Cortex-sparing infarction in triple cervical artery dissection following chiropractic neck manipulation.

BACKGROUND: Multivessel cervical dissection with cortical sparing is exceptional in clinical practice. CASE PRESENTATION: A 55-year-old man presented with acute-onset neck pain with associated sudden onset right-sided hemiparesis and dysphasia after chiropractic manipulation for chronic neck pain. RESULTS AND DISCUSSION: Magnetic resonance imaging revealed bilateral internal carotid artery dissection and left extracranial vertebral artery dissection with bilateral anterior cerebral artery territory infarctions and large cortical-sparing left middle cerebral artery infarction. This suggests the presence of functionally patent and interconnecting leptomeningeal anastomoses between cerebral arteries, which may provide sufficient blood flow to salvage penumbral regions when a supplying artery is occluded. CONCLUSION: Chiropractic cervical manipulation can result in catastrophic vascular lesions preventable if these practices are limited to highly specialized personnel under very specific situations.

Prevalence, demographics and clinical characteristics of multiple sclerosis in Qatar.

No published epidemiologic data on multiple sclerosis (MS) in Qatar exist. Our objectives were to determine the prevalence, demographics and clinical characteristics of MS in the Middle Eastern country of Qatar. We analyzed data for Qatari MS patients fulfilling the McDonald diagnostic criteria. A total of 154 patients fulfilled the inclusion criteria. On 31 April 2010, the crude prevalence of MS in Qatar was 64.57 per 100,000 inhabitants (95% CI: 58.31-70.37). The female-to-male ratio was 1.33:1. A positive family history was found in 10.4% of included MS patients. We conclude that Qatar is now a medium-to-high risk area for MS, with some important differences in clinical characteristics as compared to other countries in the region.

Hypothalamic hamartoma presenting with gelastic seizures, generalized convulsions, and ictal psychosis.

We report a case of hypothalamic hamartoma in an adult female who presented with gelastic seizures, generalized convulsions, and ictal aggressive psychotic behavior. Anticonvulsant treatment was ineffective in controlling the epileptic seizures. Surgical excision after accurate imaging diagnosis 3 decades after the onset of symptoms markedly ameliorated her condition. Delayed and erroneous diagnosis had unnecessarily prolonged the suffering of our patient.

Guillain-Barré syndrome associated with Salmonella paratyphi A.

A 31-year-old Nepali man was admitted to the intensive care unit with a 3-day history of fever associated with four-limb weakness, followed by difficulty in swallowing. The patient came from Nepal 20 days before admission. On examination the patient was conscious and appeared ill, with a temperature of 38.0 degrees C. His four limbs were weak (grades 2-3) and he was areflexic with mild facial weakness and absent gag reflex. Brain CT and MRI were normal. Cerebrospinal fluid analysis showed high protein. A neurophysiologic study showed data consistent with motor axonal polyradiculopathy. The patient was diagnosed with Guillain-Barré syndrome (GBS), and intravenous immunoglobulin (0.4 g/kg day for 5 days) was administered. On the third hospitalization day, the patient developed respiratory failure for which he was intubated and mechanically ventilated. On the same day, blood samples grew Salmonella paratyphi A (S. paratyphi A), which was sensitive to ceftriaxone. The patient was then diagnosed with GBS associated with S. paratyphi A, and treated with ceftriaxon (2 g administered intravenously, daily for 10 days). On the eleventh hospitalization day the patient was weaned from ventilator and extubated successfully. Subsequently, the patient improved, his fever subsided, and he regained muscle power satisfactorily.

Irreversible papillitis and ophthalmoparesis as a presenting manifestation of neurobrucellosis.

A 35-year-old man presented with a meningeal syndrome and acute onset of visual blurring. Clinical investigations revealed bacterial meningitis with bilateral papillitis and ophthalmoparesis. Serum and cerebrospinal fluid serology confirmed the diagnosis of chronic active neurobrucellosis. Following therapy there was no improvement and he developed optic atrophy. Extensive literature review revealed, one case of bilateral irreversible papillitis resulting from neurobrucellosis. However no cases of neurobrucellosis have been reported with meningitis, irreversible papillitis and ophthalmoparesis. This case demonstrates that in endemic areas, acute meningitis is a potential manifestation of neurobrucellosis and that bilateral irreversible papillitis with ophthalmoparesis can be a potential serious complication.

