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1/194. paraplegia after thoracotomy--not caused by the epidural catheter.

    BACKGROUND: paraplegia and peripheral nerve injuries may arise after general anaesthesia from many causes but are easily ascribed to central block if the latter has been used. CASE REPORT: A 56-yr-old woman, with Bechterev disease but otherwise healthy, was operated with left-sided thoracotomy to remove a tumour in the left lower lobe. She had an epidural catheter inserted in the mid-thoracic area before general anaesthesia was started. bupivacaine 0.5% 5 ml was injected once and the infusion of bupivacaine 0.1% with 2 micrograms/ml fentanyl and 2 micrograms/ml adrenaline (5 ml/h) started at the end of surgery. The patient woke up with total paralysis in the lower limb and sensory analgesia at the level of T8, which remained unchanged at several observations. laminectomy, performed 17 h after the primary operation, showed a large piece of a haemostatic sponge (Surgicel) compressing the spinal cord, which was then decompressed but the motor and sensory deficit remained virtually unchanged both then and a year later. CONCLUSIONS: This case shows--once again--that although central blocks may cause serious neurological complications and paraplegia, other causes are possible and have to be considered. However, all patients with an epidural catheter must be monitored for early signs and symptoms of an intraspinal process and the appropriate treatment has to be instituted instantly.
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2/194. Transient pseudo-hypoaldosteronism following resection of the ileum: normal level of lymphocytic aldosterone receptors outside the acute phase.

    Pseudo-hypoaldosteronism (PHA) is due to mineralocorticoid resistance and manifests as hyponatremia and hyperkalemia with increased plasma aldosterone levels. It may be familial or secondary to abnormal renal sodium handling. We report the case of a 54-year-old woman with multifocal cancer of the colon, who developed PHA after subtotal colectomy, ileal resection and jejunostomy. She was treated with 6 g of salt daily to prevent dehydration, which she stopped herself because of reduced fecal losses. One month later she was admitted with signs of acute adrenal failure, i.e. fatigue, severe nausea, blood pressure of 80/60 mmHg, extracellular dehydration, hyponatremia (118 mmol/l); hyperkalemia (7.6 mmol/l), increased blood urea nitrogen (BUN) (200 mg/dl) and creatininemia (2.5 mg/dl), and decreased plasma bicarbonates level (HCO3-: 16 mmol/l; N: 27-30). However, the plasma cortisol was high (66 microg/100 ml at 10:00 h; N: 8-15) and the ACTH was normal (13 pg/ml, N: 10-60); there was a marked increase in plasma renin activity (>37 ng/ml/h; N supine <3), active renin (869 pg/ml; N supine: 1.120), aldosterone (>2000 pg/ml; N supine <150) and plasma AVP (20 pmol/l; N: 0.5-2.5). The plasma ANH level was 38 pmol/l (N supine: 5-25). A urinary steroidogram resulted in highly elevated tetrahydrocortisol (THF: 13.3 mg/24h; N: 1.4 /-0.8) with no increase in tetrahydrocortisone (THE: 3.16 mg/24h; N: 2.7 /-2.0) excretion, and with low THE/THF (0.24; N: 1.87 /-0.36) and alpha THF/THF (0.35; N: 0.92 /-0.42) ratios. The number of mineralocorticoid receptors in mononuclear leukocytes was in the lower normal range for age, while the number of glucocorticoid receptors was reduced. Small-bowel resection in ileostomized patients causes excessive fecal sodium losses and results in chronic sodium depletion with contraction of the plasma volume and severe secondary hyperaldosteronism. Nevertheless, this hyperaldosteronism may be associated with hyponatremia and hyperkalemia suggesting PHA related to the major importance of the colon for the absorption of sodium. In conclusion, this case report emphasizes 1) the possibility of a syndrome of acquired PHA with severe hyperkalemia after resection of the ileum and colon responding to oral salt supplementation; 2) the major increase in AVP and the small increase in ANH; 3) the strong increase in urinary THF with low THE/THF and alpha THF/THF ratios; 4) the normal number of lymphocytic mineralocorticoid receptors outside the acute episode.
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3/194. Home inotrope treatment for intractable heart failure following heart transplantation.

