[Cerebral vasculitis and Basedow-Graves disease: report of two cases]

OBJECTIVE

To report two cases of patients with cerebral vasculitis and Basedow-Graves disease.

CASE REPORT

Two young female patients presented at emergency with acute neurological picture of hemiparesis and speech distress. The first patient, 22 year-old, has been on clinical treatment for hyperthyroidism for one month. On clinical examination she had an elevated cardiac rate, bilateral exophthalmia and a diffuse goiter. On neurological examination we could observe a mild dysarthria and left hemiparesis. The second patient was a 15 year-old girl, who presented sudden conscious loss, aphasia and right hemiparesis.

RESULTS

CT scan and MRI showed areas of cerebral infarcts. Angiographic study showed multiple vascular stenosis similar to an arteritic angiographic pattern. Extensive medical and laboratorial workout disclosed no other risk factor for stroke or for nervous system vasculitis. The antimicrosomal and antithyreoglobulin antibodies were positive and thyroidian hormones confirmed hyperthyroidism.

CONCLUSION

The concurrence of cerebral arteritis and Basedow-Graves' disease suggest a possible pathogenic link between Graves' disease and specific cerebral vascular disorders, possibly through a common autoimmune mechanism.

[Relapsing polychondritis associated with meningoencephalitis: case report]

Polychondritis is a disease manifesting as an episodic inflammation of cartilagenous structures throughout the body with progressive course. We describe a patient with a presentation picture of two episodes of meningoencephalitis and after the outcome with polychondritis. Neurological involvement is rare in this disease as neurologic presenting symptoms do. The diagnostic precision was determinant for a satisfactory outcome with corticosteroids and methotrexate.

[Cerebrovascular disease and neurocysticercosis]

We report three cases of stroke secondary to neurocysticercosis. The first one is a 36 years old man with bilateral middle cerebral artery occlusions who had presented acute right hemiparesia and aphasia. MRI demonstrated several enhancing subarachnoid cysts surrounding the occluded vessels, a right parietal racemose cyst and a left temporal large infarction area. Angiographic study showed total occlusion of left middle cerebral artery and a subtotal occlusion of right middle cerebral artery. The second one is a 42 years old man with vasculitis of small cortical vessels who presented with headache, seizures and focal neurological deficit. CT scan demonstrated several calcifications and a left temporal infarction area. Cerebral angiographic study was normal. The third case was a woman, 53 years old, with a past history of six stroke events and an actual behavior disturbance and seizures. MRI demonstrated several cortical and subcortical infarction areas and cisternal cysts. Angiographic study showed diffuse arteritis of basilar and carotid arterial system. In all three cases CSF study showed linfomonocitic pleocytosis and positive ELISA for cysticercosis.

[Topiramate: an experience in children with partial epilepsy]

Topiramate (TPM) is a new drug currently used in Brazil. We verified the clinical responses to TPM in children under 15 years-old. We started with 12.5 mg/day (1-7 mg/kg/day) and the doses increased 12,5 mg each week. Eleven children were studied, 9 females and 2 males, from 3 to 14 years-old with partial epilepsy associated to different etiological factors. Only one patient had an intense abdominal pain. The patients had weekly or daily seizures and after began TPM 1 patient stayed free from seizures, 5 improved more than 75% in frequency, 1 patient improved more than 50% and 3 had no control. A good control of seizures was achieved with a low dose of TPM as monotherapy and add-on therapy with carbamazepine even in severe cases.

Applicability of the CERAD neuropsychological battery to Brazilian elderly

There is a limited choice of psychometric tests for Portuguese speaking people which have been evaluated in well defined groups. A Portuguese version of CERAD neuropsychological battery was applied to a control group of healthy elderly (CG) (mean age 75.1 years/ education 7.9 years), 31 Alzheimer disease (AD) patients classified by clinical dementia rating (CDR) as CDR1 (71.4/ 9.0) and 12 AD patients CDR 2 (74.1/ 9.3). Cut-off points were: verbal fluency-11; modified Boston naming-12; Mini-mental State Examination (MMSE) -26; word list memory-13; constructional praxis-9; word recall-3, word recognition-7; praxis recall-4. There was a significant difference between CG and AD-CDR1 (p<0.0001) for all tests. There was a less significant difference for constructional praxis and no difference for Boston naming. Comparison between AD-CDR1 and AD-CDR2 showed difference only for MMSE, verbal fluency, and Boston naming. The performance of CG was similar to that of a US control sample with comparable education level. These results indicate that this adaptation may be useful for the diagnosis of mild dementia but further studies are needed to define cut-offs for illiterates/low education people.

