Association Between First-time Neurologic Events and Metronidazole Treatment: A Case-time Control Study

PURPOSE

Metronidazole, a widely used antimicrobial medication, has been linked to neurologic adverse drug reactions. This study investigates the association between metronidazole use and first-time neurologic events.

METHODS

We conducted a case-time-control study using data from the Danish National Patient Register and the National Prescription Register in years 2013 to 2021. Patients with a first-time diagnosis of encephalopathy, cerebellar dysfunction, or peripheral neuropathy were included. Conditional logistic regression analyses were performed to estimate the risk of neurologic events associated with metronidazole use.

FINDINGS

Out of 476,066 first-time metronidazole prescriptions, the 100-day cumulative incidence of peripheral neuropathy was 0.016%, and 0.002% for cerebellar dysfunction or encephalopathy. In the case-time control study, we identified 17,667 persons with a first-time neurologic event and were included for the analysis. The estimated odds ratio for the combined neurologic events was 0.98 (95% CI, 0.59-1.64, P = 0.95) with no statistically significant association across different subgroups and time windows.

IMPLICATIONS

Our findings suggest that metronidazole-induced neurologic events may be rarer than previously described, and we did not find any consistent or statistically significant association between metronidazole exposure. Nonetheless, clinicians should remain vigilant to potential neurologic risks in patients receiving metronidazole, to ensure its safe and effective use.

Multidisciplinary Treatments of True Posterior Inferior Cerebellar Artery Aneurysms: Single-Center Retrospective Study and Treatment Algorithm

BACKGROUND

True posterior inferior cerebellar artery (PICA) aneurysms outside the vertebral artery-PICA region are rare, with approximately 30 cases reported in just a few papers; no treatment paradigm has been advocated. The objective of this study was to present detailed clinical features and outcomes for several treatments for true PICA aneurysms and suggest an algorithm for treatment strategies.

METHODS

We retrospectively analyzed outcomes of patients treated for PICA aneurysms with microsurgical and endovascular treatments. We also investigated the influence of several factors on the modified Rankin Scale score.

RESULTS

Cases with PICA aneurysms (n = 36) outside the vertebral artery-PICA region were identified angiographically. Aneurysm locations included anterior medullary (n = 7), lateral medullary (n = 10), tonsillomedullary (n = 4), telovelotonsillar (n = 12), and cortical (n = 3) segments of the PICA. Aneurysm morphology was as follows: dissecting: 22; fusiform: 6; and saccular: 8. On multivariate analysis, age (P = 0.028) and lack of vermian infarction (P =0.037) were associated with a significantly better prognosis. Prognosis was not significantly different for the 5 aneurysm locations and among the 4 treatment groups: clipping/coiling, trapping/parent artery occlusion, trapping/parent artery occlusion + bypass, and observation including external ventricular drainage.

CONCLUSIONS

This study suggests that factors associated with significantly better prognosis include age, clip/coil treatments, and no vermian infarction complication. A treatment algorithm for true PICA aneurysms was supported according to pretreatment H and K grade, PICA segments, aneurysm morphology, and 3 types of ischemia linked to the brainstem, cerebellar hemisphere, or vermis.

The Cerebellar Cognitive Affective/Schmahmann Syndrome: a Task Force Paper

Sporadically advocated over the last two centuries, a cerebellar role in cognition and affect has been rigorously established in the past few decades. In the clinical domain, such progress is epitomized by the "cerebellar cognitive affective syndrome" ("CCAS") or "Schmahmann syndrome." Introduced in the late 1990s, CCAS reflects a constellation of cerebellar-induced sequelae, comprising deficits in executive function, visuospatial cognition, emotion-affect, and language, over and above speech. The CCAS thus offers excellent grounds to investigate the functional topography of the cerebellum, and, ultimately, illustrate the precise mechanisms by which the cerebellum modulates cognition and affect. The primary objective of this task force paper is thus to stimulate further research in this area. After providing an up-to-date overview of the fundamental findings on cerebellar neurocognition, the paper substantiates the concept of CCAS with recent evidence from different scientific angles, promotes awareness of the CCAS as a clinical entity, and examines our current insight into the therapeutic options available. The paper finally identifies topics of divergence and outstanding questions for further research.

Fourth ventricle index: sonographic marker for severe fetal vermian dysgenesis/agenesis

OBJECTIVE

Prenatal diagnosis of midbrain-hindbrain (MB-HB) malformations relies primarily on abnormal size and shape of the cerebellum and retrocerebellar space, particularly 'open fourth ventricle' (4V), the most common indicator of MB-HB malformations. The aim of this study was to present the fourth ventricle index (4VI), and to evaluate its role as a marker for severe vermian dysgenesis/agenesis in cases without open 4V.

METHODS

This was a prospective cross-sectional study of patients with singleton low-risk pregnancy at 14 + 1 to 36 + 6 gestational weeks presenting between May 2016 and November 2017 for routine ultrasound examination. Axial images of the fetal 4V were obtained and the 4VI was calculated as the ratio between the laterolateral and the anteroposterior diameters. Reference ranges were constructed and retrospectively collected values from 44 fetuses with confirmed anomalies involving severe vermian dysgenesis/agenesis (Joubert syndrome and related disorders, rhombencephalosynapsis, cobblestone malformations and cerebellar hypoplasia) but without open 4V were compared with the normal values.

RESULTS

In total, 384 healthy fetuses were enrolled into the study, from which reference ranges were produced, and 44 cases were collected retrospectively. The 4VI in the normal fetuses was always > 1. In affected fetuses, it was always below mean -2 SD and < 1.

CONCLUSIONS

The 4VI is a sonographic marker for severe fetal vermian dysgenesis/agenesis in the absence of an open 4V. It may be incorporated easily into the routine brain scan; 4VI < 1 indicates a need for dedicated fetal neuroimaging for diagnosis and prenatal counseling. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Cerebral small vessel disease in patients with spontaneous cerebellar hemorrhage

BACKGROUND

Spontaneous cerebellar-intracerebral hemorrhage (ICH) can be associated with both cerebral amyloid angiopathy (CAA) and hypertensive small vessel disease (HTN-SVD, i.e. arteriolosclerosis). To better understand the underlying microangiopathy of cerebellar-ICH, we aimed to evaluate the spatial distribution of supratentorial cerebral microbleeds (CMBs) and neuropathologic profiles in these patients.

METHODS

We enrolled consecutive cerebellar-ICH patients. Clinical variables and MRI markers specific for CAA and HTN-SVD were assessed. Patients were classified into categories according to the topography (strictly-lobar, strictly-deep, and mixed) of supratentorial CMBs and comparisons were performed. Available neuropathological material was reviewed to evaluate the presence and severity of arteriolosclerosis and CAA.

RESULTS

Ninety-eight cerebellar-ICH patients were enrolled. Fifty patients (51%) had at least one supratentorial CMB. Twelve patients (12%) had strictly lobar-CMBs, 12 patients (12%) showed strictly deep-CMBs and mixed-CMBs (lobar and deep CMBs) were present in 26 cerebellar-ICH patients (27%). In multivariable analysis, cerebellar-ICH patients with mixed-CMBs were associated with higher prevalence of hypertension (OR 4.9, 95% confidence interval [CI] 1.2-20, p = 0.017) but with lower prevalence of severe centrum-semiovale enlarged perivascular spaces (OR 0.2, CI 0.05-0.8, p = 0.024) when compared to cerebellar-ICH patients with strictly lobar-CMBs. Vascular risk factors and neuroimaging characteristics were similar between strictly deep-CMBs and mixed-CMBs. Six patients had available neuropathological material for analyses and they all showed some degree of arteriolosclerosis.

