Compartment syndrome following thrombolysis: clinical features and associated conditions.

Major complications of thrombolysis are intracranial and extracranial bleedings. Compartment syndrome (CS) as a serious adverse event is sparsely reported. The purpose of the study is to present a systematic review of the literature on this complication based on a case vignette. A PubMed and Google Scholar search on CS following thrombolysis was performed. Twenty-four patients (11 male, 11 female, 2 not noted; median age 66 years, range 19-85 years) with thrombolysis associated CS were identified. Fifteen patients had thrombolysis with rtPA, 4 patients with streptokinase, 3 patients with urokinase, and 2 patients with tenecteplase. In 15 cases, CS affected the upper limb, and in 9 cases the lower limb. Indication for thrombolysis was myocardial infarction in 11 patients, arterial occlusion of the leg in 6 patients, pulmonary embolism in 4 patients, stroke in 2 patients, and deep venous thrombosis in 1 patient. In addition, in 15 cases, aspirin/ticlopidin, and/or heparin in therapeutic dosages had been prescribed. In 15 cases manipulations of the affected limb had been preceding. In both stroke patients, a hidden fracture was later diagnosed. The median time to the diagnosis of CS was 12 h (2 h-3 days). Therapy was mostly surgical with fasciotomy. The outcome of CS was favorable in 14 cases. However, in 5 cases, nerve damage persisted, and amputation was indicated in 2 patients. CS following thrombolysis is a rare condition. As predisposing factors different manipulations, hidden fracture and pronounced antithrombotic therapy are encountered.

Dressing Apraxia as Initial Manifestation of Creutzfeldt-Jakob Disease.

Background: Creutzfeldt-Jakob disease (CJD) is a rare prion disease characterized by rapidly progressive dementia. Case Report: A 76-year-old woman exhibited pronounced signs and symptoms of dressing apraxia for about seven weeks before the disease progressed and probable CJD was diagnosed supported by imaging and CSF findings. Discussion: Dressing apraxia as the initial manifestation of CJD has been sparsely reported. This remarkably focal syndrome should be considered with view on movement and neuropsychological disorders in early CJD.

Solitary epileptic seizures in the clinical practice. Part II: findings of various modifications of EEG examination and imaging methods in patients who experienced solitary unprovoked epileptic seizure.

BACKGROUND: The occurrence of the first unprovoked epileptic seizure always requires thorough examination. The risk of incorrect diagnosis is high, non-epileptic seizures represent 20-33% of newly diagnosed cases. The aim of the study is to evaluate findings of various modifications of EEG examination in the group of patients who experienced solitary unprovoked epileptic seizure and compare benefits of CT and MRI examination of the brain of these patients. MATERIAL AND METHODS: The group involved 84 patients hospitalized at the 1st Department of Neurology , Faculty of Medicine, Comenius University in Bratislava between January 1997 and January 2007 after experiencing unprovoked epileptic seizure. It is a retrospective analysis of information from medical records and clinical documentation. For statistic comparing of benefits of various modifications of EEG examination and between CT and MRI examination of the brain binomic test of proportion was used. RESULTS: Interictal epileptiform EEG graphoelements in native EEG was recorded only in 14.29% of patients. Statistically significantly more epileptiform graphoelements comparing EEG and EEG after sleep deprivation of the patient (SD) with one- hour recording was recorded with 24-hour 8 channels EEG monitoring after SD, EEG after SD with one- hour recording was of no significance comparing to native EEG. MRI examination of the brain was statistically more significant comparing to CT examination. CONCLUSION: Low catchment of epileptiform EEG graphoelements in patients with solitary unprovoked seizure shows the importance of precise history in diagnostics of these patients. Though EEG is a very important examination it is an auxiliary one. We confirmed that MRI examination in patients who experienced solitary unprovoked epileptic seizure is undoubtedly the first choice method.

Solitary epileptic seizures in the clinical practice. Part I: etiological factors responsible for their occurrence.

BACKGROUND: Approximately 5% of the general population experiences at least one unprovoked epileptic seizure in the lifetime. This is in contrast to the cumulative incidence of epilepsy (approx. 3-4%) and incidence of acute symptomatic seizures (approx. 4%). Nearly 2% of the population experiences a febrile seizure before the 5 years of age. The aim of this article was evaluation of the distribution of acute symptomatic and unprovoked seizures in our patient cohort after the solitary epileptic seizures, as well as determination of particular etiological factors responsible for the occurrence of solitary epileptic seizure. MATERIAL AND METHODS: Our patient cohort comprised 116 patients experiencing the solitary epileptic seizure, who were hospitalised at the 1st Department of Neurology, Faculty of Medicine of Comenius University and Faculty Hospital in Bratislava, Slovakia over a period of 10 years (January 1, 1997 - January 1, 2007). It is a retrospective analysis of data from case records and health records; eventually we contacted the patients by phone or by sending a questionnaire. RESULTS: Of the 116 patients there were 32 cases (37.12%) of an acute symptomatic seizure and 84 cases (62.88%) of an unprovoked seizure. In the group of unprovoked solitary epileptic seizures the etiological conclusions were idiopathic and cryptogenic in 35 cases (41.7%) and late symptomatic in 49 cases (58.3%). The most frequent etiological factor in the group of acute symptomatic seizures was alcohol (40.6%). In the subgroup of late symptomatic seizures the etiology was mostly vascular (17.85%). CONCLUSION: Data management of etiological factors responsible for the solitary epileptic seizure confirmed a need for a thorough evaluation of the first epileptic seizure.