[Lafora's disease: diagnosis by muscle biopsy (case report)]

A 16-year-old female patient had myoclonic epilepsy caused by Lafora's disease. Muscle biopsy showed a prominent splitting pattern in muscle fibers with the nicotinamide adenine nucleotide dehydrogenase-tetrazolium reductase reaction, hematoxylin-eosin, and PAS stains. This morphologic appearance of the tissue permits diagnosis using the benign technique of muscle biopsy. The ultrastructural examination of muscle may be necessary to confirm the diagnosis of Lafora myoclonus epilepsy if light microscopical findings are equivocal.

[Implicit memory and its contribution to the rehabilitation of an amnesic patient: case report]

Even severe amnesic patients usually are able to learn new information using implicit memory strategies. In the present study we describe our experience in the rehabilitation of an amnesic patient who had suffered cerebral anoxia. He was taught to use a computer text editor, enabling him to sheltered work. The training program lasted 14 weeks and was based on errorless learning and drilling practice techniques. The patient succeeded in all tasks, even though he could not remember accurately the training sessions. These results meet previous studies which point out that interaction between implicit and residual explicit memory can provide a basis new learning in amnesic patients. The domain-specific knowledge acquisition is demonstrating effectiveness in neuropsychological rehabilitation of brain injured patients.

[Procedures to improve daily activities performance in individuals with cerebral anoxia: case report]

OBJECTIVE

To present a rehabilitation case study; procedures to improve the performance on daily activities were used by the caregiver.

PATIENT

Cerebral anoxia due to cardiac arrest. He presented memory deficits for both visual and verbal material, temporal disorientation, abulia, psychomotor slowing and bradypsychism.

METHODS

daily activities were developed in fixed hours; calendar was presented 3 times a day; daily walks were performed; self-care activities were performed by the patient with short verbal commands and cues from the caregiver.

RESULTS

We observed improvement on initiative and autonomy for daily activities, attention, temporal orientation and bradypsychism. There was also reduction on response time.

CONCLUSIONS

Behavioral control strategies result on improvement for patients and their family although limit their routine. Behavioral control strategy promotes learning through the preserved implicit memory mechanism and results on enhancement at patient's autonomy at home.

Neurologic outcome after heart transplantation in Chagas' disease. Preliminary results

OBJECTIVE

To evaluate the neurologic morbidity after orthotopic heart transplantation (OHT), we examined consecutive Chagas' (Ch) and non-Chagas' (NCh) patients, before and after surgery.

MATERIAL AND METHODS

We undertook neurological and neuropsychological evaluations in Ch and NCh patients with end-stage cardiac failure, from September 1993 to September 1995.

RESULTS

Of 10 Ch patients (mean age = 33.6 years; 7 male; mean follow-up = 10.8 months) and 13 NCh patients (mean age = 50.9 years; 12 male; mean follow-up = 15 months) 3 died (rejection and sepsis) without neurologic symptoms. Neurologic complications occurred in 4 Ch and 5 NCh patients. Two Ch patients had skin and myocardial Chagas' reactivation successfully treated, without CNS involvement. NPS performance and return to work rates were similar in both groups.

CONCLUSION

Although Ch patients are potentially at a higher risk of Trypanosoma cruzi reactivation, in addition to all known neurologic complications of OHT, early neurologic complications detected in this sample were similar in Ch and NCh patients and could not be specifically related to Chagas' disease.

[Normative data on the verbal fluency test in the animal category in our milieu]

OBJECTIVE

Evaluate the performance on verbal fluency (VF) in our population in a Brazilian sample checking the influence of age and literacy.

METHODS

336 people without neurological or psychiatric complaints evaluated through Mini-Mental State Examination and VF (animals). For comparison, and to determine cut-off points, 65 people with cognitive loss followed at our clinic were also evaluated.

RESULTS

We found a mean of 13.8 animals in 1 minute, with the following distribution: illiterates, 11.9; up 4 years of education, 12.8; 4 to 7 years, 13.4; 8 years or more, 15.8 (p = 0.0001). In relation to age the means were: up to 64 years, 13.7; 65 years or more, 13.9. There was no difference between the two groups. The cut-off points were 9 for people under 8 years of education with a sensitivity of 75% for illiterates, 100% for low educational level (up 4 years), and 87% for middle level (4 to 7 years). The specificity was respectively 79%, 84%, and 88%. For the high educational level the mean was 13 with a sensitivity of 86% and specificity of 67%.

