Behavioural improvement in a minimally conscious state after caloric vestibular stimulation: evidence from two single case studies.

OBJECTIVE: To investigate whether caloric vestibular stimulation, a non-invasive form of neuro-modulation, alters the level of awareness in people residing in a minimally conscious state. DESIGN: Single-case ( n = 2), prospective, controlled (ABAB) efficacy study. SETTING: Tertiary, neuro-rehabilitation inpatient ward within a university hospital. PARTICIPANTS: Two individuals in a minimally conscious state. INTERVENTION: Left ear caloric vestibular stimulation was performed in two four/five-week blocks interleaved with two four/five-week blocks of sham stimulation. Session duration and frequency gradually increased within each block from once per day for 10 minutes (Week 1) to once per day for 20 minutes (Week 2) to 20 minutes twice per day in the remaining weeks. MEASURES: Wessex Head Injury Matrix, JFK Coma Recovery Scale - Revised. RESULTS: Both participants' Wessex Head Injury Matrix scores indicated a transition from involuntary (i.e. mechanical vocalization) to voluntary (i.e. gesture making, selective responses to family members) behaviour that was time-locked to the onset of active stimulation. In one participant, this improvement persisted for at least four weeks after active stimulation, while in the other it diminished two weeks after stimulation. Allied, although less dramatic, changes were seen on the arousal and auditory subscales of the JFK Coma Recovery Scale - Revised. CONCLUSION: The data provide the first evidence that vestibular stimulation may help improve outcome in a low awareness state, although further studies are needed to replicate effect and determine longer-term benefit.

Cognitive function in ambulatory patients with systolic heart failure: insights from the warfarin versus aspirin in reduced cardiac ejection fraction (WARCEF) trial.

We sought to determine whether cognitive function in stable outpatients with heart failure (HF) is affected by HF severity. A retrospective, cross-sectional analysis was performed using data from 2, 043 outpatients with systolic HF and without prior stroke enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) Trial. Multivariable regression analysis was used to assess the relationship between cognitive function measured using the Mini-Mental Status Exam (MMSE) and markers of HF severity (left ventricular ejection fraction [LVEF], New York Heart Association [NYHA] functional class, and 6-minute walk distance). The mean (SD) for the MMSE was 28.6 (2.0), with 64 (3.1%) of the 2,043 patients meeting the cut-off of MMSE <24 that indicates need for further evaluation of cognitive impairment. After adjustment for demographic and clinical covariates, 6-minute walk distance (ß-coefficient 0.002, p<0.0001), but not LVEF or NYHA functional class, was independently associated with the MMSE as a continuous measure. Age, education, smoking status, body mass index, and hemoglobin level were also independently associated with the MMSE. In conclusion, six-minute walk distance, but not LVEF or NYHA functional class, was an important predictor of cognitive function in ambulatory patients with systolic heart failure.

Spinal cord infarction secondary to nucleus pulposus embolization in pregnancy.

Nucleus pulposus (NP) embolism is an extremely rare cause of spinal cord infarction. To our knowledge, it has not been reported in pregnancy in the English literature. A 41-year-old pregnant woman presented with clinical symptoms initially attributed to a transverse myelitis. After a complicated clinical course, she expired, and was found at autopsy to have NP embolism to the spinal cord. In conclusion NP embolism is a rare cause of spinal cord infarction, and should be considered in the differential of a patient presenting with symptoms compatible with spinal cord infarction in the pregnant as well as nonpregnant state.

Paradoxical brain embolism from thrombus associated with vena caval filter in a patient with cancer.

A 71-year-old man experienced sudden onset of hemiparesis and aphasia. He had a 4-month history of gallbladder cholangiocarcinoma, complicated with a postoperative deep-vein thrombosis (DVT) that necessitated a vena caval filter placement. Diffusion-weighted magnetic resonance imaging of the brain showed multiple hyperintense foci. Magnetic resonance spectroscopy was compatible with cerebral infarction. Abdominal computed tomography showed a thrombus in the inferior vena cava extending through the filters. A transcranial Doppler bubble study revealed the presence of a right-to-left shunt. Paradoxical cerebral embolism must be considered in patients with DVT who have new onset neurologic deficits even in the presence of a caval filter.

Primary central nervous system lymphoma masquerading as herpes encephalitis: clinical, magnetic resonance imaging, and pathologic findings.

An 84-year-old man presented with acute confusion, global aphasia, and fever. Magnetic resonance imaging (MRI) showed hyperintense lesions on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images predominantly affecting the cortical gray matter of the left mesial temporal and inferior frontal lobes, and insula. Acyclovir was prescribed for presumed viral encephalitis. Clinical and MRI worsening prompted a left temporal lobe biopsy that revealed primary central nervous system lymphoma (PCNSL). This case adds to the MRI spectrum of PCNSL and illustrates that it may mimic the clinical and MRI presentation of herpes simplex encephalitis.