoma of the cerebellum. This is a focally indolent growth of the cerebellar cortex in which the folia enlarge due to a profusion of dysplastic cortical neurons and a thickening of the molecular layer. Loss of Purkinje cells and thinning of medullary white matter results. The enlarged folia lose their secondary foldings and asymmetrically expand the cerebellar hemisphere. These morphologic features produce a characteristic pattern on some CTs and all MRIs, affording an opportunity for a preoperative diagnosis. MRI of a pathologic specimen suggested that the abnormal T1 and T2 signals corresponded to the atrophic folial white matter, thickened granule cell layer, and outer molecular layer. Because of inherent Hounsfield artifact in posterior fossa with CT, MRI is the imaging modality of choice, with better visualized striated pattern. The uniqueness of these imaging features obviates the need for an obligatory biopsy for asymptomatic patients and either permits more definitive planning for surgical decompression or, in restricted lesions, guides more assuredly complete excision of the cerebellar mass.

Optic neuropathy, headache, and diplopia with MRI suggestive of cerebral arteritis in relapsing polychondritis

The pathogenesis of central nervous system disease in relapsing polychondritis (RPC) is unknown but may be related to cerebral arteritis. Previous reports have described clinical and histopathologic evidence of cerebral vasculitis in RPC; however, a neuroimaging correlate has not been reported. We present a 36-year-old man with neuro-ophthalmic features of RPC whose magnetic resonance imaging revealed multifocal gray- and white-matter high intensities. This pattern is consistent with cerebral arteritis as described in other systemic vasculitides.

Uhthoff and his symptom

At the turn of the last century, Wilhelm Uhthoff was a renowned clinical neuro-ophthalmologist, and probably the first clinician whose entire career was devoted to this discipline. His achievements are among those that mark the commencement of contemporary neuro-ophthalmology. Uhthoff's symptom of visual loss with exercise is most frequently associated with optic neuritis. The symptom carries a major risk for recurrence of optic neuritis and development of multiple sclerosis. This study and its companion in the publication show that, independently, a metabolic byproduct of exercise or increases in body temperature cause a reversible conduction block in demyelinated optic nerves and result in temporary loss of vision [corrected].

Visual evoked potentials during hyperthermia

OBJECTIVES

We sought to evaluate the effect of hyperthermia (HT) on central conduction pathways by alterations in pattern visual evoked potentials (PVEPs) in normal and demyelinated optic nerves.

MATERIALS AND METHODS

We studied PVEP peak latency and amplitudes in 10 normal subjects and six patients with demyelinating optic neuropathy before and during HT.

RESULTS

In normal subjects, a mean rise in temperature of 2.5 degrees C resulted in a decrease in the second positive peak (P2) latency of 6.1 ms (p < 0.0001) and a slight decline in P2 amplitude of 1.16 muV (p < 0.009). These results were compared to those obtained from six patients with multiple sclerosis. These patients had a history of monocular optic neuritis; two patients had had bilateral optic neuritis, and one patient had not had involvement of the optic nerve. Average temperature elevations during PVEPs were 1.60 degrees C. PVEPs among these patients showed decrease in mean P2 latencies, except in patients with multiple sclerosis, who showed an increase in latency with 60 min check size in the left eyes. There was a consistent decline in P2 amplitudes. Loss of amplitude was greater among the six optic nerves of those patients having transient, mild losses in visual acuity during HT. Reductions in P2 amplitude were best explained by partial or complete conduction block.

CONCLUSIONS

These changes in conduction time and amplitude during HT provide a neurophysiologic correlation to the well-known sensitivity of demyelinated optic nerves to elevated temperatures. They are also relevant to the monitoring of central pathways in the operative or intensive care setting. The demonstrated reversible loss of amplitudes also gives promise to therapeutic manipulation of impaired pathways by impeding the loss of current from denuded nerve fibers.

