Cerebral venous thrombosis in young adults: 2 Case reports.

Cerebral venous thrombosis (CVT) is a disease with multiple known etiologies that present with a remarkably wide spectrum of clinical signs and symptoms. We present a case of a 34-year-old man with a history of meningeal symptoms for 1 week after receiving a lumbar injection for lower back pain. He subsequently developed dense right hemiplegia and global aphasia. Head magnetic resonance imaging revealed superior sagittal sinus thrombosis. The patient was started on intravenous heparin but deteriorated neurologically. Urokinase infusion directly into the superior sagittal sinus was performed, with striking functional and neurologic improvement. Lupus anticoagulant was positive. We also present the case of a 24-year-old pregnant woman who developed an acute onset of meningeal symptoms and resultant left hemiparesis. Head magnetic resonance angiography revealed thrombosis of right transverse and sigmoid sinuses. Protein S deficiency was found. She was started on intravenous heparin, then enoxaparin, with improvement in symptoms. These cases demonstrate that CVT can be a cause of stroke in young patients with hypercoagability disorders, and a heightened awareness of CVT will promote optimal medical care and functional outcomes. Excellent functional recovery is likely with early recognition and treatment of the underlying etiology, as well as successful lysis of the clot.

The triad of substance abuse, violence, and depression are interrelated in pregnancy.

A study group of 271 registrants had their medical and social history taken by a nurse-interviewer and were requested to take the Substance Abuse Subtle Screening Inventory. If the nurse interviewer felt that the patient needed social service assessment, referral was made, and a social worker completed the the Social Service Review Questionnaire. The patients who were reported as positive for substance abuse did not respond differently from their negative counterparts for issues of demographics, pregnancy, social support, and career. They were highly likely to have had a history of severe depression and/or have been a victim of physical and/or sexual abuse. On the basis of these data we recommend that the prenatal patient who responds positively in her personal history regarding any of these three experiences should be carefully evaluated for problems related to the other two.

Stroke rehabilitation. 2. Co-morbidities and complications.

This self-directed learning module highlights new advances in the understanding of co-morbid conditions and medical complications of stroke. It is part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers co-morbid conditions of stroke patients, including cardiovascular disease, diabetes, and sleep apnea. It reviews recent information on complications of stroke, including deep venous thrombosis, dysphagia and aspiration, hospital-acquired infections, depression, falls, spasticity, shoulder pain, and seizures. Treatment advances in diabetes, depression, and spasticity are highlighted. Recent information is presented regarding exercise guidelines for the stroke patient with cardiovascular disease, the relationship between stroke and sleep apnea, prophylaxis of deep venous thrombosis, the changing spectrum of hospital-acquired infections, malnutrition in stroke patients, the problem of falls during rehabilitation, the evaluation and management of poststroke shoulder pain, and the risk of seizures after stroke.

Stroke rehabilitation. 3. Rehabilitation management.

This self-directed learning module highlights new advances in the treatment of patients after stroke by means of a case study format. It is part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses both medical and rehabilitation issues that arise in the care of persons with strokes involving the right and left middle cerebral arteries and the vertebral artery. Cases were chosen to cover problems seen in both older and younger persons. Management of common sequelae that are typical of these stroke syndromes and identification of common co-morbidities are included.

Return to work after stroke: development of a predictive model.

Seventy-nine stroke patients who underwent a vocationally oriented, comprehensive, inpatient stroke rehabilitation program were followed up to evaluate their return to work. At follow-up, 49% had returned to work a mean of 3.1 months after rehabilitation discharge. Factors associated with success and with failure of vocational rehabilitation were then identified, and a predictive model was developed. There were positive associations between return to work and Barthel Index on admission (p = 0.0002) and discharge (p = 0.0015). Negative associations were found between return to work and aphasia (p = 0.0009), rehabilitation length of stay (p less than 0.0001), and prior alcohol consumption (p = 0.03). A step-wise multiple regression model explained 42% of the variance in return to work. Those most likely to return to work were not aphasic; they had shorter rehabilitation lengths of stay and higher Barthel Index scores on discharge; and they were lighter consumers of alcoholic beverages before their strokes. In conclusion, a set of factors predictive of return to work in younger stroke patients was identified, including, most notably, a strong negative association with aphasia and an intriguing negative association with prior alcohol consumption.

Diagnosis of intracranial hemorrhage in utero after a maternal seizure.

Reported is a patient who noted decreased fetal movements after a seizure at 32 weeks' gestation. Sonography revealed fetal death and findings consistent with an intraventricular hemorrhage. The possible explanations for and the significance of an association between a maternal seizure and fetal intraventricular hemorrhage are discussed.

