Haemorrhagic stroke related to the use of 4-fluoroamphetamine.

INTRODUCTION: The use of the new psychoactive substance 4-fluoroamphetamine (4-FA) and the number of 4-FA-related intoxications substantially increased in The Netherlands in recent years. We describe two patients with severe 4-FA-related complications and the characteristics of a large sample of 4-FA-intoxicated patients. METHODS: Information on patients with 4-FA-related intoxications between January 2009 and June 2017 was available from the Monitor Drug-related Incidents. Detailed clinical information was obtained of two patients with haemorrhagic stroke after toxicologically confirmed 4-FA use. RESULTS: We report on two patients who presented with headache and mild hypertension after 4-FA use. Patient A developed one-sided weakness and decreased consciousness after a few hours. A computed tomography scan showed a left-sided intracerebral haemorrhage. Because of life-threatening cerebral herniation, haematoma evacuation was performed. Postoperatively, she suffered from a right-sided hemiparalysis and severe aphasia, requiring clinical rehabilitation. Patient B had a subarachnoid haemorrhage without neurological deficits. In total, 939 4-FA-intoxicated patients were registered. These patients used 4-FA alone (44%) or in combination with alcohol (13%) and/or other drugs (43%). DISCUSSION: Patients using 4-FA are at risk for life-threatening health problems, including intracranial haemorrhage. Additional brain imaging should be considered in 4-FA-intoxicated patients, not only in the presence of neurological deficits, but also in the case of severe headache.

Bleeding risk of cerebrovascular malformations in hereditary hemorrhagic telangiectasia.

OBJECT: Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal-dominant vascular dysplasia with a high prevalence of cerebrovascular malformations (CVMs), mostly manifested as arteriovenous malformations (AVMs). The natural history and bleeding risk of these CVMs is unknown. The authors investigated the risk of bleeding in conjunction with clinical and radiological features in patients with HHT and proven CVMs. METHODS: Intravenous digital subtraction (DS) angiography was used to screen 196 patients with HHT for the presence of CVMs. Patients with abnormal results on DS angiography were asked to undergo a conventional cerebral angiographic study. All patients with a proven CVM were assessed by a neurologist. The bleeding risk was retrospectively and prospectively calculated for patients with AVMs only, as well as for the whole cohort of patients with CVMs. Twenty-four patients (12.2%; 16 female and eight male), aged 14 to 66 years (mean 35.4 years) with one or more CVMs were identified. Fifteen patients (62.5%) had a CVM and a pulmonary AVM. Eleven patients (45.8%) exhibited no neurological signs of their CVM; six (25%) had headache or migraine; four (16.7%) had seizures; and three (12.5%) had an intracranial hemorrhage. Twenty-two patients had at least one AVM (with a total of 28 AVMs), whereas two patients only had telangiectases. Twenty-seven AVMs were small (96%), 36% were located in eloquent areas of the brain, and 82% had superficial venous drainage. One third of the patients had multiple CVMs. The bleeding risk for patients with at least one AVM ranged from 0.41 to 0.72% per year, and for the whole cohort the range was 0.38 to 0.69% per year. Calculation of the bleeding risk as determined by lesion-years ranged from 0.36 to 0.56% per year for patients with AVMs and from 0.27 to 0.46% per year for all patients with CVMs. CONCLUSIONS: Patients with HHT have a high risk of harboring a CVM, especially in the presence of a pulmonary AVM. These CVMs are mostly low-grade AVMs (Spetzler-Martin Grade I or II), are frequently multiple, and have a lower risk of bleeding than that associated with sporadic AVMs. Female patients are more often affected than male patients. The inherent low sensitivity of DS angiography screening for CVMs may yield false negative results.

External lumbar drainage in uncontrollable intracranial pressure in adults with severe head injury: a report of 7 cases.

The retrospective results of external lumbar drainage in 7 adult patients with severe closed head injury and intracranial pressure (ICP) refractory to aggressive management strategies are presented. All patients had Glasgow Coma Scale (GCS) scores of 8 or less within 24 hours after admission and were treated by a staircase protocol including sedation, ventricular drainage, hyperventilation and mannitol. In three cases barbiturate drugs and an artificially induced hypothermia were used. Four patients required surgical evacuation of mass lesions. Three patients made a good functional recovery, 2 were severely disabled and 2 patients died. In none of the patients clinical signs of cerebral herniation occurred. We recommend additional external lumbar drainage in adults with severe head injury unresponsive to aggressive ICP control with open basilar cisterns and absent focal mass lesions on computerized-tomography scan before drainage.

Independence of soleus H-reflex tests in control and spastic subjects shown by principal components analysis.

Different soleus H-reflex tests are used in the study of neurophysiological mechanisms of motor control. We studied the interdependence pattern of a number of soleus H-reflex tests, i.e., vibratory inhibition, the ratio of the reflex response to direct muscle potential (H/M ratio) and the homonymous recovery curve with a principal components analysis in 48 healthy controls and 38 patients with signs of the upper motoneuron syndrome. In controls, the analysis showed 3 independent principal components (PCs). Vibratory inhibition and H/M ratio loaded on separate components. Late facilitation and late inhibition variables of the recovery curve loaded on the third component due to the positive correlation (P < 0.001) between these variables. In spastic patients the analysis identified 4 independent PCs corresponding with vibratory inhibition, H/M ratio, late facilitation and late inhibition variables, respectively. The findings suggest that the mutual independence of the different soleus H-reflex tests in patients with the upper motoneuron syndrome has retained the control situation to a large extent.

Soleus H-reflex tests in dystonia.

Vibratory inhibition, the homonymous recovery curve and the ratio of the maximal H-reflex to direct muscle potential (H/M ratio) of the soleus H-reflex were assessed in 10 patients with leg dystonia and in six patients with arm or neck dystonia. The results were compared with those obtained in 48 healthy control subjects. H-reflex variables most helpful for the discrimination of patients and healthy subjects were identified. In patients with leg dystonia, vibratory inhibition was less marked than in control subjects, whereas late facilitation of the recovery curve was increased. In patients with leg dystonia, area values of test reflexes in the late facilitatory phase of the recovery curve exceeded peak-peak values, in contrast to findings in control subjects. This finding may be attributable to less synchronization of enhanced test reflexes in dystonia than in the control condition. In differentiating patients with leg dystonia from control subjects, a combination of parameters of vibratory inhibition and the late facilitatory phase of the recovery curve appeared most useful. In patients with arm or neck dystonia and in the unaffected legs of hemidystonic patients, soleus H-reflex test results were in the normal range. Abnormalities in the results of the soleus H-reflex tests we used appear to be related to the presence of clinical signs in the extremity under examination and not to the severity of features.