Magnetic resonance evidence of perineural metastasis

Contiguous spread along perineural and endoneural spaces, that is, perineural tumor extension, in cutaneous squamous cell carcinoma is fairly common. Infrequently, these tumors spread and involve intracranial structures. One consequence of this complication is meningeal carcinomatosis which is underrecognized. Herein described is a patient with recurrent cutaneous squamous cell carcinoma with perineural invasion along the maxillary nerve that was subsequently shown by magnetic resonance imaging to the trigeminal root. The patient initially presented with a cavernous sinus syndrome but despite aggressive treatment, extensive meningeal carcinomatosis and cauda equina dysfunction developed. Awareness of perineural invasion and proper evaluation are crucial. Perineural spread intracranially worsens the prognosis and limits treatment options to palliation.

Hyperdense basilar artery. An early computed tomography sign of thrombosis

Noncontrast computed tomographic scans (CT scans) may show a hyperdense basilar artery before a brainstem infarct is visualized. This early sign should assist clinicians in confirming the diagnosis of basilar artery thrombosis. In a review of admission records of 750 patients with acute cerebrovascular disease from July 1991 to June 1993, at Saint Louis University Hospital, 20 patients were identified with clinical signs of nonlacunar, vertebrobasilar distribution infarction. Eight of these had pontomesencephalic ischemia. Their neuroimaging studies and medical records were evaluated. Four patients with acute clinical signs of pontomesencephalic infarction were found to have a hyperdense basilar artery on CT scans. The scans of 2 patients were excluded because of dolichoectasia; in the other 2 patients, the basilar artery appeared normal on the CT scan. The hyperdense basilar artery was detected within the early hours of neurological symptoms and often was the only detectable abnormality on the scan. In 3 patients extensive brainstem infarcts subsequently developed and they died. Basilar artery thrombosis was confirmed by pathological study in all these patients. In the fourth patient basilar artery occlusion and a large pontine infarct were evident by magnetic resonance imaging and angiography. A hyperdense basilar artery is a common feature on CT scans of patients presenting with an early clinical diagnosis of thrombosis. Untreated, the hyperintense basilar artery often portends a poor prognosis. Its ready recognition should guide further interventional studies and treatment.

Delayed sequelae of vertebral artery dissection and occult cervical fractures

We report three patients who developed delayed (ie, more than a week after the injury) symptoms of vertebrobasilar ischemia following motor vehicle accidents. The patients all had angiographic evidence of vertebral artery dissection and, upon further evaluation, occult fractures of the second cervical vertebra that were not detected by simple cervical spine radiography and required polytomography or CT for diagnosis. Vertebral artery dissection can result from occult cervical spine fractures and may present with delayed symptoms of brain ischemia.

Epidermoid-induced pulsating eye

An otherwise asymptomatic 62-year-old woman had a pulsating but not proptotic eye. Computed tomography showed a low-density mass lesion in the temporal lobe that extended through a defective greater wing of the sphenoid, indented the lateral rectus muscle, and displaced the optic nerve. Magnetic resonance imaging confirmed these findings and showed no enhancement of the lesion by gadolinium. An epidermoid cyst was diagnosed on the basis of its location in the cleavage lines of the temporal lobe, irregular margins, low density by imaging scans, lack of enhancement, and invasion of the orbit. Epidermoid tumors are, therefore, another cause for a pulsating eye.

Meso-diencephalic infarction: a not so rare form of stroke

26 patients admitted with clinical pictures consistent with meso-diencephalic infarction were studied using computerized axial tomography, magnetic resonance imaging and angiography. All of the patients presented symptoms in two of three major categories which comprise the "top of the basilar" syndrome. Lesions in the territory of the basilar-communicating artery were demonstrated in 22 of them. The remaining patients died before adequate neuroimaging documentation was obtained. Overall prognosis appeared relatively good since 80% of the patients recovered completely or incompletely from the ictus. Meso-diencephalic infarction is a very important and not uncommon subtype of cerebrovascular disorder.