CONCLUSIONS

Cerebellar-ICH patients frequently show supratentorial CMBs. The mixed-CMBs pattern appears to be the most common. Our radiological and pathological results suggest that the majority of cerebellar-ICH patients harbor HTN-SVD as dominant microangiopathy.

Nationwide survey of Arima syndrome: revised diagnostic criteria from epidemiological analysis

AIM

We have never known any epidemiological study of Arima syndrome since it was first described in 1971. To investigate the number of Arima syndrome patients and clarify the clinical differences between Arima syndrome and Joubert syndrome, we performed the first nationwide survey of Arima syndrome, and herein report its results. Furthermore, we revised the diagnostic criteria for Arima syndrome.

METHODS

As a primary survey, we sent out self-administered questionnaires to most of the Japanese hospitals with a pediatric clinic, and facilities for persons with severe motor and intellectual disabilities, inquiring as to the number of patients having symptoms of Arima syndrome, including severe psychomotor delay, agenesis or hypoplasia of cerebellar vermis, renal dysfunction, visual dysfunction and with or without ptosis-like appearance. Next, as the second survey, we sent out detailed clinical questionnaires to the institutes having patients with two or more typical symptoms.

RESULTS

The response rate of the primary survey was 72.7% of hospitals with pediatric clinic, 63.5% of national hospitals and 66.7% of municipal and private facilities. The number of patients with 5 typical symptoms was 13 and that with 2-4 symptoms was 32. The response rate of the secondary survey was 52% (23 patients). After reviewing clinical features of 23 patients, we identified 7 Arima syndrome patients and 16 Joubert syndrome patients. Progressive renal dysfunction was noticed in all Arima syndrome patients, but in 33% of those with Joubert syndrome.

CONCLUSION

It is sometimes difficult to distinguish Arima syndrome from Joubert syndrome. Some clinicians described a patient with Joubert syndrome and its complications of visual dysfunction and renal dysfunction, whose current diagnosis was Arima syndrome. Thus, the diagnosis of the two syndromes may be confused. Here, we revised the diagnostic criteria for Arima syndrome.

Cerebellar hemorrhage in very low birth weight premature infants: the advantage of the posterolateral fontanelle view

OBJECTIVE

The purpose of this study was to determine the prevalence of cerebellar hemorrhage in very low birth weight infants using the posterolateral fontanelle for ultrasound (US) examination.

METHODS

The study included 125 very low birth weight premature infants (defined as equal or less than 1500 grams at birth) hospitalized in the premature or neonatal intensive care departments that had at least one head US examination including both anterior and posterolateral fontanelle scans.

RESULTS

On US performed through the posterolateral fontanelle, four (3.2%) infants had echogenic posterior fossa lesions interpreted as hemorrhages. None of these lesions were initially or retrospectively observed through the standard anterior fontanelle scan. Two infants died at age 4 and 39 days, respectively. All survivors are being followed up in the hospital's neurodevelopment outpatient clinic.

CONCLUSIONS

Cerebellar hemorrhage may be overlooked on standard anterior fontanelle views. The posterolateral approach may assist in diagnosing these lesions.

Herniation of cerebellar tonsils in acromegaly: prevalence, pathogenesis and clinical impact

Herniation of cerebellar tonsils (CTH) might occur in acromegaly patients and improve after acromegaly treatment. Our study investigated CTH prevalence in acromegaly, its relationship with clinical, laboratory and neuroimaging findings and its possible pathogenesis and clinical impact. 150 acromegaly patients (median-age 56 years, age-range 21-88, 83 females) underwent brain magnetic resonance imaging (MRI). Clinical data, laboratory and pituitary adenoma imaging findings were recorded. CTH, posterior cranial fossa area, tentorial angle, clivus, supraocciput and Twining's line length were measured in acromegaly patients and controls, who included MRI of 115 consecutive subjects with headache or transient neurological deficits (control group-1) and 24 symptomatic classic Chiari 1 malformation patients (control group-2). Acromegaly patients were interviewed for symptoms known to be related with CTH. 22/150 acromegaly patients (15 %) and 8/115 control group-1 subjects presented with CTH (p = 0.04). In acromegaly patients, CTH correlated positively with younger age and inversely with GH-receptor antagonist treatment. Control group-2 had a shorter clivus than CTH acromegaly patients (40.4 ± 3.2 mm vs 42.5 ± 3.3 mm, p < 0.05), while posterior fossa measures did not differ among acromegaly subgroups (with and without CTH) and control group-1. Headache and vision problems were more frequent in CTH acromegaly patients (p < 0.05); two acromegaly patients presented with imaging and neurological signs of syringomyelia. Despite no signs of posterior fossa underdevelopment or cranial constriction, CTH is more frequent in acromegaly patients and seems to contribute to some disabling neurological symptoms.

Role of MR imaging in prenatal diagnosis of pregnancies at risk for Joubert syndrome and related cerebellar disorders

BACKGROUND AND PURPOSE

JSRD are rare autosomal recessive brain malformations. We hypothesized that MR imaging can assess fetuses at risk for JSRD and might influence their diagnoses.

MATERIALS AND METHODS

We prospectively performed cranial MR imaging for 12 fetuses (mean GA, 23 weeks; SD, 3.7) at 25% recurrence risk for JSRD. We correlated prenatal MR imaging findings with postnatal MR imaging and clinical outcome. Retrospectively, we compared posterior fossa measurements of the cases with those of 24 age-matched fetuses with proved normal brain MR imaging. Institutional review board approval and consents were obtained. Statistical methods included a t test and ANCOVA tests.

RESULTS

Fetal MR imaging correctly diagnosed 3 cases at 22, 28, and 29 weeks of gestation as JSRD, and 9 cases as normal. In JSRD-affected fetuses, prenatal MR imaging detected narrow pontomesencephalic junction (isthmus) with deepening of the interpeduncular fossa and thick horizontally placed superior cerebellar peduncles (MTS), deformed anteriorly convex floor of the fourth ventricle, and midline cerebellar cleft in place of the hypoplastic vermis. Measurements on axial fetal MR imaging at pontomesencephalic junction, ratio of AP diameters of interpeduncular fossa to midbrain/isthmus, and ratio of the AP to transverse diameters of the fourth ventricle were significantly higher in JSRD-affected fetuses than in nonaffected cases and the control group.

CONCLUSIONS

MR imaging can diagnose JSRD in at-risk pregnancies by detecting posterior fossa signs. Measurements at the pontomesencephalic junction may enhance fetal MR imaging accuracy in diagnosing JSRD.

Separating coordinative and executive dysfunction in cerebellar patients during motor skill acquisition

OBJECTIVE

Patients with cerebellar stroke are impaired in motor skill acquisition and cognitive/executive performance. The aim was to test whether skill acquisition in cerebellar patients is influenced by executive demands such as the intermittent exercise of a conflicting motor task.

