Regional cerebral blood flow following single-dose and continuous-dose tadalafil after stroke.

PURPOSE: Tadalafil is a potent and selective phosphodiesterase type 5 inhibitor that provides effective treatment for erectile dysfunction (ED). The purpose of this study was to explore the effect of a single on-demand dose of tadalafil compared to low-dose continuous administration on regional cerebral blood flow (rCBF), in patients after stroke. METHODS: Thirty consecutive male patients (mean age 58.3 ± 7.9 years) with ED and a history of stroke were included in the study. The baseline single-photon emission computed tomography (SPECT) study was performed 15 min after iv injection of 740 MBq Tc-99m-HMPAO (Ceretec; GE Healthcare Ltd. Chalfont St. Giles, UK). Fifteen randomized patients received a single dose of 20 mg tadalafil in the morning, and a second SPECT study was performed 6 h later. Fifteen other patients received 5 mg of tadalafil each morning for seven consecutive days, and the second SPECT study was performed 6 h after the last dose. The imaging data were evaluated using SPM software (Wellcome Department of Cognitive Neurology, University College, London). RESULTS: Associations between any of the risk factors/comorbidities and the perfusion changes were not detected. All patients showed areas of reduced relative rCBF in the affected hemisphere after tadalafil administration compared to baseline (P < 0.001). No significant difference was found between patients on 5 mg tadalafil and 20 mg dose. CONCLUSION: Tadalafil administration after cerebral stroke may be associated with diminished blood flow to areas adjacent to the stroke. The alterations in perfusion suggest a need for caution in prescribing tadalafil to patients with a history of stroke, especially with continuous administration that may impose constant stress on the cerebral circulation.

The effect of sildenafil citrate (Viagra) on cerebral blood flow in patients with cerebrovascular risk factors.

OBJECTIVES: Sildenafil citrate is widely used for erectile dysfunction. The present study examined the short-term effects of sildenafil administration in individuals with cerebrovascular risk factors, including patients with a history of stroke. MATERIALS AND METHODS: Twenty-five consecutive male patients with erectile dysfunction and vascular risk factors were included in the study. A perfusion brain SPECT study was performed at baseline and 1 h after the oral administration of sildenafil. RESULTS: Associations between any of the risk factors and the perfusion scores were not detected, with the exception of stroke. Stroke patients showed significantly more areas with diminished perfusion after sildenafil administration compared to baseline. CONCLUSIONS: In patients with diabetes or hypertension, a dose of 50 mg sildenafil does not appear to produce detrimental effects on cerebral blood flow. However, patients with a history of stroke may be at increased risk of hemodynamic impairment after the use of sildenafil.

Treatment of status epilepticus and acute repetitive seizures with i.v. valproic acid vs phenytoin.

OBJECTIVE: To evaluate the efficacy and tolerability of the treatment with valproic acid (VPA) in patients with status epilepticus (SE) or acute repetitive seizures (ARS) comparing it with phenytoin (PHT) treatment. MATERIALS AND METHODS: Patients with SE or ARS were treated in a consecutive manner with either VPA or PHT intravenously. The primary endpoint was defined as clinical seizure cessation; the secondary endpoint was evaluation of drug tolerability. RESULTS: Seventy-four adult patients with SE or ARS participated in the study, 49 with VPA i.v. and 25 PHT i.v. In 43 (87.8%) of the VPA patients, the seizures discontinued, and no rescue medication was needed. Similar results were found in the PHT group in which seizures of 22 (88%) patients were well controlled. Side effects were found in 12% of the PHT group, and in none of the VPA group. CONCLUSIONS: VPA i.v. seems to be effective and well tolerated in adult patients with SE or ARS.

Autosplenectomy complicating pneumococcal meningitis in an adult.

We present a rare complication of pneumococcal meningitis. A 56-year-old female patient with pneumococcal meningitis developed acute hyposplenism. Left-sided hypochondriacal pain accompanied by a marked thrombocytosis developed during the convalescent period. Abdominal radionuclide and computed tomographic scans demonstrated damage to the spleen. The findings were compatible with autosplenectomy.

Early treatment of a single generalized tonic-clonic seizure to prevent recurrence.