Bilateral altitudinal visual fields

We describe two patients with absolute, complete, binocular inferior altitudinal hemianopias. These altitudinal visual-field defects (AVFDs) involved both nasal and adjacent temporal quadrants and respected the horizontal meridian. The reported conditions and locations in the visual system that cause "conventional" AVFDs and their bilateral occurrence are reviewed. Division of the visual system into altitudinal halves results from the topographic arrangement of nerve fibers and their blood supply in the retina, optic nerves, and visual cortex. Lesions at these locations resulting in AVFDs are usually due to vascular occlusion or may result from a penetrating missile injury to the superior occipital lobes. It is important to emphasize that the nerve fiber layer of the retina respects the horizontal meridian only in the nasal field, not in the temporal field; therefore incomplete AVFD is more common. Because of the anastomotic blood supply of the occipital pole, only AVFDs due to occipital infarcts spare fixation. Diagnosis of retinal branch artery occlusion or anterior ischemic optic neuropathy is aided by the presence of a unilateral AVFD along with ipsilateral funduscopic abnormalities and, in most bilateral examples, by its sequential temporal development. Bilateral occipital infarcts, as in our two cases, are characterized by sudden, simultaneous onset of AVFDs, an absence of retinal, retinovascular, or optic nerve abnormality and confirmation by computed tomographic scanning.

Post-traumatic midbrain tremors

We report 3 patients with post-traumatic tremor and describe the characteristics of the tremor and accompanying neurologic signs. Radiographic and pathologic examination indicated a contralateral midbrain localization of the lesion. The tremor responded to anticholinergic or dopaminergic therapy.

Acute thalamic esotropia

Three men developed acute esotropia, stupor, and impaired upward gaze. Vestibulo-ocular stimulation showed that the adducted eye remained immobile while the fellow eye responded normally. The alteration of consciousness, the long-tract neurologic signs, and the esotropia quickly resolved. Upgaze paresis and brief bursts of convergence-retraction nystagmus were the major residual signs. Imaging techniques demonstrated lesions of the contralateral posterior thalamus in each patient. Several mechanisms are proposed to explain the acute esotropia. Impairment of monocular projections in the contralateral posterior thalamus could disinhibit neurons in the oculomotor complex, or ischemia of inputs to neurons involved with vergence control in the midbrain could result in tonic activation of the medial rectus. The clinical and radiographic findings are consistent with infarction in the territory of penetrating branches of the basilar-communicating (mesencephalic) artery. Embolism to the top of the basilar artery is presumed to be the precipitating event.

Parkinsonism induced by high-dose cytosine arabinoside

We report a severe parkinsonian condition following high dose, parenteral cytosine arabinoside (Cytosar) that persisted for 8 weeks. The drug was used in a patient with acute myelogenous leukemia that was refractory to all other treatment. The syndrome was partially responsive to antiparkinsonian drugs and fortunately remitted completely within 12 weeks.

Oculomasticatory myorhythmia: a unique movement disorder occurring in Whipple's disease

We describe two patients and a previously reported patient who acquired unique pendular vergence oscillations of the eyes and concurrent contractions of the masticatory muscles, i.e., oculomasticatory myorhythmia (OMM). The smooth disjunctive eye movements cycled with a frequency of 0.8 to 1.2 Hz. An analysis of peak velocities (15 to 200 degrees/sec) with respect to peak amplitudes (5 to 25 degrees) revealed dynamics characteristic of normal vergence movements. The pathological alterations resulting in pendular vergence oscillations implicate a separately functioning, physiologically normal vergence system within the brainstem. In addition to paralysis of vertical gaze, each patient also experienced progressive somnolence and intellectual deterioration. An intestinal biopsy in 1 patient established a diagnosis of Whipple's disease, which led to appropriate treatment and amelioration of the OMM. A pathological diagnosis of Whipple's disease of the central nervous system was made in the other 2 patients; results of an intestinal biopsy in one of these patients were normal. No patient had palatal myoclonus, and olivary pseudohypertrophy was not found in two autopsy examinations. Thus, OMM is a distinct movement disorder and has been recognized only in Whipple's disease. We conclude that patients with OMM should be treated presumptively for Whipple's disease of the central nervous system, even if a jejunal biopsy is normal.