METHODS

Patients with cerebellar stroke and healthy controls were tested in two serial reaction time experiments. In Experiment 1, participants performed practice runs (always same sequence) and interference runs (new sequence for each run) in a strictly alternating fashion. In Experiment 2, participants rested between successive practice runs; the duration of rests was adapted to the duration of interference runs in the other experiment. Participants of Experiment 1 were also tested for cognitive-executive functions (Wisconsin Card Sort, Word Fluency, Trail Making, Digit Span backwards).

RESULTS

(1) Patients in Experiment 1, although always slower than controls, acquired motor skills in the first run before interference but in contrast to controls failed to improve their performance in subsequent runs. (2) Patients in Experiment 2 improved their performance consistently over several runs. (3) Patients of Experiment 1 were worse than controls in several cognitive-executive functions; however, these deficits did not correlate with the degree of interference in motor skill acquisition.

INTERPRETATION

Simple movement coordination and higher order context-related movement organisation are separate cerebellar functions. In cerebellar patients, impaired movement coordination is associated with generally slower reaction times whereas organisational deficits are associated with a specific impairment to change between motor sets. Motor-executive functions responsible for the latter impairment might be independent from cognitive-executive functions.

Follow-up of vestibular function in bilateral vestibulopathy

OBJECTIVE

Bilateral vestibulopathy (BV) leads to a bilateral deficit of the vestibulo-ocular reflex and has various aetiologies. The main goal of this study was to determine the frequency and degree of recovery or worsening of vestibular function over time.

METHODS

82 patients (59 males, 23 females; mean age at the time of diagnosis 56.3 (SD 17.6) years) were re-examined 51 (36) months after the first examination. All patients underwent a standardised neuro-ophthalmological and neuro-otological examination. Electronystagmography with bithermal caloric irrigation was analysed by measurement of the mean peak slow phase velocity (SPV) of the induced nystagmus. Patients evaluated the course of their disease in terms of balance, gait unsteadiness and health related quality of life.

RESULTS

Statistical analysis of the mean peak SPV of caloric induced nystagmus revealed a non-significant worsening over time (initial mean peak SPV 3.0 (3.5) degrees/s vs 2.1 (2.8) degrees/s). With respect to subgroups of aetiology, only patients with BV due to meningitis exhibited an increasing, but non-significant SPV (1.0 (1.4) degrees/s vs 1.9 (1.6) degrees/s). Vestibular outcome was independent of age, gender, time course of manifestation and severity of BV. Single analysis of all patients showed that a substantial improvement > or = 5 degrees/s occurred in two patients on both sides (idiopathic n = 1, Sjögren's syndrome n = 1) and in eight patients on one side (idiopathic n = 6, meningitis n = 1, Menière's disease n = 1). In 84% of patients there was impairment of their health related quality of life (42% slight, 24% moderate, 18% severe). Forty-three per cent of patients rated the course of their disease as stable, 28% as worsened and 29% as improved.

CONCLUSIONS

Our data support the view that more than 80% of patients with BV do not improve. Thus the prognosis of BV is less favourable than assumed.

Exaggerated crying and tremor with a cerebellar cyst

The authors describe clinical, neuropsychological, and neuroimaging findings in a 70-year-old man with a cystic lesion in the midline cerebellum. He presented with pathological crying in parallel to a worsening of his ataxia. This report suggests a role for the cerebellum in the regulation of emotional expression.

Causative factors and epidemiology of bilateral vestibulopathy in 255 patients

OBJECTIVE

To determine the causative factors and epidemiology of bilateral vestibulopathy (BV).

METHODS

This is a retrospective review of 255 patients (mean age, 62 +/- 16 years) with BV diagnosed in our dizziness unit between 1988 and 2005. All patients had undergone a standardized neurophthalmological and neurootological examination, electronystagmography with caloric irrigation, cranial magnetic resonance imaging or computed tomography (n = 214), and laboratory tests.

RESULTS

Sixty-two percent of the study population were male subjects. Previous vertigo attacks had occurred in 36%, indicating a sequential manifestation. The definite cause of BV was determined in 24% and the probable cause in 25%: The most common causes were ototoxic aminoglycosides (13%), Menière's disease (7%), and meningitis (5%). Strikingly, 25% exhibited cerebellar signs. Cerebellar dysfunction was associated with peripheral polyneuropathy in 32% compared with 18% in BV patients without cerebellar signs. Hypoacusis occurred bilaterally in 25% and unilaterally in 6% of all patients. It appeared most often in patients with BV caused by Cogan's syndrome, meningitis, or Menière's disease.

INTERPRETATION

The cause of BV remains unclear in about half of all patients despite intensive examinations. A large subgroup of these patients have associated cerebellar dysfunction and peripheral polyneuropathy. This suggests a new syndrome that may be caused by neurodegenerative or autoimmune processes.

Niemann–Pick C disease in Spain: Clinical spectrum and development of a disability scale

OBJECTIVES

To describe the clinical evolution of Niemann-Pick C disease to identify possible factors involved in the diagnosis and severity of the disease.

METHODS

A clinical database and a severity scale was created to evaluate 45 patients diagnosed with Niemann-Pick type C in the last 28 years in Spain.

RESULTS

Complete clinical data were obtained from 30 patients, all were confirmed to have mutations in the NPC1 gene. Regarding clinical form, 3 were perinatal, 7 severe infantile, 6 late infantile, 11 juvenile and 3 adult. Biochemical phenotype was classic in 26. Splenomegaly was present in 28 patients (93%) with a wide range of age at detection. The first symptom of neurological disease was clumsiness, followed in 2-4 years by cerebellar signs. Ophthalmoplegia appeared 2-4 years later and became complete 1-2 years after onset. Dysarthria appeared by the time of complete ophthalmoplegia. Diagnosis was made before the onset of neurological signs in patients with the severe infantile form, at the time of onset of cerebellar signs in the late infantile form and complete ophthalmoplegia in late onset forms.

CONCLUSIONS

In our series, splenomegaly is present in 96% of patients, even in late onset forms during the first years of life. Clumsiness in children with otherwise normal motor development precedes the onset of ataxia by 2-4 years in Niemann Pick type C. A disability scale could be useful for monitoring evolution, establishing possible phenotypic correlations and evaluating future therapies.

Cerebellar infarction presenting isolated vertigo: Frequency and vascular topographical patterns

OBJECTIVE

To determine the frequency of cerebellar infarction mimicking vestibular neuritis (VN), the pattern of clinical presentation, and the territory of the cerebellar infarction when it simulates VN.

METHODS

We studied 240 consecutive cases of isolated cerebellar infarction in the territories of the cerebellar arteries diagnosed by brain MRI from the acute stroke registry at the Keimyung University Dongsan Medical Center.

RESULTS

We identified 25 patients (10.4%) with isolated cerebellar infarction who had clinical features suggesting VN. Two types of cerebellar infarction simulating VN were found: isolated spontaneous prolonged vertigo with imbalance as a sole manifestation of cerebellar infarction (n = 24) and isolated spontaneous prolonged vertigo with imbalance as an initial manifestation of cerebellar infarction (n = 1) followed by delayed neurologic deficits 2 days after the onset. The cerebellar infarction territory most commonly involved was the medial branch of the posterior inferior cerebellar artery territory (24/25: 96%), followed by the anterior inferior cerebellar artery territory (1/25: 4%). None of patients with infarcts in the territory of the superior cerebellar artery or multiple cerebellar arteries showed isolated spontaneous prolonged vertigo.

