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1/860. Transient paralytic attacks of obscure nature: the question of non-convulsive seizure paralysis.

    Eleven patients with transient paralytic attacks of obscure nature are described. paralysis could involve face or leg alone, face and hand, or face, arm and leg. The duration varied from two minutes to one day. Four patients had brain tumors, six probably had brain infarcts, and one a degenerative process. The differential diagnosis included TIAs, migraine accompaniments, and seizures. In the absence of good evidence for the first two, the cases are discussed from the standpoint of possibly representing nonconvulsive seizure paralysis (ictal paralysis, inhibitory seizure paralysis or somatic inhibitory seizure). Because of the difficulty in defining seizures as well as TIAs and migraine in their atypical variations, a firm conclusion concerning the mechanisms of the spells was not attained. Two cases of the hypertensive amaurosis-seizure syndrome have been added as further examples of ictal deficits. ( info)

2/860. Intra-arterial infusion of fasudil hydrochloride for treating vasospasm following subarachnoid haemorrhage.

    In this pilot study we treated cerebral vasospasm in patients with subarachnoid haemorrhage to assess intra-arterial fasudil hydrochloride. We analysed effects of intra-arterial infusion on angiographically evident cerebral vasospasm in 10 patients including 3 with symptoms of vasospasm. Over 10 to 30 min 15 to 60 mg was administered via the proximal internal carotid artery or vertebral artery following standard angiography, without superselective techniques. A total of 24 arterial territories (21 internal carotid, 3 vertebral) were treated. Angiographic improvement of vasospasm was demonstrated in 16 arterial territories (local dilation in 2, diffuse dilation in 14) in 9 patients. In 2 symptomatic patients, intra-arterial fasudil hydrochloride was associated with resolution of symptoms without sequelae. In the third symptomatic patient the benefit of fasudil hydrochloride was only temporary, and a large cerebral infarction occurred. All asymptomatic patients showed no progression of angiographic to symptomatic vasospasm after treatment with intra-arterial fasudil hydrochloride. No adverse effect was encountered. ( info)

3/860. Clinical evaluation of the effect of percutaneous transluminal angioplasty and intra-arterial papaverine infusion for the treatment of vasospasm following aneurysmal subarachnoid hemorrhage.

    The clinical efficacy of percutaneous transluminal angioplasty and intra-arterial papaverine infusion for treatment of vasospasm following subarachnoid hemorrhage was investigated. Between 1990 and 1993, 84 patients were treated for cerebral vasospasm in National Defense Medical College Hospital. angioplasty was performed for asymptomatic vasospasm in 18 patients and for symptomatic vasospasm in 12 patients. Intra-arterial papaverine infusion was performed for asymptomatic vasospasm in 10 patients and for symptomatic vasospasm in four patients. The other 40 patients were treated with standard conservative therapy including hypervolemic and hypertensive hemodilution. The outcomes of these patients were analyzed using the glasgow outcome scale. The outcome tended to be better for patients treated with angioplasty, but not for those treated with papaverine infusion, than for those treated conservatively. recurrence of vasospasm was more frequent after papaverine infusion than after angioplasty. Undesirable complications such as abrupt development of unconsciousness were experienced during papaverine infusion but not during angioplasty. We conclude that percutaneous transluminal angioplasty is superior to intra-arterial papaverine infusion for prevention and treatment of vasospasm following aneurysmal subarachnoid hemorrhage. ( info)

4/860. Resolution of early diffusion-weighted and FLAIR MRI abnormalities in a patient with TIA.

    We report a patient with a clinical history and neurologic examination consistent with acute stroke. diffusion-weighted and fast fluid-attenuated inversion recovery MRI obtained 4 hours after stroke onset detected focal abnormalities suggestive of acute ischemic brain damage. The neurologic deficit and the imaging abnormalities both resolved completely at follow-up. This patient illustrates complete resolution of early changes observed with diffusion-weighted MRI at the hyperacute phase in a TIA. ( info)

5/860. mastication steal: an unusual precipitant of cerebrovascular insufficiency.

    An 83-year-old man had episodic dizziness, visual disturbance, and facial and extremity weakness associated with eating. Occlusion of the ipsilateral common carotid artery and stenosis or occlusion of the major collateral sources were demonstrated. We believe this anatomic configuration, combined with increases in demand for external carotid artery blood flow necessitated by the act of chewing, resulted in a vascular steal syndrome. An extended carotid endarterectomy was performed, and there were no additional episodes. ( info)

6/860. Bedside-microdialysis for early detection of vasospasm after subarachnoid hemorrhage. Case report and review of the literature.