Intravenous nitroglycerin-induced intracranial hypertension

Nitroglycerin therapy can cause dose-related increases in intracranial pressure. Rare cases of neurologic sequelae attributed to nitroglycerin have appeared in the literature. We report such a case, in which symptoms completely resolved after cessation of nitroglycerin therapy. Widespread use of high-dose iv nitroglycerin makes knowledge of this effect important for all practitioners.

Reversible monocular cataract simulating amaurosis fugax

In a patient having brittle, juvenile-onset diabetes, transient monocular visual loss occurred repeatedly whenever there were wide fluctuations in serum glucose. Amaurosis fugax was suspected. The visual loss differed, however, in that it persisted over a period of hours to several days. Direct observation eventually revealed that the relatively sudden change in vision of one eye was associated with opacification of the lens and was not accompanied by an afferent pupillary defect. Presumably, a hyperosmotic gradient had developed with the accumulation of glucose and sorbitol within the lens. Water was drawn inward, altering the composition of the lens fibers and thereby lowering the refractive index, forming a reversible cataract. Hypoglycemia is also hypothesized to have played a role in the formation of a higher osmotic gradient. The unilaterality of the cataract is attributed to variation in the permeability of asymmetric posterior subcapsular cataracts.

Pseudotumor cerebri secondary to lithium carbonate

Three patients were initially seen with headache, blurred vision, and papilledema while taking lithium carbonate for their respective bipolar affective disorder. A diagnosis of pseudotumor cerebri was made in each case when a thorough evaluation revealed only elevated intracranial pressure. Two of the patients had complete resolution of their symptoms and papilledema after discontinuing use of the drug. Increased intracranial pressure with papilledema persisted in the third patient when she failed to adjust psychiatrically, necessitating continuance of the lithium carbonate therapy. A history of lithium carbonate ingestion should be sought in patients with the syndrome of pseudotumor cerebri. All patients receiving this drug should have a regular funduscopic examination.

Papilledema after acute head injury

Low grade papilledema after acute, severe head injury was identified in 15 (3.5%) of 426 patients. Papilledema was recognized immediately after head injury in 1 patient, during the 1st week in 10 patients, and in the 2nd week or after in 4 patients. Initial computed tomographic scans showed evidence of brain injury in 11 of these patients. The intracranial pressure (ICP) was monitored continuously for 3 or more days in 9 patients; it was mildly elevated (20 to 40 mm Hg) in 7 patients and moderately elevated (40 to 60 mm Hg) in 2 patients. Intracranial hypertension was controllable in each patient. A sudden, severe, but transient increase in ICP best explained the immediate development of papilledema and survival of 1 patient. Sustained but mild to moderately elevated ICP accounted for papilledema appearing in the 1st week. Papilledema in the 2nd week or after occurred from impaired cerebrospinal fluid absorption and consequent communicating hydrocephalus or delayed focal or diffuse cerebral swelling. A lesser degree of head injury in patients with posttraumatic papilledema was suggested by a higher Glasgow coma score, milder and controllable elevations in ICP, and the absence of any fatality in this group. The favorable outcome was significant compared to the mortality of the more severely injured patients (chi square-4.327; P less than 0.04). Papilledema did not occur in 6 patients with sustained, severely elevated ICP (greater than 60 mm Hg) for 3 or more days. Each of these patients died. The severity of the trauma apparently accounts for the failure of papilledema to develop, possibly by arresting axoplasmic production and transport in retinal nerve fibers.

Neuro-ophthalmology of sphenoid sinus carcinoma

Three cases of sphenoid sinus carcinoma observed personally and 39 identified in the English language publications are reviewed. Sphenoid carcinoma constitutes only 0.3 per cent of sinus cancer. Its symptoms and signs are nonspecific until the sinus wall is penetrated. Once breached, specific neuro-ophthalmological symptoms and signs ensue, resulting from involvement of anatomically contiguous structures. These are characterized most commonly by the sphenocavernous syndrome and less frequently by isolated sixth nerve palsies and visual loss. Identified best by plain radiography, polytomography and computerized tomography, diagnosis of sphenoid carcinoma requires direct biopsy. Treatment, principally with radiotherapy supplemented by chemotherapy, has been disappointing with most patients dead by three years. The authors believe that in rapidly evolving neuro-ophthalmological syndromes of basal origin, accompanied by intractable headache, sphenoid sinus cancer must be considered.