CONCLUSIONS

Cerebellar infarction simulating vestibular neuritis is more common than previously thought. Early recognition of the pseudo-vestibular neuritis of vascular cause may allow specific management.

Frequency and clinicopathological characteristics of alcoholic cerebellar degeneration in Japan: a cross-sectional study of 1,509 postmortems

Alcoholic cerebellar degeneration (ACD) is a pivotal neurological complication in alcoholics. However, although there are a few autopsy reports and some data on its frequency, it is considered very rare in Japan. The aims of this study were (1) to estimate the frequency of the disease in Japanese autopsy cases, and (2) to examine the clinicopathological features of symptomatic and asymptomatic cases of ACD. We reviewed the records of 1,509 Japanese autopsies obtained from three autopsy series in Japan, and selected all 55 cases (3.6%) with alcoholism. On neuropathological reexamination, ACD was confirmed in six male alcoholics [0.4% of all subjects; 10.9% of all alcoholics; mean age at death 59.3+/-13.4 years (+/- SD)], including three asymptomatic cases. These frequencies were much lower than some previous Western findings, but more common than that has been expected in Japan. The frequencies of memory impairment and ataxia in ACD cases were significantly higher than those in alcoholics without any alcohol-related pathologies. In ACD cases, loss of Purkinje cells, narrowing of the width of the molecular layer, and tissue rarefaction in the granular layer were observed in the anterior and superior portions of the vermis of the cerebellum. In adjacent regions, the Purkinje cell and molecular layers were more mildly affected. The distribution of severely affected regions was more restricted in the asymptomatic cases than in the symptomatic cases. This study confirmed the frequency of asymptomatic cerebellar degeneration in alcoholics, suggesting that early intervention in alcoholism in the subclinical phase is important to prevent the development of cerebellar symptoms.

[Otogenic intracranial complications from data collected at Department of Otolaryngology Collegium Medicum Jagiellonian University between 1998-2006]

BACKGROUND

Otogenic intracranial complications are rare diseases. If misdiagnosed and untreated they can lead to serious condition of patient and life-threatening. This group of complications ought to be kept in mind in patients with chronic otitis media.

AIM OF THE STUDY

We discuss types of otogenic complications and performed treatment.

MATERIAL AND METHODS

Retrospective analysis of patients treated in our department between 1998-2006 was made. About 700 ear operations were performed in that period of time.

RESULTS

Intracranial otogenic complications were noticed in 9 cases. Despite performed treatment one patient with cerebellum abscess died. The rest patients were operated with good result.

CONCLUSIONS

Precise otolaryngological examination with additional investigations like CT and MRI are very important to establish the final diagnosis and save patient's health or life.

Cerebellar hemorrhage in the preterm infant: ultrasonographic findings and risk factors

Cerebellar hemorrhage (CBH) in premature infants is increasingly diagnosed secondary to improved neuroimaging techniques and survival of very small preterm infants. Information is limited, however, on the incidence, topography, and risk factors for CBH in the preterm infant.

OBJECTIVES

To define the incidence of CBH in preterm infants diagnosed by neonatal cranial ultrasound (US), describe the sonographic features of CBH, and identify maternal and perinatal risk factors associated with this lesion.

METHODS

A systematic electronic database search identified preterm infants born 1998-2002 with US diagnosis of CBH. For 35 cases of CBH we double-matched (according to gestational age, gender, and year of birth) 70 preterm controls with normal cranial USs and performed detailed medical-record reviews for both patients and controls.

RESULTS

Unilateral CBH was seen in 25 patients (71%), vermian hemorrhage was seen in 7 (20%), and combined bihemispheric and vermian hemorrhage was seen in 3 (9%). Isolated CBH occurred in 8 patients (23%); the remaining infants had associated supratentorial lesions. The incidence of CBH in preterm infants weighing <750 g at birth showed significant increase over the study period. Univariate analyses identified maternal, intrapartum, and early postnatal hemodynamic risk factors; multivariate regressions indicated that emergent caesarian section, patent ductus arteriosus, and lower 5-day minimum pH independently increased the odds of CBH. Neonatal mortality and morbidity were significantly higher among patients with CBH compared with preterm controls.

CONCLUSIONS

CBH is an important complication of extreme preterm birth and has been underrecognized in surviving preterm infants. Predictors of CBH seem to be multifactorial and include combined maternal, intrapartum, and early postnatal factors.

Focal symmetrical encephalomalacia in swine from ingestion of Aeschynomene indica seeds

A spontaneous outbreak of neurological disease in swine caused by the ingestion of Aeschynomene indica seeds and reproduction of the disease in the same specie are reported. In the natural outbreak the morbidity, mortality and lethality rates were respectively 25%-40%, 8.5%-20%, and 25%-66%. Clinical signs were variable degrees of incoordination of gait, falls, sternal recumbency with wide base stance of the hind limbs, lateral recumbency and death. For experimental reproduction of the intoxication, 5 (A-E) pigs were fed a ration containing 10% (PigA), 15% (Pig B) and 20% (Pigs C-E) of A. indica seeds. Pigs A and B were euthanatized and Pigs C-E died of acute disease respectively 16, 21 and 24 hours after the start of the experiment. Clinical signs were similar to those observed in pigs from the spontaneous outbreak. Histopathological findings in the brain of pigs fed rations with 20% A. indica seeds (C-E) were congestion, edema and hemorrhage and swollen capillary endothelia in nuclei and in the telencephalic cortex. Pigs fed 10% and 15% A. indica had histopathological changes in the brain of discrete focal symmetrical areas of malacia. These findings indicate that one or more toxic principles in A. indica seeds are responsible for this neurological condition and that clinical outcome and pathological changes are dose-dependent. The symmetrical malacic foci from the ingestion of A. indica seeds in pigs affected vestibular and cerebellar nuclei, putamen, and the mesencephalic substantia nigra, oculomotor, and red nucleus; thus, focal symmetrical encephalomalacia is suggested as a better name for the disease.

Postanesthetic cerebellar dysfunction in cats

Eleven cats with signs of cerebellar dysfunction, developed on recovery from a brief and uneventful general anesthesia, were examined at the Koret School of Veterinary Medicine Teaching Hospital (KSVMTH) between 1998 and 2002. Neurological signs included mild to severe ataxia of all 4 limbs, intentional tremor, lack of menace response, and delayed hopping. The cats were of different ages when anesthetized and none had shown any prior signs of neural disease. They were examined 1 day to 4 years after onset of clinical signs, and the neurological deficits remained unchanged in a follow-up period of 6 months to 8 years. Medical and anesthetic records showed that all were Persian cross cats, 7 of them originating in the same city in Israel. Ketamine was the only anesthetic drug that had been used with all cats. It might be that a genetic component predisposes Persian cross cats to nonreversible cerebellar damage after exposure to an anesthetic dose of ketamine.

Idiopathic scoliosis as a presenting sign of familial neurologic abnormalities

STUDY DESIGN

Familial cases of "idiopathic" scoliosis associated with neurologic abnormalities are reported with a review of the literature.

OBJECTIVE

To investigate the prevalence of neurologic abnormalities such as syringomyelia, Chiari 1 malformation, and tonsillar ectopia in patients with genetically determined "idiopathic" scoliosis.