BACKGROUND: The question of whether to start antiepileptic treatment after a single unprovoked seizure remains controversial and has been the subject of much debate in the relevant literature. OBJECTIVES: To determine the rate of recurrence of a second attack after a single unprovoked epileptic seizure by using 2 study groups of treated and untreated patients and, thus, to establish a treatment policy for these patients. PATIENTS AND METHODS: A group of 91 patients with a single generalized tonic-clonic seizure were prospectively studied; 87 of these patients completed the study. The end point of the study was 36 months after the single attack or the occurrence of a subsequent epileptic attack. The patients were randomly divided into 2 groups; 45 patients who immediately received anticonvulsive treatment and 42 who remained untreated for the follow-up period. Patients in the treated group were given monotherapy with carbamazepine. The results of recurrences were statistically analyzed by using the Kaplan-Meier method. RESULTS: Results indicated a significantly higher percentage of seizure-free patients in the treated group compared with that in the untreated group (P = .001). The treated men were proved to be less at risk for recurrent seizures compared with treated women (P < .001 vs P = .03, respectively). CONCLUSION: Treatment after a single unprovoked seizure leads to a significant reduction in the risk of relapse of generalized tonic-clonic epilepsy.

Selective acalculia with sparing of the subtraction process in a patient with left parietotemporal hemorrhage.

We describe a patient with left parietotemporal hemorrhage with selective acalculia for addition, multiplication, and division, but with an intact ability to subtract. There was no impairment in the ability to distinguish mathematical signs. This case suggests that different processing systems are responsible for each of the basic arithmetic operations.

Anterior operculum syndrome localized by SPECT.

UNLABELLED: The aim of this case report was to present a patient with complete anarthria and orofacial apraxia without other relevant neurological deficit. The clinical features are compatible with anterior operculum syndrome. METHODS: A regional brain perfusion scan was done using 99mTc-HMPAO and a SPECT gamma camera. A brain CT scan and an MRI were also performed. RESULTS: Brain CT and MRI were not diagnostic. On brain SPECT, hypoperfusion of the left inferior area of the frontal lobe was noted. CONCLUSION: The patient studied showed an uncommon case of anterior operculum syndrome of focal degenerative origin localized by SPECT. SPECT may be a useful and effective method for diagnosis of this unusual neurological deficit.

Cerebrospinal fluid magnesium level as a prognostic factor in ischaemic stroke.

Magnesium has been reported to have a dilatatory effect on cerebral arteries. Reduction of extracellular Mg+2 has been shown to be directly correlated with the intensity of cerebral spasm. A neuroprotective effect of magnesium in stroke has also been hypothesized. The aim of our study was to examine the Mg+2 levels in serum and cerebrospinal fluid (CSF) in the early stage of stroke and to evaluate the correlation between Mg+2 levels and the development of neurological deficits. Between 1986 and 1994, 96 patients who had a stroke of 24- to 48-h duration were enrolled in the study. Serum and CSF levels of magnesium were checked on admission, 2448 h after the onset of stroke. Using a neurological score, the neurological deficit was assessed on the 1st day, 1 and 4 weeks later. Computed tomography (CT) was performed after 1 week, and the volume and location of infarction were calculated and measured. Statistical analysis was performed for cortical and subcortical patients separately, using Spearman correlation and multiple linear and logistic regression analyses. Significant correlation was found between CSF Mg+2 and the size of the infarct (P < 0.0001). There was no correlation between serum Mg+2 and CSF Mg+2 levels. Regression analysis demonstrated an increase in the values of the Mathew Neurological Score with higher CSF Mg+2 levels. This association remained true after other factors such as age, associated heart disease, diabetes and infarction size had been taken into account by the regression model. The results confirm that there is a relationship between a low Mg+2 concentration in CSF during the first 48 h after onset of ischaemic stroke and the intensity of the neurological deficit. The therapeutic consequence of this finding may have some importance.

Rhabdomyolysis induced by simvastatin and ketoconazole treatment.

Rhabdomyolysis is described as an adverse event of simvastatin therapy either by itself or in combination with other medications. It is unclear whether this phenomenon is specific to simvastatin or to all cholesterol-lowering agents as single-dose therapy or caused by the association of special coadministered medications. We describe two cases in which rhabdomyolysis developed after coadministration of simvastatin (20 mg/d) and the antifungal ketoconazole. The clinical features, blood examination results, and positive outcome were very similar in both cases. We concluded that ketoconazole, an antifungal sterol synthetic inhibitor of the azol group, may induce rhabdomyolysis in patients undergoing treatment with simvastatin, a lipid lowering agent, and increase the possibility of muscle-damaging adverse events of the agents.

Weight gain, increased appetite, and excessive food intake induced by carbamazepine.

Four young patients who developed weight gain induced by carbamazepine therapy are described. The patients received the carbamazepine as anticonvulsant treatment, and soon after starting the drug, abruptly developed an increase in appetite with a concomitant increase in food intake. During a period of 2 months the patients' weights rose by between 7 and 15 kg. Dietary restriction during the carbamazepine treatment was ineffective in promoting weight loss, and loss of the excess weight was achieved only when the drug was discontinued. These patients demonstrate an as yet unpublished adverse effect of carbamazepine. In carbamazepine-induced weight gain, overeating and fat deposition must be taken into consideration as a differential diagnosis to the hitherto described water retention and edema.