CONCLUSIONS

In the VF (animals) there is a significant influence of schooling and different cut-off points should be used.

[Normative data on the verbal fluency test in the animal category in our milieu]

OBJECTIVE

Evaluate the performance on verbal fluency (VF) in our population in a Brazilian sample checking the influence of age and literacy.

METHODS

336 people without neurological or psychiatric complaints evaluated through Mini-Mental State Examination and VF (animals). For comparison, and to determine cut-off points, 65 people with cognitive loss followed at our clinic were also evaluated.

RESULTS

We found a mean of 13.8 animals in 1 minute, with the following distribution: illiterates, 11.9; up 4 years of education, 12.8; 4 to 7 years, 13.4; 8 years or more, 15.8 (p = 0.0001). In relation to age the means were: up to 64 years, 13.7; 65 years or more, 13.9. There was no difference between the two groups. The cut-off points were 9 for people under 8 years of education with a sensitivity of 75% for illiterates, 100% for low educational level (up 4 years), and 87% for middle level (4 to 7 years). The specificity was respectively 79%, 84%, and 88%. For the high educational level the mean was 13 with a sensitivity of 86% and specificity of 67%.

CONCLUSIONS

In the VF (animals) there is a significant influence of schooling and different cut-off points should be used.

Neurological outcome in coronary artery surgery with and without cardiopulmonary bypass

INTRODUCTION

The neurological complications of coronary artery surgery with cardiopulmonary bypass (CPB) have been extensively studied, but to our knowledge those without CPB (NCPB) have not been defined.

PATIENTS & METHODS

We prospectively examined 81 patients, before and up to seven days after surgery, to compare the neurological morbidity between patients subjected to coronary artery bypass graft (CABG) surgery with and without CPB. We analyzed demographic variables, risk factors and neurological examination including neuropsychological (NPS) tests using chi-square and non-parametric analysis (Mann-Whitney and Kruskal-Wallis).

RESULTS

Forty-eight patients (34M; median age = 62 yrs; median number of grafts = 3 and median total surgery duration = 300 min) operated with CPB and 33 without CPB (23M; median age = 64 yrs; median number of grafts = 2 and median total surgery duration = 240 min) differed only in relation to number of grafts (p = 0.0001) and surgery duration (p = 0.0001).

CONCLUSION

We found no difference in early neurological outcome in patients subjected to CABG with or without CPB.

Botulinum toxin A for trismus in cephalic tetanus

Cephalic tetanus is a localized form of tetanus. As in generalized forms, trismus is a prominent feature of the disease, leading to considerable difficulty in feeding, swallowing of the saliva and mouth hygiene. These difficulties often precede respiratory problems and aspiration bronchopneumonia is a frequent life-threatening complication. Muscle relaxants other than curare drugs may show a limited benefit for relieving trismus. Tetanospasmin, the tetanic neurotoxin, and botulinum toxin share many similarities, having a closely related chemical structure, an origin from related microorganisms (Clostridium tetani and Clostridium botulinum, respectively), and presumably, the same mechanisms of action in the neuron. The difference between the two lies in their peculiar neurospecificity, acting in different neurons. Injection of minute doses of botulinum toxin in the muscles involved in focal dystonias or other localized spastic disorders have proved to be very effective in these conditions. We describe the use of botulinum toxin A in the successful treatment of trismus in a patient suffering from cephalic tetanus. We believe that this form of treatment may be of value in lowering the risk of pulmonary complications in tetanic patients.

[The Mini-Mental State Examination in a general population: impact of educational status]

To assess the influence of age and education on cognitive performance in our population, 530 adults were interviewed using the MMSE (Mini-Mental Status Examination). Education level, classified as illiterate, elementary and middle (< 8 years) and high (> 8 years), was a significant predictor of performance (p < 0.0001). Nevertheless, the total scores were not significantly different among the age-groups, young (< or = 50 years), middle age 51 to 64 years) and elderly (> or = 65 years). The reference cut-off values were taken from the fifth percent lowest score for each group: illiterate, 13; elementary and middle, 18; and high, 26. When compared to 94 patients with cognitive impairment, our cut-off values achieved high sensitivity (82.4% for illiterates; 75.6% for elementary and middle; 80% for high) and specificity (97.5% for illiterate; 96.6% for elementary and middle; 95.6% for high educational level). Education-specific reference values for the MMSE are necessary in interpreting individual test results in populations of low educational level, in order to reduce the false positive results.