SUMMARY OF BACKGROUND DATA

Idiopathic scoliosis is widely considered to be a genetic disorder of unknown etiology. Magnetic resonance imaging (MRI) studies have shown that several cases of "idiopathic" scoliosis show neurologic abnormalities including syringomyelia and Chiari 1 malformation. Recently, several familial cases of either syringomyelia or Chiari malformation were reported, and it is suspected that genetic factors may influence the development of the craniovertebral malformation. It was hypothesized that some cases of "idiopathic" scoliosis include a craniovertebral malformation that is genetically determined.

METHODS

This study, using clinical examinations and MRI, investigated 71 patients with scoliosis and a family history of "idiopathic" scoliosis in third-degree relatives for the presence of neurologic abnormalities. If neurologic abnormalities were confirmed with MRI, the relatives affected with scoliosis were also examined.

RESULTS

Nine (13%) patients showed neurologic abnormalities on MRI. Magnetic resonance imaging showed syringomyelia with Chiari 1 malformation in four patients, Chiari 1 malformation in three patients, and tonsillar ectopia in two patients. Among the relatives of these patients, 4 of 15 individuals affected with scoliosis also showed neurologic abnormalities on MRI.

CONCLUSIONS

It is suggested that familial neurologic abnormalities may have a wide range of expression, and that some patients with "idiopathic" scoliosis present with genetically determined craniovertebral malformations such as syringomyelia, Chiari 1 malformation, and tonsillar ectopia.

Clinical signs of cerebellar dysfunction in schizophrenia, alcoholism, and their comorbidity

Abnormalities of cerebellar structure and function, long recognized as a hallmark of chronic alcohol abuse, have also occasionally been noted in patients with schizophrenia. We used a four-point rating scale to assess clinical signs of cerebellar dysfunction in men meeting DSM-IV criteria for schizophrenia (N=34) and alcohol dependence (N=15) as well as normal control subjects (N=28). Compared to controls, alcoholics had impaired ratings of gait ataxia and instability of stance with eyes closed, and schizophrenics had impaired ratings of stance with eyes closed. The incidence of dysdiadochokinesia was greater in schizophrenics, but not alcoholics, than controls. The incidence of gait and stance abnormalities was higher in both patient groups relative to controls: within the schizophrenic group, 50-70% of those with positive signs for gait or stance impairment were comorbid for alcoholism, while only 25% of those with positive signs for dysdiadochokinesia were comorbid for alcoholism. The presence of dysdiadochokinesia in the schizophrenic group suggests cerebellar dysfunction that is independent of the effects of alcohol. By contrast, clinical signs of cerebellar dysfunction of gait and stance in patients with schizophrenia may be secondary to the effects of alcohol on the cerebellum.

Psychopathology in patients with degenerative cerebellar diseases: a comparison to Huntington's disease

OBJECTIVE

This study estimated the psychiatric morbidity of patients with degenerative cerebellar diseases.

METHOD

The study included a series of 31 patients with degenerative cerebellar diseases, compared with 21 patients with Huntington's disease and 29 neurologically healthy comparison subjects. Comprehensive psychiatric evaluations, including the Structured Clinical Interview for DSM-IV and psychopathology rating scales, were administered.

RESULTS

The overall rate of noncognitive psychiatric disorders was 77% in the patients with degenerative cerebellar diseases, nearly identical to that in the patients with Huntington's disease (81%) and about double that seen in the neurologically healthy subjects (41%). There were high rates of all mood disorders in both the degenerative cerebellar diseases group (68%) and the Huntington's disease group (43%); the rate in the degenerative cerebellar diseases group was significantly higher than that in the neurologically healthy subjects (31%). The frequency of personality change in the three groups was striking: change was present in 26% of the degenerative cerebellar diseases patients, 48% of the Huntington's disease patients, and none of the neurologically healthy comparison subjects. A total of 19% of the degenerative cerebellar diseases subjects and 71% of the Huntington's disease subjects met DSM-IV criteria for either cognitive disorder or dementia.

CONCLUSIONS

The high rate of psychiatric and cognitive disorders in the patients with degenerative cerebellar diseases suggests that many, if not most, patients with degenerative cerebellar diseases may benefit from psychiatric interventions. These results also support previous findings that the cerebellum may have a role in modulating emotion and cognition.

[Relation of the cerebellum with cognitive function: neuroanatomical, clinical and neuroimaging evidence]

INTRODUCTION

Published studies in the last decades, employing a variety of methodologies, suggest that the cerebellum function is not only limited to motor control but also has an important role in cognition and emotion.

DEVELOPMENT

In the present paper we review the main neuroanatomical and functional neuroimaging studies supporting the idea that the cerebellum has a role in non motor behavior. On the other hand, we expound the results of the neuropsychological studies of patients with cerebellar lesions. The deficits showed after cerebellar lesions include disturbances in executive functions, learning, memory, attention, visuo-spatial functions, language and personality change. Some studies propose that the cerebellum, through its afferent and efferent circuits with the cerebrum, perform a global function capable to influencing motor behavior, in cognitive functions and in emotion. A fault in this function would cause the behavioral deficits shown in patients with cerebellar lesions.

CONCLUSION

The evidence available in the anatomical, functional and clinical studies support the conclusion that the cerebellum participates not only in motor functions, but also in cognitive functions and in emotion.

[Progressive neurological deficits in cerebral arteriovenous malformations]

Progressive neurological deficits are uncommonly associated with cerebral arteriovenous malformations. We present 25 cases (3.54%) from our series of 705 patients treated by radiosurgery. Common characteristics were preferentially: large cerebral arteriovenous malformations, arterial steal, arterial recruitment, venous reflux and deep location. After multivariate analysis, only arterial steal was significantly associated with neurological deficits. Course after treatment was variable and correlated with cerebral arteriovenous malformations regression. Different pathophysiologic hypotheses and their therapeutic consequences are discussed.

[Cerebellar hematomas: a surgically treatable stroke]

INTRODUCTION

Spontaneous cerebellar hematomas make up nearly 10% of the intracranial intraparenchymatous hemorrhages. In recent years several algorithms have been published for the management of these patients.

OBJECTIVE

To study the type of treatment, conservative or operative, and the main prognostic factors.

PATIENTS AND METHODS

We present a retrospective analysis of 52 cases of spontaneous cerebellar hematomas diagnosed over the past 10 years in the Hospital General de Galicia. We studied the clinical and radiological factors with the greatest effect on prognosis and the approach to treatment.

RESULTS

We found a male/female ration of 2/3. The age of 90.3% of our patients was over 60 years. Arterial hypertension had previously been diagnosed in 55.7% of the cases. The clinical picture was characterized by the profile of a stroke with headache (90.3%), vomiting (63.4%) and impaired consciousness (50%) being the commonest presenting symptoms. The most important factors in prognosis were the level of consciousness and the size of the hematoma. The prognosis was worse in cases with hydrocephalus, intraventricular hemorrhage or extension of the hematoma towards the midline. Neither age, sex nor the previous diagnosis of arterial hypertension were of importance in prognosis. Mortality was 25%.

CONCLUSIONS

The spontaneous cerebellar hematomas typically affect patients over the age of 60 years and present with headache and vomiting of sudden onset. In our series the major prognostic factors were the size of the hematoma and level of consciousness, and treatment was given in accordance with this.