Intravenous administration of magnesium sulfate in acute stroke: a randomized double-blind study.

A randomized, placebo-controlled, double-blind study was performed as a pilot study to examine the benefit of the administration of magnesium sulfate given intravenously as a protective substance during the first 24 hours following a stroke. Patients who had cortical infarction in the middle cerebral artery territory with moderate to severe neurologic deficits lasting for more than 15 minutes with onset less than 24 hours were included. The patients were treated with magnesium sulfate or placebo for 5 days and examined by a blinded investigator. Patients had follow-up for 30 days. The primary efficacy variable was the proportion of patients reaching mild to moderate neurologic deficit on the Orgogozo scale (80 points) and relative functional independence on the Barthel index (60 points). Orgogozo scale and Mathew scale values were obtained on admission and days 2, 4, 8, and 30 after stroke. Barthel activities of daily living index and Rankin disability score were obtained on day 30. Forty-one patients (22 given treatment and 19 given placebo) demonstrated significant beneficial effects on the Orgogozo scale (84 +/- 11 vs. 64 +/- 10, p < 0.0001) and (83 +/- 14 vs. 70 +/- 15, p < 0.009), respectively. At the end of 1-month follow-up, the Barthel ADL index was nonsignificantly higher and the Rankin disability score was marginally significantly lower in the magnesium-treated group (84 +/- 26 vs. 71.8 +/- 26, p < 0.143) than in control subjects (2.3 +/- 1.1 vs. 3 +/- 1.3, p < 0.077). Intravenous magnesium sulfate had significant positive effect on the outcome in patients with acute stroke. Further studies on a larger scale are needed to confirm these findings.

Intracranial meningiomas: correlation of peritumoral edema and psychiatric disturbances.

Patients with proven intracranial meningioma were reexamined for psychiatric morbidity. Distribution according to type of meningioma was as follows: 72% convexity meningiomas and 28% base-of-skull meningiomas. No psychiatric disorders were diagnosed in the nonconvexity group in contrast to 44% in the convexity meningiomas. Among the convexity meningiomas, no difference between right- and left-hemispheric locations was found. Psychiatric comorbidity in the right-hemisphere group was found only in patients with frontal lobe meningiomas. Edema width was measured on all computed tomographic scan slices on which it appeared, and the average of all the slices was calculated. No correlation was found between neurological symptoms and edema severity. A statistically significant correlation was found between edema volume and the presence of coexisting psychiatric disorders, but not between the tumor's mass volume and the psychiatric symptoms.

Bilateral ptosis and changes in state of alertness in thalamic infarction.

Uni- or bilateral supranuclear ptosis is known to be caused by cerebral lesion. The exact anatomical cortical and subcortical basis is still undefined. We report a case of a patient developing bilateral ptosis with a left thalamic lesion. The bilateral ptosis was associated with transient changes in the state of alertness. We postulate that the thalamus, especially the anterior region, may have an influential role on the pathway from the cortex via the posterior branch of the internal capsule to the levator palpebrae superioris nuclei.

Strokes mimicking peripheral nerve lesions.

Sensory-motor deficit in a peripheral nerve pattern due to brain lesion is rarely documented. We report on seven patients with a clinical manifestation of sensory-motor deficit, imitating peripheral nerve involvement, due to lacunar brain infarcts verified by brain computed tomography scan. Five of the patients had an ulnar nerve-like deficit and two median nerve-like deficits. The infarcts were located in the thalamus and the corona radiata. No clinical or electrophysiological evidence for peripheral nerve involvement was found. The unusual peripheral nerve pattern of lesions caused by lacunar brain infarcts can be defined as an additional lacunar syndrome and must be taken into consideration in the clinical evaluation of peripheral nerve deficits with normal nerve conduction velocity.

Familial dyslexia associated with cavum vergae.

Three members of one family, diagnosed as dyslexic, are described. All of them have variations of midline cavity: cavum vergae or cavum septum pellucidum, diagnosed by neuroradiological examination. In contrast, the non dyslexic members of the same family have no neuroanatomical congenital variations. We raise the possibility of a functional correlation between the dyslexia and the anatomical findings in the affected members of this family.

Benign intracranial hypertension: correlation of cerebral blood flow with disease severity.