The pupil and its disorders

Pertinent information concerning the pupil is provided for the practicing and aspiring neurologist, including anatomy and physiology of the normal pupil, a discussion of pupillary disorders, and unusual pupillary abnormalities.

Parainfectious optic neuritis. Report and review following varicella

Severe loss of vision and bilateral optic disc edema occurred in a 10-year-old girl 38 days after the rash of varicella first appeared and subsequent encephalitis developed. Recovery of visual function was nearly complete, but optic atrophy persisted. Parainfectious optic neuritis following other viral infections, with the exception of herpes zoster, has a similar clinical profile: delayed onset, severe visual loss, optic disc edema, bilaterality, good recovery, and residual optic atrophy. Conduction delays in our patient's patterned visual evoked potentials implicated demyelination within the optic nerves. The often favorable recovery, frequency of delayed onset, and bilateral involvement of the optic nerves support an autoimmune process in the pathogenesis of parainfectious optic neuritis.

Myoclonic ocular jerks

A 39-year-old woman with a familial trait for myoclonic jerks of the neck presented with spontaneous 5- to 40-degree single jerks of the eyes, usually upward, each producing a brief interruption in fixation. Eye movement recordings showed the myoclonic ocular jerks to be saccades with variable intersaccadic intervals. Treatment with 6.0 mg per day of clonazepam reduced her symptoms.

Sarcoid optic neuropathy

Three patients presented with unilateral progressive optic neuropathy. None of these patients had signs of symptoms referable to the chiasm or eye, thus confining their decline in vision to the optic nerve. Clinical and neuroradiographic evidence suggested a meningioma involving the optic nerve at the orbital-canalicular junction in one patient and the intracranial optic nerve in another patient. Surgical exploration in both patients, however, revealed a noncaseating granuloma. Decline in vision from granulomatous invasion of the retrobulbar optic nerve is an uncommon manifestation of sarcoidosis. Review of our patients' findings suggests that a nonsurgical diagnosis of sarcoid optic neuropathy may have been tenable.

Ischemic optic neuropathy: a complication of cardiopulmonary bypass surgery

Ischemic optic neuropathy followed cardiopulmonary bypass surgery in the postoperative period in 7 of 7685 consecutive procedures. Th visual loss was unilateral in four patients and bilateral in three and there was little improvement. This ischemic infarction of the optic nerve disk was attributed to hypotension, hypothermia, and activation of certain complement factors by the bypass procedure.

Anterior ischemic optic neuropathy with internal carotid artery occlusion

We examined three patients who had anterior ischemic optic neuropathy and ipsilateral internal carotid artery occlusion. Each patient had transient cerebral ischemic attacks associated with the occluded carotid artery. In two patients there attacks were in temporal proximity to the anterior ischemic optic neuropathy. Carotid angiography showed retrograde filling of the ophthalmic artery through the external carotid artery demonstrating altered perfusion and, perhaps, hypoperfusion of the distal optic nerve head.

Ventriculostomy for hydrocephalus in cerebellar hemorrhage

In a matter of hours the neurologic status of two hypertensive patients deteriorated to coma. Cranial computed tomography (CT) showed mild to moderate cerebellar hemorrhage and secondary hydrocephalus. Ventriculostomy resulted in clinical improvement within 20 minutes and obviated the need for suboccipital craniectomy. Both patients made a very satisfactory recovery. Similar patients have occasionally been observed by others. Ventriculostomy should be considered for patients with cerebellar hemorrhage who have hydrocephalus by CT scan and undergo progressive neurologic deterioration. Because the frequency of improvement and the risk of upward cerebellar herniation following ventriculostomy is unknown, immediate surgical evacuation of the hemorrhage should be anticipated.