Significance of cerebellar atrophy in intractable temporal lobe epilepsy: a quantitative MRI study

PURPOSE

To determine the incidence of cerebellar atrophy (CA) in patients with intractable temporal lobe epilepsy, whether any clinical factors are significantly associated with CA, whether CA is unilateral or asymmetric and whether this feature has any relationship to the side of epileptogenicity, and whether the presence of CA is related to epilepsy surgery outcome.

METHODS

We developed a magnetic resonance imaging method of measuring the presurgical volumes of the cerebellar hemispheres of 185 patients who underwent temporal lobectomy for intractable epilepsy and of 80 control subjects. In addition, cerebellar volumes were normalized to the total brain volumes. CA was determined as being present when the measured volume was smaller than two standard deviations from the mean value found in control subjects.

RESULTS

Both absolute and normalized cerebellar volumes were found to be significantly reduced in the epilepsy patients compared with the control subjects. Without normalization of the cerebellar volumes, CA was present in 25.9% of the epilepsy patients; with normalization, it was present in only 16.2%. The atrophy was symmetric between the cerebellar hemispheres, and there was no significant difference in volume between the hemisphere ipsilateral and the hemisphere contralateral to the side of the temporal lobectomy. The duration of epilepsy was significantly longer and the age at onset of epilepsy was younger in patients with CA than in those without CA. The presence of CA was not associated with the outcome of temporal lobectomy.

CONCLUSIONS

CA is symmetric and common in patients with intractable temporal lobe epilepsy. However, the results suggest that the atrophy in one third of patients with CA also proportionately affects the cerebral hemispheres. The duration of epilepsy and the age at onset of epilepsy are associated with the occurrence of CA. Seizure control after temporal lobectomy is not influenced by the presence of CA.

Clinical features and prognosis in young adults with infratentorial infarcts

BACKGROUND AND PURPOSE

Many comprehensive descriptions of the clinical spectrum of infratentorial infarcts in elderly patients and with a retrospective design have been published. The aim of this study was to describe the clinical characteristics and prognosis in young patients with isolated infratentorial infarcts.

METHODS

In a prospective series of 105 patients aged 18-44 years with cerebral infarction 24 had a brainstem or cerebellar infarction. The patient selection was validated in a population-based epidemiological survey. The patients were assessed acutely and at 4 and 12 months after onset. Extensive evaluation included CT and MRI scans, angiography, ultrasonic duplex scanning, transesophageal echocardiography and a chemistry panel including hematologic testing. The modified Rankin scale and NIH stroke scale were used for assessment of disability and neurological dysfunction.

RESULTS

Eighteen patients had a cerebellar infarct (posterior inferior cerebellar artery territory in 9 patients, superior cerebellar artery in 6, anterior inferior cerebellar artery in 2, nonterritorial in 1). Two patients had lateral medullary infarcts and 2 isolated pontine infarcts. In 2 patients MRI was normal despite repeated investigations. Hearing loss and tinnitus were the only explicit symptoms for superior cerebellar artery infarcts, but it was otherwise impossible to classify each case to a vascular territory according to clinical characteristics. The age-specific incidence of isolated cerebellar infarction was 1.8/100,000/year. The presumed causes were arterial dissection in 8 patients, idiopathic in 7, cardioembolic in 5, oral contraceptive use in 3 and protein S deficiency in 1 patient. One patient died during the acute phase and another developed a locked-in syndrome. At follow-up, 1 patient had a transitory ischemic attack and 1 a silent cerebral infarction. Twenty-two patients had a favorable outcome according to the modified Rankin scale (grade 0-2) and the NIH scale.

CONCLUSIONS

Cerebellar infarctions are frequent among young stroke patients in northern Sweden. Arterial dissection is the prevailing stroke mechanism in infratentorial infarcts. The prognosis is favorable regarding motor impairment but cognitive deficits may prevent return to work.

Bilateral loss of vestibular function: clinical findings in 53 patients

The clinical presentations and aetiologies of a series of 53 cases of bilateral vestibular failure (BVF) seen by the authors over a decade were evaluated by retrospective review of the medical records. Thirty-nine per cent of patients had associated neurological disease; 13% had a progressive cerebellar syndrome with disabling gait ataxia, abnormal eye movements and cerebellar atrophy on neuro-imaging. BVF was usually unsuspected. Nine per cent had cranial or peripheral neuropathies and in this group there was no abnormality of brain stem/cerebellar oculomotor function, but hearing loss was common. Eleven per cent revealed BVF and hearing loss secondary to meningitis, and 6% had other neurological disorders. Idiopathic BVF was found in 21% of cases, characterised by paroxysmal vertigo and/or oscillopsia, but no abnormal clinical signs. Gentamicin ototoxicity accounted for a further 17%, while autoimmune disease was present in 9% of patients. Otological or neoplastic disease was diagnosed in the remaining 13% of patients. It was concluded that neurological, audiological and ocular motor assessments allow the probable cause of BVF to be defined in approximately 80% of cases. A group of BVF related to autoimmune pathologies is reported for the first time, indicating the need for immunological screening. Idiopathic BVF may present with only minor visual or vestibular symptoms, while in patients with cerebellar degeneration, BVF may be unsuspected and, thus, underdiagnosed.

A preliminary study on delayed vestibulo-cerebellar effects of Tokyo Subway Sarin Poisoning in relation to gender difference: frequency analysis of postural sway

To evaluate delayed (long-term) effects of acute sarin poisoning on postural balance, nine male and nine female victims of the Tokyo Subway Sarin Poisoning in Japan (sarin cases) were examined by computerized posturography 6-8 months after the poisoning. Their plasma cholinesterase activities (ChE) on the day of the poisoning (March 20, 1995) were 13-95 (mean 68.2) IU/l for females and 19-131 (mean 75.9) IU/l for males, which were not significantly different between the two sexes. In females, the postural sway of low frequency (0-1 Hz) in the anterior-posterior direction and area of sway with eyes open was significantly larger in the cases than in the controls. Romberg quotients for the low-frequency sway in the anterior-posterior direction for females and low-frequency sway and length of sway in the medio-lateral direction for males were significantly related to log ChE. It is suggested that a delayed effect on the vestibulo-cerebellar system was induced by acute sarin poisoning; females might be more sensitive than males.

Spectrum of neuropsychiatric complications in 791 cases of typhoid fever

Over a 6-year period, we studied 791 patients with multidrug-resistant typhoid fever, of whom 665 individuals (84%) developed neuropsychiatric manifestations. These were: acute confusional state (73%); myelitis (6%); cerebellitis (1%); parkinsonism (1%); acute psychosis (0.6%); meningo-encephalitis (0.5%); encephalitis (0.25%); sensory motor polyneuropathy, polymyositis, acute schizophrenia and bizarre neurological syndromes (0.12% each). Severe parkinsonian rigidity and meningo-encephalitis are associated with significant morbidity but very low mortality (0.5%).

Teratogenicity of Aino virus in the chick embryo

Aino virus (JaNAr 28 strain), a possible agent of a congenital anomaly of calves, was inoculated into the yolk sac of chick embryos at a dose of 10(2), 10(3), 10(4) or 10(5) TCID50 0.2 ml-1 at four, six or eight days of incubation. At 21 days of incubation all the unhatched embryos or hatched chickens in the experimental and control groups were sacrificed for pathological examination. The incidence of hydranencephaly, cerebellar hypoplasia or agenesis and arthrogryposis or scoliosis was highest (85 per cent in the chicks inoculated with 10(3) TCID50 0.2 ml-1 at eight days of incubation. The lesions were very similar to those found in congenital abnormalities in calves suspected of a natural infection with Aino virus.