    A 49 year old man developed intractable heart failure three years after undergoing heart transplantation. coronary angiography showed no evidence of graft vascular disease. An initial cardiac biopsy identified one episode of rejection which responded to augmented immunosuppressive treatment. The patient became inotrope dependent and has now survived at home for 22 months using an ambulatory delivery system for intravenous adrenaline (epinephrine), without significant complications. There has been a noticeable improvement in symptoms and left ventricular systolic performance, both clinically and as seen through echocardiographic and radiographic examination. This improvement was substantiated by the results of cardiac catheterisation, which showed a return to normal left ventricular filling pressure and cardiac output. The case is noteworthy because this treatment has allowed a patient who otherwise would have been hospital bound to return to the community. With the current shortage of organs, he would have been unlikely to receive a second transplant. The clinical features and outcome, and social, medicolegal, and financial issues are discussed.
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4/194. Multicentric warfarin-induced skin necrosis complicating heparin-induced thrombocytopenia.

    Two patients developed catastrophic multicentric skin necrosis while receiving warfarin to treat venous thromboembolism complicated by immune-mediated heparin-induced thrombocytopenia (HIT). Patient 1 developed skin necrosis involving the breasts, thighs, and face, as well as venous limb gangrene and bilateral hemorrhagic necrosis of the adrenal glands, resulting in death. The second patient developed bilateral mammary necrosis necessitating mastectomies, as well as skin necrosis involving the thigh. Neither patient had an identifiable hypercoagulable syndrome, other than HIT. HIT may represent a risk factor for the development of multicentric warfarin-induced skin necrosis (WISN).
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5/194. Smooth pursuit and saccadic eye movement performance in a prefrontal leukotomy patient.

    The authors wished to examine the role of the prefrontal cortex in oculomotor performance. They assessed smooth pursuit and saccadic performance in a patient with schizophrenia who had undergone a bilateral prefrontal leukotomy. Her performance on neuropsychological test measures sensitive to frontal lobe functioning were also examined. Against a background of intact intellectual and neurological functioning, the patient displayed a dissociation in premotor and prefrontal functioning. Smooth pursuit performance was within normal limits, as were the patient's finger tapping scores. In contrast, the patient performed poorly on the wisconsin Card Sorting Test, and verbal and design fluency tasks. Similarly, her performance on the antisaccade task was markedly deviant. Despite advanced age and a frontal leukotomy, this patient with schizophrenia displayed intact smooth pursuit, indicating that the frontal cortex is not necessary for normal smooth pursuit performance.
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ranking = 1.7702209118226
keywords = cortex
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6/194. An unusual case of aspergillus endocarditis in a kidney transplant recipient.

    The incidence of aspergillosis in kidney transplant recipients is low and most commonly occurs in the early posttransplantation period. We report an unusual case of a 52-year-old female patient with aspergillus endocarditis as a late complication after kidney transplantation, presumably spread from a necrosis in the gut, associated with previous cytomegalovirus colitis. As complications, the patient experienced septic embolization into the coronary and pulmonary arteries, and an infarction of the right parietal cortex and insula. The patient died as a result of global heart failure after a 10-day course of antimycotic therapy with amphotericin b plus 5-flucytosine during surgical valve replacement.
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ranking = 0.88511045591131
keywords = cortex
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7/194. adrenal insufficiency masquerading as sepsis in a patient with tetraparesis: a case report.

    Several endocrine changes have been reported in patients with tetraplegia after spinal cord injury (SCI). These changes should be considered when prescribing medications that influence the endocrine pathways. megestrol acetate has gained acceptance as a way to promote weight gain in cachectic patients without significant adverse effects. We present a case of a 51-year-old man with C5-C6 tetraparesis who was only 67% of his ideal body weight and was placed on megestrol acetate 5 months before admission for a urologic procedure. Postoperatively, the patient had severe hypotension and tachycardia that was interpreted as a septic or cardiac event. Further workup revealed subnormal levels of 8AM cortisol. An adrenocorticotrophic hormone stimulation test demonstrated results consistent with adrenal suppression. Hydrocortisone supplementation was started, and 6 months later cortisol levels were within normal limits. cachexia, hypotension, and mild tachycardia are not uncommon in patients with SCI. When severe hypotension and tachycardia are seen in patients with tetraplegia, the diagnosis of adrenal insufficiency should be considered.
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keywords = adrenal
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8/194. Inhibitory simple partial (non-convulsive) status epilepticus after intracranial surgery.