Downbeat nystagmus with magnesium depletion

Two patients with neurological signs of magnesium depletion complained of oscillopsia and manifested downbeat nystagmus. Serum magnesium levels measured less than 1.0 mg/dL. Hypomagnesemia resulted from debilitating intestinal disease in both patients and apparently was aggravated in one case by failure to add magnesium sulfate to the patient's regimen for total parenteral nutrition. Neither patient had any of the neurological conditions reported with downbeat nystagmus. Thus, downbeat nystagmus in the primary position occurs with the metabolic derangement of severe magnesium depletion. Another apparent metabolic cause of downbeat nystagmus is thiamine deficiency. Downbeat nystagmus also may occur from a partial deficiency of the metabolic cofactors, magnesium and thiamine.

Flaccidity after head injury: diagnosis, management, and outcome

Upon admission, 17 of 223 (8%) consecutive patients with severe head injury exhibited a flaccid, wholly unresponsive motor examination. In this study alcoholic intoxication neither caused depressed motor responsiveness in head-injured patients with high serum ethanol levels nor accounted for the motor examination in those exhibiting the flaccid state. Flaccidity was attributed principally to impaired ventilation in 4 patients, a major intracranial mass in 12, and a spinal cord injury in 1. Compared to the larger group of head-injured patients, the flaccid patients had a significantly greater incidence of hypercapnia (P less than 0.001), acidosis (P less than 0.01), and both elevated and uncontrollable intracranial pressure (ICP) (P less than 0.001). These findings and the high mortality rate (76%) in this study suggest that the magnitude of respiratory complications and the severity of mechanical brain injury are greater in flaccid patients. The flaccid patients undergoing surgical decompression for major intracranial mass lesions (11 cases) have all died and, although still small in number, this group may represent an important subset with a poor prognosis. Nonetheless, a protocol that encourages rapid radiological and electrophysiological assessment and vigorous surgical and ICP management until the probable cause of flaccidity is identified and treated has benefit. The flaccid state was reversed and a good recovery was attained after the restoration of blood pressure and/or ventilation in 2 patients who appeared to have sustained a very grave head injury. In another patient, absent somatosensory evoked potentials greatly facilitated the diagnosis of a spinal subdural hematoma. This program of prompt diagnosis and intense therapy did not result in a protracted course or undue numbers of severely brain-damaged survivors.

Micromethod for detection of oligoclonal IgG in unconcentrated CSF by polyacrylamide gel electrophoresis

A micromethod to detect oligoclonal IgG from 50 microL of unconcentrated CSF was developed by using polyacrylamide gel electrophoresis in sodium dodecyl sulfate (SDS-PAGE). Of 17 patients with multiple sclerosis, oligoclonal bands were demonstrated in 16 instances (94%) by micro-SDS-PAGE and in 13 (76%) by agarose gel electrophoresis. The corresponding figures among 30 patients with optic neuritis were 16 (54%) and five (17%), respectively, and among ten patients with other neurological disease the figures were two (20%) and none, respectively. Thus, micro-SDS-PAGE is more sensitive than agarose gel electrophoresis for detection of oligoclonal IgG. The small volume of unconcentrated CSF that is required enhances the usefulness of this test.

Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure

An analysis of clinical signs, singly or in combination, multimodality evoked potentials (MEP's), computerized tomography scans, and intracranial pressure (ICP) data was undertaken prospectively in 133 severely head-injured patients to ascertain the accuracy, reliability, and relative value of these indicants individually, or in various combinations, in predicting one of two categories of outcome. Erroneous predictions, either falsely optimistic (FO) or falsely pessimistic (FP), were analyzed to gain pathophysiological insights into the disease process. Falsely optimistic predictions occurred because of unpredictable complications, whereas FP predictions were due to intrinsic weakness of the indicants as prognosticators. A combination of clinical data, including age, Glasgow Coma Scale (GCS) score, pupillary response, presence of surgical mass lesions, extraocular motility, and motor posturing predicted outcome with 82% accuracy, 43% with over 90% confidence. Nine percent of predictions were FO and 9% FP. The GCS score alone was accurate in 80% of predictions, but at a lower level of confidence (25% at the over-90% level), with 7% FO and 13% FP. Computerized tomography and ICP data in isolation proved to be poor prognostic indicants. When combined individually with clinical data, however, they increased the number of predictions made with over 90% confidence to 52% and 55%, respectively. Data from MEP's represented the most accurate single prognostic indicant, with 91% correct predictions, 25% at the over-90% confidence level. There were no FP errors associated with this indicant. Supplementation of the clinical examination with MEP data yielded optimal prognostic power, an 89% accuracy rate, with 64% over the 90% confidence level and only 4% FP errors. The clinical examination remains the strongest basis for prognosticating outcome in severe head injury, but additional studies enhance the reliability of such predictions.