Neuro-Ophthalmology at the Bedside: A Clinical Guide.

Neuro-ophthalmological signs and symptoms are common in the emergency department but are a frequent source of diagnostic uncertainties. However, neuro-ophthalmological signs often allow a precise neuro-topographical localization of the clinical problem. A practical concept is presented how to perform a neuro-ophthalmological examination at the bedside and to interpret key findings under the aspect of emergency medicine with limited resources.

[Cranial nerve palsies: ganglioside autoantibodies indicating an immunoneuropathy]. / Isolierte Hirnnerven-Läsionen: Gangliosid-Autoantikörper als Hinweis auf Immunneuropathie.

BACKGROUND: Cranial neuropathies are not infrequent and need a broad differential diagnostic approach. Etiologically autoimmune processes have to be considered. METHOD: In five patients with cranial neuropathy (in two cases lesion of the abducens nerve, in one case bilateral facial palsy, in one case abducens, facial and bilateral vestibular lesion, in one case bilateral glossopharyngeal lesion) IgG and IgM autoantibodies directed against most relevant gangliosides were quantitatively analyzed (Bühlmann Laboratories AG, Schönenbuch, Switzerland). All patients underwent lumbar puncture and cranial imaging. RESULTS: Trauma, tumor, elevated intracranial pressure and vascular lesion could be excluded. In one patient varicella infection as a cofactor was probable, in the remaining patients direct infection could be excluded. In one patient a prominent cyto-albumin dissociation of the CSF was found. In all patients autoantibodies directed against gangliosides were detected with positive antibodies against GD1a and GD1b in all patients. Prior to the cranial neuropathy one patient reported an infection of the upper airway and one reported an infection of the gastrointestinal tract. One patient was treated with steroids and one patient with intravenous immunoglobulin, the other patients were been carefully observed. All patients recovered well. CONCLUSION: Autoimmune processes with positive autoantibodies directed against gangliosides can be found in cranial neuropathy. Based on these observations an immunomodulating therapy should be considered.

Acute inferior homonymous quandrantanopia in a 71-year-old woman.

A 71-year-old woman presented with acute inferior homonymous quadrantanopia initially mimicking acute ischemic stroke. As clinical signs and symptoms progressed to akinetic mutism with myoclonus the diagnosis of the Heidenhain variant of Creutzfeldt-Jakob disease was made. Brain MRI 4 days after symptom onset revealed ribbon-like high signal intensity in the medial occipital cortex.

Pitfalls associated with the diagnosis of herpes simplex encephalitis.

Herpes simplex encephalitis (HSE) still remains a serious illness with high morbidity and mortality. The characteristic presentation of HSE usually consists of fever, headache, and altered mental function. We present three patients with atypical features of HSE. First, a 48-year-old man with symptomatic posttraumatic epilepsy, who developed a gastrointestinal infection, seizures, and fever. After significant clinical improvement, the patient had fever again and developed a status epilepticus, which led to the diagnosis of HSE. Second, an 84-year-old woman with hyperactive delirium after levofloxacin intake. Cranial computed tomography (CCT) revealed hypodense temporal changes, prompting lumbar puncture and diagnosis of HSE. Third, a 51-year-old diabetic woman presented with fever and acute confusion. As CCT and cell count of cerebrospinal fluid (CSF) were normal, infection and hyperglycemia as initial diagnoses were postulated. Due to aphasic symptoms, the differential diagnosis of a stroke was taken into account. Thus a second lumbar puncture led to the correct diagnosis of HSE. These atypical presentations need a high grade of suspicion and a high willingness to reconsider the initial working diagnosis, in order to prevent a diagnostic delay.

Cerebral air embolism via port catheter and endoscopic retrograde cholangio-pancreatography.

BACKGROUND: Cerebral air embolism (CAE) is a critical clinical condition necessitating rapid diagnosis and therapeutic measures. METHODS: The authors describe two patients with lethal CAE. RESULTS: An 81-year-old man rapidly developed coma with tetraplegia. CT-scan revealed prominent CAE whereby the entry of the air was via a port catheter for parenteral nutrition. A 45-year-old man with severe alcohol-toxic multiple organ damage needed endoscopic retrograde cholangio-pancreatography (ERCP) and a second esophagogastroscopy. After an epileptic seizure, the CT-scan of the brain showed small amounts of cerebral air in the posterior right hemisphere and in the sagittal superior sinus. Despite critical care the patient died. CONCLUSION: CAE is a neurocritical emergency case. Early CT-scan of the brain can detect air, guide further therapy, and contribute to the assessment of the prognosis.