| We report functional neuroimaging studies of a 54-year-old man with marchiafava-bignami disease (MBD). glucose metabolic images obtained by [18F]-2-fluoro-2-deoxy-D-glucose positron emission tomography showed diffusely reduced whole brain metabolism and strongly decreased metabolism in the frontal and parietal lobes, orbital gyrus, and thalamus. Cerebral perfusion images showed a similarly decreased radioactivity pattern as the metabolic images. Functional neuroimages would be useful for understanding the pathophysiologic processes of MBD. ( info) |
2/10. Improvement of central pontine myelinolysis as demonstrated by repeated magnetic resonance imaging in a patient without evidence of hyponatremia. Central pontine myelinolysis is usually associated with hyponatremia or rapid correction of this condition. In general, this neurological disorder has a fatal prognosis. We observed a 30-year-old woman with a history of chronic alcohol abuse but without evidence of hyponatremia, who developed severe pontine central myelinolysis. The initial magnetic resonance (MR)-imaging showed a marked lesion in the central pontine area, sequential MR-imaging revealed progressive reduction of this defect over the following months. This reduction was accompanied by excellent clinical recovery. This case report demonstrates that central pontine myelinolysis is not always associated with hyponatremia and illustrates that, although in general the prognosis is bad, some patients may recover with improvement of the abnormalities on the MR-images. ( info) |
| OBJECTIVE: We postulated that disruption of callosal pathways as occurs in marchiafava-bignami disease (MBD) is associated with marked impairment in brain functioning as measured by cognitive assessment and neuroimaging. BACKGROUND: MBD is considered to be a rare and severe complication of chronic alcoholism. It is characterized by necrosis and subsequent atrophy of the corpus callosum, which is the major brain structure connecting corresponding areas of both hemispheres. methods: We review the existing literature on MBD with respect to conceptualization, theories of pathogenesis, forms of the disease, and neuroimaging and neuropsychological findings. We then present the case of a middle-aged man with MBD who underwent extensive clinical, neuropsychological, and neuroimaging studies. RESULTS: Neuropsychological evaluation revealed a pattern of severe global dementia. magnetic resonance imaging showed moderate atrophy of anterior callosal regions and severe atrophy of posterior callosal regions in the setting of cortical and subcortical atrophy. Resting metabolism positron emission tomography revealed decreased glucose metabolism most pronounced in subcortical and mesial frontal regions. The differential diagnosis, function of the corpus callosum, and potential limitations of our case study are discussed. CONCLUSIONS: On account of the history, clinical presentation, and results of magnetic resonance imaging of the brain, we diagnosed our patient with chronic MBD. ( info) |
4/10. Pitfall: a pseudo tumor within the left liver lobe presenting with abdominal pain, jaundice and severe weight loss. A 51 year old male patient with a history of chronic alcohol consumption and recurrent pancreatitis was referred to our hospital with jaundice, epigastric pain, severe diarrhoea and weight loss of 28 kg within the last 12 months. A CT scan of the abdomen 4 months before admission had shown a pancreatitis with free fluid around the corpus and tail of the pancreas as well as dilated intrahepatic bile ducts and a cavernous transformation of the portal vein. Moreover, a tumor (3.5 x 3.0 x 3.6 cm) with irregular contrast enhancement was seen within the left liver lobe. The patient was referred to us for further evaluation and treatment. The initial B-Mode sonogram revealed a bull's eye like well defined lesion (8.1 x 7.5 x 7.0 cm) within the left liver lobe, consistent with a tumour or abscess. Prior to a diagnostic needle biopsy a PTCD was performed in this case presenting with dilated intrahepatic bile ducts and having a history of Billroth II operation. An additional colour coded Duplex Doppler ultrasonography demonstrated a visceral artery aneurysm and prevented us from performing the diagnostic puncture. The aneurysm was assumed to originate from a variant or a branch of the left hepatic artery. angiography revealed a pseudoaneurysm of the pancreaticoduodenal artery and coil embolization was performed because of the increasing size and the risk of a bleeding complication. Postinterventional colour duplex ultrasound measurement showed no blood flow within the aneurysm. Retrospectively, the pseudoaneurysm must have led to a compression of the common bile duct, since the patient did not develop cholestasis after embolization and removal of the PTCD. Thus, a pseudoaneurysm of the pancreaticoduodenal artery must be included in the differential diagnosis of liver tumours in patients with chronic pancreatitis, despite its unusual localization near the liver. Therefore, we suggest that colour coded ultrasonography should be applied to any unclear, bull's eye like lesion, even though this method alone cannot exactly determine the origin of the pseudoaneurysm. Interventional angiography remains the gold standard for the diagnosis and therapy of visceral artery aneurysm. ( info) |
