Asterixis: a study of 103 patients.

In 1949, asterixis was first described in patients with hepatic encephalopathy. It was quickly recognized that this phenomenon also occurs in other generalized encephalopathies and sometimes results from structural brain lesions. This paper is a study of asterixis in the general neurology clinic and on the inpatient neurology consultation service. The neurologists recorded the findings on inpatients and clinic patients for 12 consecutive months. Of the 1,109 inpatients with adequate examination, asterixis was documented in 97. Eighteen of the 97 cases were unilateral (18.6%) and 79 cases were bilateral (81.4%). Of the 614 outpatient visits with well documented examination, 6 (1%) individuals had asterixis. Since a small number of patients were examined more than once, the study yielded 103 individuals with adequate data for analysis. Asterixis resulted from varied causes: medications, renal disorder, hepatic dysfunction, pulmonary insufficiency, stroke and other brain lesions (including malignancy, subdural hematoma, and epidural abscess). Asterixis occurred in various patterns: in some cases it was easier to elicit in the upper extremities, in some it was easier to elicit in the lower limbs, and some it was solely or predominantly unilateral. The findings are discussed in light of the literature on asterixis with regard to its varied causes, patterns and presentations. Lastly, asterixis is examined from a historical perspective and the terminology is elucidated.

Subclinical brain embolization in left-sided infective endocarditis: results from the evaluation by MRI of the brains of patients with left-sided intracardiac solid masses (EMBOLISM) pilot study.

BACKGROUND: Acute brain embolization (ABE) in left-sided infective endocarditis has significant implications for clinical decision making. The true incidence of ABE, including subclinical brain embolization, is unknown. METHODS AND RESULTS: We prospectively studied 56 patients with definite left-sided infective endocarditis. Patients were examined by a study neurologist, and those without contraindication had magnetic resonance imaging of the brain. Patients without clinical evidence of acute stroke but with magnetic resonance imaging evidence of ABE were considered to have subclinical brain embolization. Clinical stroke was present in 14 of 56 patients (25%). Among 40 patients undergoing magnetic resonance imaging, the incidence rates of subclinical brain embolization and any ABE were 48% and 80%, respectively. ABE was present in 18 of 19 patients (95%) with Staphylococcus aureus infection. At 3 months, mortality was similar among patients with clinical stroke and subclinical brain embolization (62% versus 53%; P=NS) and was higher among patients with any ABE than among those without ABE (56% versus 12%; P=0.046). Valvular surgery was performed in 25 patients (45%), including 16 with ABE, at a median of 4 days. No patient suffered a postoperative neurological complication. Surgery was independently associated with a lower risk of mortality at 3 months (odds ratio, 0.1; 95% confidence interval, 0.03 to 0.6; P=0.008). CONCLUSIONS: Magnetic resonance imaging detected subclinical brain embolization in a substantial number of patients with left-sided infective endocarditis, suggesting that the incidence of ABE may be significantly higher than reports based on clinical and computed tomography findings have indicated. Brain magnetic resonance imaging may play a role in the complex decision about surgical intervention in infective endocarditis.

Less Pulsatile Levodopa Therapy (6 Doses Daily) Is Associated with a Reduced Incidence of Dyskinesia.

OBJECTIVE: To evaluate whether less pulsatile levodopa therapy (LPT) can reduce the development of levodopa-induced dyskinesia (LID). METHODS: This is a retrospective cohort study of patients with Parkinson's disease at the movement disorders clinic of Medstar Washington Hospital Center. The study was not blinded or randomized. Patients were seen between August 2002 and August 2018. During these years, we treated patients with less pulsatile (6 doses daily) levodopa treatment to reduce LID. Occurrence of LID was recorded. RESULTS: Ninety-five patients with Parkinson's disease taking levodopa were divided into two groups: 1) patients who were initially managed on LPT or who switched from traditional therapy (TT) (n = 61) (mean disease duration: 7.7 ± 4.8 years, mean levodopa duration: 5.6 ± 4.5 years and mean observation time: 4.3 ± 3.4 years), and 2) patients on TT throughout the observation period or until they developed dyskinesia (n = 34) (mean disease duration: 8.3 ± 3.8 years, mean levodopa duration: 6.2 ± 4.2 years and mean observation time: 4.1 ± 3.4 years). Three of the 61 LPT patients developed dyskinesia during the observation period. One of the patients developed dyskinesia after being switched to pulsatile doses by another doctor. In the other two, dyskinesia was minimal. In contrast to this 4.9% cumulative incidence, dyskinesia occurred in 50% (17/34) of TT patients, an incidence similar to that in published data (p < 0.001). CONCLUSION: Less pulsatile levodopa with 6 daily doses was associated with a low incidence of LID. Further study of this method of treatment is warranted.

Sequential MRI in pontine and extrapontine myelinolysis following rapid correction of hyponatremia.

OBJECTIVE: This study describes the MRI changes associated with pontine and extrapontine myelinolysis secondary to rapid correction of hyponatremia in dogs. The authors discuss the relevance of the results for theories of pathogenesis and for diagnosis of patients. RESULTS: MRI changes associated with pontine and extrapontine myelinolysis first occur on diffusion-weighted imaging. As a generalization, gadolinium enhancement, flair image change and T2 weighted image abnormality appear sequentially.

Human African Trypanosomiasis Encephalitis in the United States: Serial Magnetic Resonance Imaging.

It is important to recognize the signs and symptoms of human African trypanosomiasis (HAT) in order to facilitate early diagnosis and treatment. A 36-year-old man developed encephalitis caused by HAT. This encephalitis can appear many years after well-tolerated systemic infection. The neurologic manifestations developed 7 years after he had emigrated from Cameroon to the United States. We demonstrate the magnetic resonance imaging before, during, and after his treatment with intravenous eflornithine. Clinical signs and symptoms of HAT can be nonspecific and precede abnormalities on magnetic resonance imaging. Human African trypanosomiasis should be considered in the differential diagnosis of patients who have lived in sub-Saharan Africa and have a clinical presentation of subacute encephalitis.

Nutritional cerebellar degeneration, with comments on its relationship to Wernicke disease and alcoholism.

Nutritional cerebellar degeneration occurs in alcoholism and other states that predispose to malnutrition, such as gastric bypass surgery. Gait ataxia is the principal clinical manifestation. Ataxia of the lower limbs is not uncommon, but upper extremity ataxia and nystagmus are rare. Atrophy of the anterior superior vermis is the primary pathological manifestation in established disease. Typically, the onset is subacute. This cerebellar disease is part of the spectrum of the Wernicke-Korsakoff syndrome, i.e. the cerebellar manifestation of Wernicke disease. It may occur with other lesions of Wernicke disease or in isolation. Rarely, with florid disease, lesions may be hemorrhagic. Active disease should be treated with thiamine in the same way that one treats Wernicke disease. Clinicopathologic correlation in this disease has provided the best evidence that the anterior superior vermis is important in coordinating bipedal locomotion.

Lyme disease mimicking central nervous system lymphoma.

A 33-year-old male presented with a complaint of intermittently blurred vision and right facial weakness. MRI of the brain and orbits revealed numerous cranial nerve abnormalities. There were no focal brain or spinal cord lesions. Cerebral spinal fluid flow cytometry revealed a monoclonal population of B-lymphoid cells. No other evidence of disease was found. Serum Lyme antibody was reported to be IgM positive. Therapy with ceftriaxone, was followed by improvement in his symptoms. Although flow cytometry is a useful tool in distinguishing malignancy from inflammatory disorders it does not always establish the diagnosis of malignancy by itself.