Neurogenic stunned myocardium following hemorrhagic cerebral contusion.

Neurogenic stunned myocardium (NSM) is a well-known complication of subarachnoidal hemorrhage, but has been reported rarely in association with other central nervous system disorders. A case of NSM is described in a patient with hemorrhagic brain contusion associated with cerebral edema. An 18-year-old man was admitted with severe cranial trauma following a car roll-over. Six days after admission, he developed findings suggestive for NSM. The troponin T and creatine kinase-MB level were elevated and echocardiogram showed apical and inferoposterior hypokinesis and diffuse left ventricular akinesis with severely reduced ejection fraction (18%). Invasive measurements confirmed low cardiac output. His cardiac function resolved completely within 6 days after decompressive craniotomy. This case supports the presumed unifying role of the increased intracranial pressure, probably triggering a vigorous sympathetic outflow hyperactivity leading to NSM.

Algunos apuntes sobre la historia de la Neurología en Santiago de Cuba / Some notes on the history of Neurology in Santiago de Cuba

Los inicios de la Neurología en Cuba se remontan a principios del siglo XIX, pero su definición como especialidad independiente se debió fundamentalmente a la intensa labor asistencial, docente e investigativa del profesor José Rafael Estrada González. Un hito importante fue la creación en 1962 del Instituto de Neurología y Neurocirugía. En la provincia de Santiago de Cuba los primeros neurólogos comenzaron a trabajar en la década de los 70 y a partir de 1983 se inició la docencia de posgrado. En estos años transcurridos se ha consolidado el trabajo docente, asistencial e investigativo de la especialidad, plenamente integrada a todos los programas y tareas del sistema de salud en el país.

The onset of Neurology in Cuba go back to the beginning of the XIX century, but its definition as independent specialty was mainly due to the intense assistance, educational and investigative work of professor José Rafael Estrada González. An important landmark was the creation of the Neurology and Neurosurgery Institute in 1962. In the province of Santiago de Cuba the first neurologists began to work in the 70´s and since 1983 the postgrade teaching began. During those years the educational, assistance and investigative work of the specialty has consolidated, fully integrated to all programs and tasks of the health system in the country.

Risk factors, management and outcome of subtypes of ischemic stroke: a stroke registry from the Arabian Gulf.

BACKGROUND: Data on the determinants and outcome of ischemic stroke (IS) from the Arabian Gulf countries (AGC) are still scanty. The aim of this study was to characterize IS in six large stroke centers on the Arabian peninsula. METHODS: IS subtypes were evaluated in four AGC from January 2006 to December 2007 in a large prospective multicenter hospital-based stroke registry including demographics, baseline risk factors, outcome and management. RESULTS: A total of 780 patients with IS were included. Mean age was 58.9 years (63.7% males). Large-artery atherosclerosis (LAA) (38.1%) was the most common subtype followed by lacunar stroke (LS)(34.7%), cardioembolic stroke (CE)(13.5%) and other determined causes (7%). LAA and CE were both more commonly observed over the age of 70. LAA showed a higher male preponderance, and the highest prevalence of hypertension, diabetes, obesity and ischemic heart disease among all subtypes. Obesity was a risk factor for both LAA and CE. Anterior circulation stroke was significantly more affected in LAA (21.2%), CE (19%) and LS (15.1%) subtype of stroke than in posterior circulation strokes (4.4%, 2.9% and 2.8%, respectively) (p<0.05). Only 0.8% of patients received thrombolysis. The 90-day outcome was worst in LAA and least affected in LS. The over-all 90-day mortality was 2.1%. CONCLUSIONS: Demographically, our data are different from those in Western registries but the distribution of stroke subtypes is comparable. Compared to Asian registries the ratio LS versus LAA was much lower. For the first time these data allow to study the IS profile in this population.