5/10. Central and extrapontine myelinolysis in a patient in spite of a careful correction of hyponatremia. We report the case of a 54-year-old alcoholic female patient who was hospitalized for neurologic alterations along with a severe hyponatremia (plasma Na : 97 mEq/l). She suffered from potomania and was given, a few days before admission, a thiazide diuretic for hypertension. A careful correction of plasma Na levels was initiated over a 48-hour period (rate of correction < 10 mEq/l/24h) in order to avoid brain demyelination. After a 2-day period of clinical improvement, her neurologic condition started to deteriorate. By the 5th day of admission, she became tetraplegic, presented pseudobulbar palsy, ataxia, strabism, extrapyramidal stiffness and clouding of consciousness. Scintigraphic and MRI investigations demonstrated pontine and extrapontine lesions associated with Gayet-wernicke encephalopathy. After correction of ionic disorders (hyponatremia, hypokaliemia) and vitamin B (thiamine) deficiency, the patient almost completely recovered without notable disabilities. This case illustrates that profound hyponatremia, in a paradigm of slow onset, can be compatible with life. It also demonstrates that demyelinating lesions, usually considered as a consequence of a too fast correction of hyponatremia, may occur despite the strict observance of recent guidelines. There is increasing evidence to suggest that pontine swelling and dysfunction may sometimes occur in alcoholic patients even in absence of disturbance in plasma Na levels. It is therefore of importance, while managing a hyponatremic alcoholic patient, to identify additional risk factors (hypokaliemia, hypophosphoremia, seizure-induced hypoxemia, malnutrition with vitamin b deficiency) for brain demyelination and to correct them appropriately. ( info) |
6/10. marchiafava-bignami disease: longitudinal MR imaging and MR spectroscopy study. A case of marchiafava-bignami disease was serially evaluated with MR imaging and MR spectroscopy at 1, 2, 4, and 11 months after the onset of symptoms. The first MR imaging study showed extensive abnormal signal intensity of the corpus callosum without macroscopic changes; a diagnosis of marchiafava-bignami disease was made, and vitamin therapy was initiated. follow-up studies showed progressive reduction of signal intensity abnormalities and residual callosal atrophy. MR spectroscopy revealed progressive reduction of the N-acetylaspartate:creatine ratio, with partial recovery in the last study, and a normalization of the choline:creatine ratio, which was initially slightly increased. Lactate was detectable during the subacute phase and was replaced by lipids after 4 months. This study confirmed the role of MR imaging in diagnosing marchiafava-bignami disease and particularly the value of MR spectroscopy in focusing the pathogenesis of the disease, monitoring its evolution and changes related to therapy. ( info) |
7/10. Donepezil for alcohol-related dementia: a case report. A 75-year old man with a 40-year history of alcoholism was admitted to the hospital for intoxication and inability to care for himself. He had been admitted frequently in the past for detoxification and rehabilitation. The patient had no family history of Alzheimer's disease, no history of head injury, and single-photon emission computed tomography showed no typical findings of Alzheimer's disease. His cognitive function was impaired. He was treated with donepezil for alcohol-related dementia, and 3 months later, his cognitive function had improved. More research is needed to confirm donepezil's role in treating alcohol-related dementia. ( info) |
8/10. Fatal portal thrombosis after laparoscopic Nissen fundoplication. Portal and mesenteric vein thrombosis is a very uncommon complication of laparoscopic surgery, especially after anti-reflux procedures. We report the case of a twenty-year-old man with a history of alcohol and cocaine consumption. A Nissen fundoplication was performed. The patient received a single 20-mg dose of enoxaparin (Clexane, Aventis Pharma, spain) two hours before surgery for antithrombotic prophylaxis. On the seventh postoperative day the patient had a portal and mesenteric venous thrombosis, which was confirmed at laparotomy, with both extensive small-intestine necrosis and partial colon necrosis. Despite anticoagulant therapy, the patient died 24 hours later. Surgical findings were confirmed at necropsy. Portal and mesenteric venous thrombosis is an uncommon but severe and even fatal complication after laparoscopic anti-reflux surgery. When other pro-thrombotic, predisposing conditions such as laparoscopic surgery and cocaine consumption are present, the usual prophylactic doses of low molecular weight heparin might not be sufficient to protect against this life-threatening complication. ( info) |
9/10. Hyper-anxiety in early sobriety: psychopharmacological treatment strategies. The importance of recognizing and treating anxiety disorders that co-occur with alcohol use disorders should not be underestimated, whether the anxiety is state (a transient condition) or trait (a chronic disorder). This article will discuss hyper-anxiety, a term the authors use to describe the uncomfortable, excessively anxious state that contributes to relapse. In addition, psychopharmacological strategies for relief of hyper-anxiety are suggested, and implications for recovery are discussed. ( info) |
10/10. adolescent substance abuse and psychiatric comorbidities. Substance use disorders have a serious impact on adolescents because these disorders have high prevalence rates and frequent associations with psychiatric disorders. Surveys of adolescent behaviors and substance use show that alcohol is the most common substance abused by adolescents. Despite the high rates of current alcohol use and binge drinking among adolescents, current diagnostic criteria are problematic. Adolescents may have a developing problem with substance dependence but not meet criteria for either substance abuse or dependence. At-risk adolescents, called "diagnostic orphans," may meet only 1 or 2 criteria for alcohol dependence and no abuse criteria and therefore do not receive an alcohol use disorder diagnosis from the diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision. Adolescents with substance use disorders tend to have higher rates of comorbid psychiatric disorders and are more likely to report a history of trauma and physical and/or sexual abuse than adolescents without a substance use disorder. In addition, psychiatric disorders in adolescents often predate the substance use disorder. Once the substance use disorder develops, the psychiatric disorder may be further exacerbated. ( info) |