Hydranencephaly, cerebellar hypoplasia, and myopathy in chick embryos infected with aino virus

Pathogenesis of Aino virus (AIV), a suspected causative agent of congenital abnormalities of calves, has not yet been established by experimental infection of dams. To investigate the pathogenesis, 10(3) median tissue culture infective doses per 0.2 ml of AIV strain JaNAr 28 was inoculated into the yolk sac of 8-day-old chick embryos. At 4, 7, 10, and 13 days post-inoculation (PI) 20 eggs were opened and macro- and microscopic studies combined with virus recovery and immunohistochemical detection of the virus antigen were performed. At 7 to 13 days PI chick embryos manifested marked hydranencephaly, cerebellar hypoplasia, arthrogryposis, and scoliosis, with the highest incidences of 86.7%, 73.3%, 80.0%, and 20.0%, respectively. At 4 days PI the viral antigen was found in nerve cells, gitter cells in mild necrotic foci of the central nervous system (CNS), degenerative myotubules, and macrophages in the interstitium, which was associated with the early phase of AIV-induced encephalitis and polymyositis, with occasional accompanying hemorrhage and clumping of myotubular fragments. From 7 to 10 days PI, AIV antigen increased markedly in the liquefactive necrosis and in both degenerative and normal-looking myotubules in conjunction with developing hydranencephaly and arthrogryposis. The encephalitis and myositis had a tendency to mitigate by 10 days PI, coincident with a slight decrease in amount of AIV antigen. At 13 days PI there was almost no detectable AIV antigen in CNS and skeletal muscles, probably due to depletion of cells having affinity to AIV.

Relation between human T-lymphotropic virus type I and neurologic diseases in Panama: 1985-1990

Human T-cell lymphotropic virus type I (HTLV-I) is endemic in the Caribbean basin and in Japan. HTLV-II, a closely related virus, is endemic in several groups of native Americans, including Panamanian Guaymi. In Panama, a nationwide HTLV-I/II seroprevalence of 1-2% has been reported. We evaluated the frequency of HTLV-I/II infection in patients with neurologic diseases admitted to state tertiary hospitals in Panama City between 1985 and 1990. Nineteen of 322 patients with eligible diagnoses had antibodies to HTLV-I/II, 17 with HTLV-I and 2 with HTLV-II. HTLV-I was associated with spastic paraparesis (13 of 23, 56.5% versus 4 of 299, 1.3%, p < 0.001) and with cerebellar syndrome (2 of 13, 15.4%) and multiple sclerosis (2 of 54, 3.7%) (p < 0.05 for both diseases compared with subject with none of these diagnoses). The two HTLV-I infected patients with cerebellar syndrome later developed spastic paraparesis. HTLV-II infection was noted in one patient with cerebellar syndrome and one with amyotrophic lateral sclerosis. All patients with other diagnoses were seronegative. Among patients with spastic paraparesis, HTLV-I-infected patients were clinically indistinguishable from seronegative subjects. There is apparently an overlapping clinical spectrum of neurologic diseases associated with HTLV-I and HTLV-II infection.

Silent brain infarcts in 755 consecutive patients with a first-ever supratentorial ischemic stroke. Relationship with index-stroke subtype, vascular risk factors, and mortality

BACKGROUND AND PURPOSE

We wanted to establish independent associations of various clinical variables, computed tomographic (CT) scan features, presenting stroke subtypes, and outcome with the presence of silent infarcts on CT.

METHODS

We studied 755 consecutive patients in a prospective registration of patients with first-ever supratentorial atherothrombotic, cardioembolic, or lacunar stroke or stroke of undetermined cause by multiple logistic regression analysis.

RESULTS

Two hundred six patients (27%) with a first symptomatic territorial or small deep ischemic stroke had one or more silent infarcts on CT. Of all silent lesions, 169 (82%) were small and deep. Silent infarcts were significantly more strongly associated with a lacunar than atherothrombotic (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.02 to 2.47; P = .039) or cardioembolic (OR, 1.89; 95% CI, 1.2 to 2.99; P = .005) index stroke. Silent territorial lesions were more strongly associated with cardioembolic than with lacunar stroke but not with atherothrombotic stroke. In this respect, no differences were found between the atherothrombotic and undetermined-cause group. Advanced age and hypertension were the only risk factors that were significantly associated with silent infarcts (OR, 1.76; 95% CI, 1.14 to 2.71; P = .011; and OR, 1.58; 95% CI, 1.13 to 2.21; P = .007; respectively), mainly because of a strong independent association of these risk factors with silent small deep infarcts (OR, 1.75; 95% CI, 1.10 to 2.79; P = .018; and OR, 1.57; 95% CI, 1.09 to 2.24; P = .014; respectively). A cardioembolic source or atrial fibrillation in specific was not independently associated with any type or number of silent infarcts. Significant carotid stenosis (diameter reduction > 50%) was not significantly associated with any type of silent lesion. Initial severe handicap (Rankin Scale score > 3), 30-day case fatality rate, and 1-year mortality were not affected by the presence of silent infarcts.

CONCLUSIONS

The strong association of silent small deep lesions with first symptomatic small deep infarcts suggests a common underlying mechanism (presumably small-vessel vasculopathy), whereas cardiogenic embolism and large-vessel thromboembolism are the most likely causes in both silent and first symptomatic territorial infarcts. Single or multiple silent infarcts do not predict a cardioembolic stroke mechanism in first symptomatic supratentorial brain infarcts. As silent infarcts do not predict the cause of carotid embolic stroke in first symptomatic brain infarcts, their presence should not influence the decision on carotid surgery. Silent infarcts do not affect the degree of initial handicap, 30-day case fatality, or 1-year mortality. The significance of silent infarcts for predicting possible future cognitive decline and risk of recurrent stroke deserves further study.

Predictors of outcome of stroke in infants and children based on clinical data and radiologic correlates

Outcome predictors were analyzed in 45 infants and children with cerebrovascular disorders (CVD), based on clinical features and radiological correlates. The clinical features at presentation could be categorized into three major groups: (1) generalized: alteration of consciousness with or without seizures--24 patients (54%); (2) focal: acute hemiplegia or monoplegia with or without focal seizures--18 patients (40%); (3) cerebellar disturbances--3 patients (6%). The underlying etiology was detected in 80% of children. Thirty-seven patients (82%) survived the initial debilitating event, of whom 11 (29.7%) recovered completely and the rest had either motor or cognitive handicaps during an average follow-up period of 4.2 years (range 1.5-11 years). A head CT performed in all children revealed ischemic infarction in 29 patients (64.4%), while the others had hemorrhagic infarction. Of those with an initial generalized neurological presentation, as many as 50% had multi-focal lesions on CT. All children with focal neurological findings had a solitary localized lesion on CT, mainly in the distribution of the middle cerebral artery. Statistical analysis for outcome prediction showed that the following variables were associated with increased risk of immediate death: (1) hemorrhagic infarction demonstrated by brain CT (p = 0.031); (2) patients who presented with a generalized neurological disorder, namely alteration of consciousness, with or without seizures (p = 0.036). No other clinical or laboratory variables were predictive of imminent death, motor or cognitive handicaps. These may therefore serve as outcome predictors of stroke in the pediatric age group.