Further experience in the management of severe head injury

A prospective and consecutive series of 225 patients with severe head injuries who were managed in a uniform way was analyzed to relate outcome to several clinical variables. Good recovery or moderate disability were achieved by 56% of the patients, 10% remained severely disabled or vegetative, and 34% died. Factors important in predicting a poor outcome included the presence of intracranial hematoma, increasing age, abnormal motor responses, impaired or absent eye movements or pupil light reflexes, early hypotension, hypoxemia or hypercarbia, and elevation of intracranial pressure over 20 mm Hg despite artificial ventilation. Most of these predictive factors were assessed on admission, but a subset of 158 patients was identified in whom coma was present on admission and was known to have persisted at least until the following day. Although the mortality in this subset (40%) was higher than in the total series, it was lower than in several comparable reported series of patients with severe head injury. Predictive correlations were equally strong in the entire series and in the subset of 158 patients with coma. A plea is made for inclusion in the definition of "severe head injury" of all patients who do not obey commands or utter recognizable words on admission to the hospital after early resuscitation.

Retinopathy after tilorone hydrochloride

Two patients, a 34-year-old woman and a 50-year-old woman, received tilorone HCl, an experimental antitumor drug. After taking the drug orally (total dose, 152 g), the first patient developed corneal subepithelial infiltrates and toxic retinopathy characterized by fine pigment mottling of the peripheral fundus and macula with mild arteriolar narrowing. Although visual acuity was 6/6 (20/20) throughout treatment, Goldmann perimetry showed marked peripheral constriction of the visual fields and results of an electroretinogram and an electro-oculogram were abnormal. After taking the drug orally (total dose, 189 g), the second patient developed corneal subepithelial infiltrates, severe bilateral arteriolar narrowing, and mild pigment mottling of the macula. ERG and EOG were moderately attenuated. Visual fields by Goldman perimetry were within normal limits. Tilorone HCl, like chloroquine, may be an antioxidant that affects the free radical scavenging mechanism of the retinal pigment epithelium. Extensive testing should be done on all patients taking tilorone HCl in order to detect the initial manifestations of retinopathy.

Psuedotumor cerebri and insecticide intoxication

Three patients with headache and increased intracranial pressure had elevated blood, serum, and adipose levels of the organochlorine insecticide chlordecone (Kepone). These patients were among 23 employees who suffered from chronic chlordecone intoxication resulting from industrial exposure. In our three patients, investigations eliminated an intracranial mass or other known causes of psuedotumor cerebri. In all three patients, the capacity for cerebrospinal fluid (CSF) absorption was assessed by graded infusions into the subarachnoid space, and was found to be impaired even when papilledema was minimal.

Microangiopathy of the brain and retina

Two women (26 and 40 years old) developed an unusual microangiopathy that affected the brain and retina. Psychiatric symptoms initially overshadowed the subacute features of the progressive neurologic disorder. Ophthalmoscopic findings of multifocal branch retinal artery occlusions provided clinical evidence of vasculopathy. Laboratory data did not reveal evidence of the known vasculitides, including systemic lupus erythematosus (SLE) and syphilis. Cerebral angiography suggested vasculitis in the younger patient. Brain biopsy in the older patient (after 3 months of steroid therapy) revealed a sclerosis of the small pial and cortical vessels that was consistent with a "healed" angitis. Both patients seemed to respond to steroid therapy.