Síndrome de Guillain-Barré en la infancia / Guillain-Barré syndrome in the childhood

Se realizó un estudio descriptivo y prospectivo de 25 pacientes con síndrome de Guillain-Barré, atendidos en el Hospital Infantil Docente Sur de Santiago de Cuba, desde enero de 2006 hasta diciembre de 2012, con vistas a identificar sus características clinicoepidemiológicas y determinar la utilidad del tratamiento empleado. Predominaron los niños menores de 5 años (40,0 %), el sexo masculino y la infección respiratoria alta previa (ambas con 60,0 %), así como la debilidad muscular y arreflexia osteotendinosa (76,0 % en cada caso). La polirradiculoneuropatía desmielinizante inflamatoria aguda fue la variante clínica más frecuente (72,0 %). Tanto el tratamiento con inmunoglobulina humana intravenosa como la rehabilitación resultaron beneficiosos y la mortalidad baja (4,0 %).

A descriptive and prospective study of 25 patients with Guillain-Barré syndrome, assisted in the Teaching Southern Children Hospital in Santiago de Cuba was carried out from January, 2006 to December, 2012, with the aim of identifying their clinical and epidemiological characteristics and to determine the usefulness of the treatment applied. Children younger than 5 years (40.0%), male sex and previous upper respiratory infection (both with 60.0%), as well as the muscular weakness and osteotendinous areflexia (76.0% in each case) prevailed. The inflammatory and acute desmyelinating polyrradiculoneuropathy was the most frequent clinical variant (72.0%). Either the treatment with intravenous human immunoglobulin as rehabilitation were beneficial and the mortality was low (4.0%).

Scleredema Diabeticorum with unusual presentation and fatal outcome.

We present a case of Scleredema Diabeticorum (SD) in a patient with diabetic neuropathy and restrictive respiratory disease with unusual skin lesion distribution. The onset of dermatologic symptoms heralded a progressive respiratory disease with constrictive component. Painful diabetic neuropathy was noteworthy and difficult to relieve. Predominantly, distribution of the skin lesions on the thighs makes the case exceptional. T2-weighted MRI showed abnormal hyperintensities along the muscles of the thighs in correspondence with the skin lesions. Gait and respiratory symptoms progressively worsened. After a transient remitting period, he developed sudden shortening of breath, arrested and expired at home.The atypical distribution of the skin lesions with further involvement of underlying muscles plus concomitant polyneuropathy and respiratory constrictive disease with sudden death is quite unusual and aggressive presentation of SD.

Celulitis facial iatrogénica como consecuencia de una sepsis odontógena / Facial iatrogenic cellulitis as consequence of an odontogenic sepsis

Se describe el caso clínico de un paciente de 56 años de edad, quien perdiera la obturación del canino superior derecho y acudió al servicio estomatológico de la Clínica Estomatológica Provincial Docente "Mártires del Moncada" de Santiago de Cuba con intenso dolor y sepsis apical incipiente, ante lo cual pedía una nueva obturación para aliviar sus síntomas. La especialista detectó la infección en ciernes y le alertó sobre las posibles complicaciones, pero debido a la insistencia del afectado obturó nuevamente el diente; en consecuencia, a las pocas horas se desarrolló una aguda celulitis facial con afectación periorbitaria, que solo cedió al administrar antibióticos de amplio espectro por vía endovenosa.

The case report of a 56 year-old patient who lost the obturation of the superior right canine and visited the estomatological service of "Mártires del Moncada" Teaching Provincial Estomatological Clinic in Santiago de Cuba with intense pain and incipient apical sepsis, requesting a new obturation to relieve his symptoms is described. The specialist detected the newly found infection, and alerted him on the possible complications, but due to the insistence of the affected patient she filled the tooth once more; in consequence, few hours later an acute facial cellulitis was developed with periorbital compromise, which improved only when administering wide-spectrum intravenous antibiotics.

Neurogenic stunned myocardium following hemorrhagic cerebral contusion.

Neurogenic stunned myocardium NSM is a well-known complication of subarachnoidal hemorrhage, but has been reported rarely in association with other central nervous system disorders. A case of NSM is described in a patient with hemorrhagic brain contusion associated with cerebral edema. An 18-year-old man was admitted with severe cranial trauma following a car roll-over. Six days after admission, he developed findings suggestive for NSM. The troponin T and creatine kinase-MB level were elevated and echocardiogram showed apical and inferoposterior hypokinesis and diffuse left ventricular akinesis with severely reduced ejection fraction 18%. Invasive measurements confirmed low cardiac output. His cardiac function resolved completely within 6 days after decompressive craniotomy. This case supports the presumed unifying role of the increased intracranial pressure, probably triggering a vigorous sympathetic outflow hyperactivity leading to NSM.