Renal manifestations of Kawasaki's disease.

Renal sonographic evaluation of seven patients with mucocutaneous lymph node syndrome were performed and correlated with clinical and laboratory data either supporting or not supporting renal disease associated with this entity. Four of seven patients demonstrated significant elevations of the BUN, creatinine and/or significant proteinuria. These four patients had renal sonographic findings of increased cortical echogenicity, enlarged kidneys and enhanced corticomedullary differentiation. This complication of mucocutaneous lymph node syndrome has heretofore not been noted.

Ultrasonography of scrotal trauma.

Ultrasound has emerged as the diagnostic imaging modality of choice in the evaluation of patients with scrotal trauma. Most studies of testicular rupture show great accuracy with virtually no instances of false-positive or false-negative diagnoses. Ultrasonography is capable of differentiating between scrotal hematoma, extratesticular fluid collections, posttraumatic torsion testis, posttraumatic epididymitis, epididymal hematoma, as well as testicular rupture. The differentiation of hematocele from pyocele or exudative hydrocele is generally not possible. In patients with suspected testicular rupture, an accurate diagnosis followed by prompt surgical repair is the key to preservation of testicular function. Ultrasound is an extremely useful adjunct to the physical examination in cases of blunt scrotal trauma both for the differential diagnosis of the enlarged scrotum and for determining the necessity for emergency surgery.

Renal ultrasound in acquired immune deficiency syndrome.

Ten patients with clinical and laboratory features of acquired immune deficiency syndrome (AIDS) underwent renal ultrasonography prior to biopsy because of proteinuria, azotemia, or uremia. Four patients had a history of intravenous heroin abuse and were considered separately so as to exclude it as a cause of nephropathy. Histological examination revealed focal segmental glomerulosclerosis (FSGS), which in patients with AIDS is characterized by rapid progression to severe uremia (though FSGS can also occur in several other forms of renal disease). The authors recommend that AIDS-associated FSGS be considered as a cause of type I parenchymal disease and suggest that serial sonograms may be useful in monitoring progressive renal involvement.

Nonobstructive hydrocolpos: sonographic appearance and differential diagnosis.

Hydrocolpos in the pediatric patient almost invariably occurs secondary to fluid distending the vaginal canal proximal to an obstructive lesion, usually an imperforate hymen. There are, however, other causes for fluid filling and sometimes markedly distending the vagina; many of these are not pathologic. Sonographically, fluid in the vaginal canal often has a confusing appearance and may be mistaken for a pathologic mass. Ways of differentiating hydrocolpos from other normal and abnormal pelvic fluid collections are described. Five adult patients are presented who showed a varied sonographic spectrum of nonobstructive hydrocolpos.

Sonographic identification of collecting system duplications.

Sonography can replace urography in the search for a duplication anomaly of the collecting system. As a screening procedure, sonography is more cost effective and does not require ionizing radiation or an intravascular injection.

The echoic pseudogestational sac of ectopic pregnancy simulating early intrauterine pregnancy.

The sonographic features of ectopic pregnancy have been well documented. When an early intrauterine pregnancy is identified or an obvious extrauterine sac is visualized, diagnosis is not a problem; but often a sac is seen within the uterus that may contain a well-defined rind and even internal echoes simulating an early fetal pole. This has been mistaken for an early intrauterine pregnancy. In this review, four patients with pseudogestational sacs had internal echoes within the sac, and two of them ultimately underwent dilatation and curettage, which revealed blood clots. This supports the assertion that fetal cardiac activity and/or fetal motion should be demonstrated within a fetal pole before the diagnosis of ectopic pregnancy is excluded.

The ultrasonographic spectrum of fetal omphalocele.

Four cases of fetal omphalocele diagnosed in utero by ultrasonography represent variations in the sonographic appearance of this rare anomaly. A possible pathogenesis of omphalocele is presented, with a discussion of the associated complications and the effect of diagnosing omphalocele prenatally on the management of the pregnancy itself. The association between fetal omphalocele and elevated alpha-fetoprotein is significant, and may prompt a search for a small omphalocele that would otherwise be missed on a routine obstetric sonogram. The differentiation of omphalocele from gastroschisis is difficult, yet the two anomalies can be reliably differentiated sonographically.

Sarcoidosis and mediastinal emphysema.

Mediastinal emphysema developed in a 13-year-old boy with diffuse interstitial pulmonary disease, later proved to be sarcoid. No previous report was found.