UNLABELLED: Benign intracranial hypertension (BIH) is characterized by symptoms and signs of raised intracranial pressure in the absence of an intracranial mass lesion, infection or hydrocephalus. The purpose of this study was to evaluate the effect of disease severity on cerebral blood flow in patients with BIH on acetazolamide therapy. METHODS: 11 patients (nine females, two males; mean age 30.5 years; range 22-29 years) with BIH were studied. All patients underwent CT and MRI scanning which were normal. The CSF pressure of all patients was above 200 mm H2O. All patients were under treatment with acetazolamide (1 g/day). Disease severity was determined by visual field examination and by clinical symptoms. Five patients were categorized into mild to moderate BIH (group I) and six patients had severe BIH (group II). All patients underwent perfusion brain SPECT with 740 MBq of Tc-99m-HMPAO. RESULTS: Brain perfusion abnormalities were observed in six of the 11 patients. One out of five patients in group I (20%) and five out of six patients (83%) in group II, had abnormal SPECT findings (P<0.04). In four patients of group II the left parietal lobe was involved and another patient had a right occipital abnormality. The single patient from group I with SPECT abnormalities demonstrated focal decreased perfusion in the left temporal area and decreased perfusion in the left caudate nucleus. CONCLUSION: Patients with severe degree of BIH have a higher incidence of cerebral perfusion abnormalities. This group may have an increased risk of cerebrovascular complications. The continuous administration of acetazolamide which affects the vascular autoreactivity may contribute to the regional hypoperfusion. Further studies are recommended to evaluate the natural course of disease versus iatrogenic treatment effects.

Self and body esteem perception in multiple sclerosis.

Self esteem and body esteem were examined in a group of 35 relapsing-remitting multiple sclerosis (MS) patients using the Body Esteem Scale (BES) and the Eysenck Self Esteem Scale (ESES) and compared to age and sex matched normal controls. There were 23 females and 12 males in the MS patient's group; average age 38.9 years (range: 22-52). All participants completed the self-rated BES evaluating the following subscales: females - sexual attractiveness, physical condition and weight concern; males - physical attractiveness, physical condition and upper body strength. In addition all participants were scored, following a semi-structured interview, on the ESES. Psychiatric co-morbidity was excluded using a semi-structured interview by the consulting psychiatrist. All evaluations were carried out during the remitting phase. Statistical analysis, comparing patients to healthy controls, demonstrated lowered self-rating of the physical condition (males < 0.05, females < 0.001). On the other hand, no significant differences were found in the physical (male) or sexual (female)�attractiveness subscales. The mean ESES score in the patients group was 23.2 ± 4.0, slightly above the reported average. The controls mean ESES was 28.4 ± 3.6, (P < 0.05). No correlation was found between self and body esteem amongst M.S. patients. This study emphasizes impaired perception of body esteem in multiple sclerosis patients even in remission. The preservation of physical and sexual attractiveness may be related to the non-disfiguring nature of the disease. Preservation of self-esteem in MS patients suggests that body-esteem should be the focus of supportive treatment.

Fluoxetine induced weight loss: a pilot study in postpartum women.

Twelve women who developed an average postpartum weight gain of 18.3kgs (SD +/- 6.09) entered an open trial, for three months, of fluoxetine 20 mg daily. The weight gain during their pregnancies was nearly twice that recommended by the treating gynecologists. Seventy-five percent success rate was achieved -8/12 were +/- 5% of their pre-pregnancy weights upon completion of the trial. Mean weight upon entering the trial was 82.25kgs (SD +/- 13.39), and at termination, 65.75kgs (SD +/- 8.59), P < 0.001. Anorexia and weight loss (more than 5% of body weight) have been reported in the literature in 9% and 13%, respectively, of depressed patients treated with fluoxetine. The use of this drug to promote weight loss is here reported in a selected population of women without signs or symptoms of depression, whose weight gain during pregnancy was excessive.

Body esteem in Israeli university students.

Body-esteem is an important dimension in the general concept of body-image. The Body Esteem Scale (BES) was developed and tested in the USA. We tested young men and women in Israel all of whom were university students after their army service. Our results show that Israeli men score lower (feel more negative) on the virility reflecting subscale while Israeli women score higher (feel more positive) in the weight concern subscale--compared to their American counterparts. We discuss the possible explanations of this difference, focusing mainly on the impact of army discharge and the move to the academic field.

Laboral outcome after acute unilateral vestibulopathy.

Sixty-five adult patients who had acute peripheral vestibulopathy (APV) were followed-up to determine their functional outcome. During the acute phase, they were treated with betahistine and mobilization. In the entire study population, APV was not significantly associated with a change in occupational activities, physical work or driving ability. Older individuals had significantly attributed a change in work to disease other than APV. Change attributed to APV occurred significantly more frequently in women than in men. The therapeutic approach seems beneficial.