    Continuous monitoring of cerebral metabolism would be desirable for early detection of vasospasm in SAH patients. Bedside-microdialysis, a new technique for on-line monitoring of cerebral metabolism, may reflect changes seen in cerebral vasospasm diagnosed by transcranial Doppler sonography (TCD). This report represents the first case of combined TCD monitoring and on-line microdialysis from the brain extracellular fluid in a SAH patient. A 48-year-old woman suffered subarachnoid hemorrhage grade IV according to Hunt and Hess. angiography revealed an aneurysm of the left carotid artery. The aneurysm was clipped 45 hours after bleeding. The microdialysis catheter was inserted after aneurysm clipping into the white matter of the left temporal lobe. Sampling of microdialysates started immediately, analyzing time for glucose, lactate, pyruvate and glutamate was four minutes. Postoperatively, the patient was doing well and microdialysis and TCD parameters remained within normal range. On the third postoperative day a shift to anaerob metabolism (decrease of glucose, increase of lactate and the lactate-pyruvate ratio up to pathological levels) and an increase in glutamate was observed suggesting insufficient cerebral perfusion. The patient progressively deteriorated clinically. Vasospasm was diagnosed by TCD monitoring 36 hours after onset of ischemic changes monitored by microdialysis. After elevation of mean arterial blood pressure, TCD values and metabolic parameters normalized. Interestingly, the pathological changes in on-line microdialysis preceded the typical increase in blood flow velocity by TCD and the clinical deterioration. Our case suggests, that bedside-microdialysis may be useful for early detection of vasospasm and continuous surveillance of treatment and may be a new guide to treat ischemic neurological deficits following SAH. ( info)

7/860. Morphological changes after percutaneous transluminal angioplasty.

    BACKGROUND: Percutaneous transluminal angioplasty (PTA) dilates constricted arteries at the circle of willis to reverse cerebral ischemia caused by cerebral vasospasm. Although 90% of the patients show angiographic improvement after PTA, only 70% show clinical improvement. Why some patients do not improve after PTA is unknown. We report on a 48-year-old woman who failed to improve after PTA and died from aneurysm rerupture. Pathologic studies were performed to determine why PTA failed to reverse the symptoms of cerebral ischemia. methods: The arteries of the brain were studied by light microscopy using Gomori's trichrome stain. The arteries were also studied by scanning and transmission electron microscopy. RESULTS: The arteries that were dilated with PTA showed compression of the connective tissue, stretching of the internal elastic lamina, and a combination of compression and stretching of the smooth muscle. The small arteries and arterioles that had been treated with an infusion of intraarterial papaverine were constricted with a thickened intimal layer. CONCLUSION: The persistence of cerebral vasospasm in small and perforating arteries may contribute to the failure of cerebral ischemia to reverse after PTA. ( info)

8/860. bupropion mimics a transient ischemic attack.

    OBJECTIVE: To report the development of symptoms suggesting transient ischemic attacks during bupropion treatment for smoking cessation. CASE SUMMARY: A 67-year-old white man experienced paresthesia, dizziness, tinnitus, confusion, and gait impairment shortly after starting bupropion as an aid to smoking cessation. bupropion was discontinued on hospital admission, and testing for vertebral basilar artery disease was negative. His symptoms resolved, and he remained asymptomatic until restarting bupropion two days after hospital discharge. DISCUSSION: Although separate case reports have reported sensory disturbances, tinnitus, and balance impairement associated with bupropion use, the combination of symptoms occurring in this patient has not been previously published. CONCLUSIONS: The temporal relationship between bupropion exposure and symptomatology suggests that bupropion caused symptoms mimicking transient ischemic attacks in this patient. ( info)

9/860. Unidirectional dyslexia in a polyglot.

    Alexia is usually seen after ischaemic insults to the dominant parietal lobe. A patient is described with a particular alexia to reading Hebrew (right to left), whereas no alexia was noted when reading in English. This deficit evolved after a hypertensive right occipitoparietal intracerebral haemorrhage, and resolved gradually over the ensuing year as the haematoma was resorbed. The deficit suggests the existence of a separate, language associated, neuronal network within the right hemisphere important to different language reading modes. ( info)

10/860. memory guided saccade deficit after caudate nucleus lesion.

    The role of the caudate nucleus in ocular motor control is not well determined in humans. eye movements were recorded from a 45 year old man with infarctions involving bilaterally the body of the caudate nucleus, with a greater extent on the left side. The patient exhibited a pattern of eye movement abnormalities in which a delay dependent decrease of accuracy of memory guided saccades predominated. By contrast, memory guided pointing was normal. It is concluded that the body of the caudate nucleus participates in a spatial short term memory network devoted to eye movements. ( info)
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