    OBJECTIVES: To report on five patients who developed, 2 to 4 days after an intracranial neurosurgical procedure, new, persistent, focal neurological deficits which were due to inhibitory simple partial (non-convulsive) status epilepticus, and resolved with anticonvulsant treatment. methods: The age range of the five patients was 15-74 years. The operations were: aneurysm clipping (three patients) and resections of an oligodendroglioma and a cavernous haemangioma (one patient each). The new focal deficits were: right hemiparesis and aphasia (two patients), aphasia alone (two patients), and left hemiparesis (one patient). The deficits were not explained by CT (obtained in all patients) or cerebral angiography (performed in two). RESULTS: electroencephalography showed, in all patients, continuous or intermittent focal seizures arising from cortex regionally relevant to the clinical dysfunction. Subtle positive epileptic phenomena (jerking) occurred intermittently in three patients as a late concommitant. Administration of anticonvulsant drugs resulted in significant improvement within 24 hours in four patients, with parallel resolution of ictal EEG activity. The fifth patient improved more slowly. Two patients relapsed when anticonvulsant concentrations fell, and improved again when they were raised. CONCLUSIONS: It is suggested that inhibitory simple partial (non-convulsive) status epilepticus be considered in the differential diagnosis when a new unexplained neurological deficit develops after an intracranial neurosurgical procedure. An EEG may help to diagnose this condition, leading to definitive treatment.
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ranking = 0.88511045591131
keywords = cortex
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9/194. Post operative supplementary motor area syndrome: clinical features and outcome.

    The syndrome of the supplementary motor area (SMA) is not well recognized and its features can easily be confused with pyramidal weakness. The authors describe the SMA syndrome in six patients who underwent surgery for tumours located in the SMA, three in the dominant and three in the non-dominant hemispheres. All of them underwent complete resection of the anatomically described SMA, with partial (n = 4) or total resection (n = 2) of the tumour. In the postoperative period, all these patients exhibited reduction of spontaneous movements and difficulty in performing voluntary motor acts to command in the contralateral limbs, although the tone in the limbs was maintained or increased. The function of these limbs in serial automatic motor activities (for example, dressing and walking) was, however, relatively unaffected. speech deficits were seen in only one of three patients with the dominant SMA syndrome. Besides a severe impairment of volitional movements, the salient features of the deficits in this syndrome are hemineglect and dyspraxia or apraxia involving the contralateral limbs. All patients recovered their motor functions over varying periods of time ranging from one to a few weeks. Long-term follow-up (median 24 months) in five patients revealed complete return of function in the affected limbs. It is important to recognize the entity of the SMA syndrome and differentiate it from the deficits that result from operative damage to the motor cortex as the deficits associated with the former are likely to recover almost completely over a short period of time.
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ranking = 0.88511045591131
keywords = cortex
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10/194. Surgical management of intractable epilepsy associated with cerebral neurocytoma.

    Neuronal neoplasms of the CNS constitute a rarely encountered group of tumors. This report concerns the surgical management of seizures encountered in four cases (ranging from 2 to 10 years-of-age at onset; consisting of two males and two females) of a recently recognized morphologically unique tumor, called 'cerebral neurocytoma'. All patients were associated solely with intractable complex partial seizures. The tumor involved the temporal lobe in two cases, and the frontal in two. magnetoencephalography (MEG) clearly demonstrated an accumulation of equivalent current dipoles originating from the interictal spikes on the cortex around the tumor. On intra-operative electrocorticography (ECoG), the epileptogenic zone was topographically distinct from the region of the tumor. No definite ECoG activities were observed at the tumor site, although this tumor did consist of small mature neuronal cells. Either a complete or a subtotal resection of the tumor and the epileptogenic cortex was performed and, post-operatively, universal freedom from seizures was demonstrated in all patients. A histological examination of the epileptogenic cortex revealed the presence of minute cortical dysplasia or tumor involvement in the hippocampus. A resection of the epileptogenic cortex along with the tumor was thus found to improve the seizure outcome in patients with neurocytoma-associated epilepsy without inducing any identifiable neurological deficits attributable to the incremental resection.
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ranking = 3.5404418236452
keywords = cortex
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