Cerebellar infarction. Clinical and neuroimaging analysis in 293 patients. The Tohoku Cerebellar Infarction Study Group

BACKGROUND AND PURPOSE

We performed this multicenter study to explore the full spectrum of the clinical characteristics and neuroimaging findings of cerebellar infarction, including patients with mild to severe illnesses.

METHODS

We studied 293 consecutive patients with cerebellar infarction diagnosed by computed tomography and/or magnetic resonance imaging who were admitted to 36 hospitals during 5 years.

RESULTS

Cerebellar infarcts constituted 2.3% of the total patients with acute brain infarction. The backgrounds and risk factors were similar to those in patients with infarctions of the cerebral hemispheres. At least 24% were embolic, and the diagnosis of embolism could not be ruled out in 27%. Infarcts involving the superior cerebellar artery (SCA) region (52%) and the posterior inferior cerebellar artery (PICA) region (49%) were far more frequent than those involving the anterior inferior cerebellar artery (AICA) region (20%). Patients with SCA infarcts exhibited obtunded consciousness and ataxia more frequently than those with PICA infarcts (P < .05). Infarcts in the PICA regions were associated with abnormalities of the PICA (64%) or the vertebral arteries (57%), whereas infarcts in the SCA and AICA regions were associated with abnormalities in the SCA or AICA, respectively, in approximately 30% of patients, in the basilar artery in approximately 16%, and in the vertebral artery in more than 60% of patients. Outcomes were poorer with SCA infarcts than with AICA and PICA infarcts.

CONCLUSIONS

These data indicate similar frequencies of SCA and PICA infarcts and illustrate the difference in clinical presentation and outcomes between SCA and PICA infarcts. They also indicate that not only in situ thrombosis but also cardiogenic or artery-to-artery embolism and the insufficiency of collateral circulation play important roles in the pathogenesis of cerebellar infarction.

Paraneoplastic syndromes: a challenge for neuroscience nursing

Neurologic paraneoplastic syndromes are medical and nursing challenges. Although neurologic paraneoplastic syndromes are relatively rare in the total cancer population, they may be more commonly seen in the acute neurologic setting. O'Neill et al estimate that 60% of persons with Eaton-Lambert syndrome and 50% of persons with subacute cerebellar degeneration have an underlying cancer. The slow and subtle development of neurologic paraneoplastic disorders underscores the need for careful evaluation of persons with neurologic deficits. Once the diagnosis is made, nursing care must be based on the problems associated with paraneoplastic manifestations of the disease, as well as effects of the cancer and its treatment.

Paraneoplastic Syndromes in Patients with Ovarian Neoplasia

The prevalence of several paraneoplastic syndromes associated with ovarian cancer was determined from a clinicopathological study of 908 patients with primary ovarian malignancy in the North East Thames Region. The diversity and rarity of these manifestations are great and the explanation for them is difficult. Circumstantial evidence suggests that in some cases an autoimmune phenomenon is the most plausible cause.

Some unusual diseases in the birds of Victoria, Australia

The following unusual diseases were diagnosed in birds submitted to the Veterinary Research Institute, Victoria, between 1978 and 1987: the viral diseases beak and feather disease of psittacines, infectious laryngotracheitis in peafowls, a papovavirus-like inclusion body disease in psittacines, and pox; chlamydiosis; the bacterial diseases actinomycosis, listeriosis and mycobacteriosis; the fungal diseases favus, yeast infections and systemic zygomycosis; the protozoan diseases cryptosporidiosis, hexamitiasis, suspected leucocytozoonosis, sarcosporidiosis, toxoplasmosis, trichomoniasis and an unidentified protozoan-like organism which caused pneumonia in ducks; a variety of parasites; the metabolic disorders curled-toe paralysis in pheasant poults, encephalomalacia and parenchymatous goitre; toxicity due to dimetridazole and the ingestion of the leaves of the tobacco tree; and other non-infectious conditions including asphyxiation, burns, cataracts, cerebellar degeneration and atrophy, cystic right oviducts and exertional rhabdomyolysis.

[An ambulatory regional center for extrapyramidal and cerebellar disorders. 10 years' experience in Campania]

This study concerns an analysis of outpatients seen at a Regional Clinic for Extrapyramidal and Cerebellar Disorders during the period 1974-1984. The main findings to emerge from this study are: 1) a predominance of males; 2) peak attendance figures correlated with precise factors; 3) the geographic origin of patients reflected the distance from the Regional Clinic and the relationship between local physicians and physicians at the Regional Clinic. Lastly, this epidemiological study has led to improvements in specific protocols for the management of the long-term outpatient, and to an increase in the number of patients attending the Center.

Cerebellar abiotrophy in crossbred cattle

Cerebellar abiotrophy affected 9 of 74 calves sired by a Poll Hereford bull over 2 successive calving seasons. The disease was characterised by episodes of recumbency and ataxia, with hypermetria and wide base stance. Clinical signs commenced between birth and 8 months of age. Two calves which were affected first at 8 months of age recovered clinically 9 months later. Histological lesions were found in the cerebellar cortex of 7 calves and consisted of segmental degeneration and loss of Purkinje cells, and axonal swellings. The clinical signs and pathological findings were consistent with bovine familial convulsions and ataxia, which has not been described previously in Australia. The clinical signs were not attributable to the lesions observed in the cerebellum and an underlying electrophysiological abnormality is proposed. The aetiology of the condition is probably genetic and appears to have a multifactorial basis.

[Causes and incidence of abscesses of the brain and cerebellum in adults]

The frequency of cerebral and cerebellar abscesses was analysed in relation to all intracranial tumours in the material of the Department of Neurosurgery, Medical Academy in Warsaw, and the causes of these abscesses in a group of 62 cases treated in the last ten years. The subject of interest was the variability of these parameters in the era of widely used antibiotic treatment. It was observed that in the last years the frequency of brain abscesses has decreased. They account presently for 2.2% of all intracranial tumours. The first place among the causes of abscesses is taken by otogenic infections with nasal sinusitis, although the percent of these causes is decreasing. Presently, the number of abscesses of unknown origin has been increasing, probably due to the widespread use of antibiotics which eradicate the primary infection focus early after its appearance.

[Genetic study of spinocerebellar hereditary degenerations in Tunisia. Role of consanguinity in their occurrence]

The genetic analysis of 101 genealogical trees of families with spinocerebellar heredo-degeneration enabled the authors to specify the transmission inheritance for each clinical type. Autosomic recessive transmission has been observed for Friedreich's ataxia (68 out of 69 families), Pierre-Marie's heredo-ataxia (15 families) and familial spastic paraplegia (2 families). A dominant mode of transmission has been observed in 13 families affected by familial spastic paraplegia (Strumpell-Lorrain) and in only one family with Friedreich's ataxia (an intermediate or incomplete form). It has also been observed that the consanguinity rate among this group of families is very high compared with that of the general tunisian population (25%). Marriage between cousins occurs in 75% of the cases of Friedreich's ataxia, in 78% of the cases of Pierre-Marie's heredo-ataxia and in only 61% of familial spastic paraplegia of Strumpell-Lorrain. The authors have come to the conclusion that the recessive autosomic transmission of the spino-cerebellar heredo-degenerative diseases are closely related to a high consanguinity rate.