Ictal non-forced grasping behaviour.

Our aim was to investigate whether patients with epileptiform foci in the frontal lobe, as revealed by video EEG (VEEG) analysis, exhibit non-forced grasping behaviour and manipulatory movements during seizures. We retrospectively reviewed ictal videotapes of 30 consecutive patients with frontal and 30 with temporal lobe epilepsy undergoing VEEG for the presence and type of grasping and manipulatory movements. Four of the 30 patients with frontal lobe epilepsy (13%) showed unilateral grasping behaviour, three of whom had whole hand prehension (one with manipulation movements as well) and one pinching movements. In all patients, arm abduction and elevation resembling reaching invariably preceded grasping hand movements. The epileptogenic focus was located in the contralateral and ipsilateral frontocentral region in two and one patient, respectively, and in the ipsilateral orbitofrontal region in another. However, none of the patients with temporal lobe epilepsy showed grasping behaviour. Patients with frontal lobe epilepsy may show non-forced grasping with or without manipulatory finger movements as part of ictal phenomena.

Detection of Helicobacter pylori in human carotid atherosclerotic plaques.

BACKGROUND AND PURPOSE: Several lines of evidence point toward a relationship between infection and atherosclerotic vascular disease. Thus, infection and inflammation often precede ischemic neurological events. Transient alterations in coagulation and direct arterial invasion by certain microorganisms have been reported. Helicobacter pylori infection is the major cause of peptic ulcer disease and appears to be a risk factor for ischemic cerebrovascular disease. However, in contrast to other chronic infectious agents, H pylori has not been consistently isolated from atherosclerotic lesions. METHODS: We investigated the presence of H pylori in 38 atherosclerotic plaques obtained at carotid endarterectomy by using morphological and immunohistochemical techniques and a highly sensitive polymerase chain reaction method. We performed immunohistochemical detection of intercellular adhesion molecule-1, a marker related to inflammatory cell response. We also examined 7 carotid arteries obtained at autopsy from subjects without carotid atherosclerosis. RESULTS: H pylori DNA was found in 20 of 38 atherosclerotic plaques. Ten of the H pylori DNA-positive plaques also showed morphological and immunohistochemical evidence of H pylori infection. None of 7 normal carotid arteries was positive for H pylori. Intercellular adhesion molecule-1 was expressed in 75% of H pylori-positive plaques and in 22% of H pylori-negative plaques. The presence of the microorganism was associated with male sex but was independent of age, vascular risk factor profile, and prior neurological symptoms. CONCLUSIONS: H pylori is present in a substantial number of carotid atherosclerotic lesions and is associated with features of inflammatory cell response. This study provides additional evidence of the relationship between H pylori infection and atherosclerotic disease.

Beneficial effects of lisuride in Meige disease.

We studied the therapeutic effects of apomorphine, bromocriptine, and lisuride on the dystonic spasms of two patients with Meige disease. Lisuride, a potent dopamine receptor agonist, and apomorphine had equal efficacy in lessening facial dyskinesia, while bromocriptine had no consistent effect. Lisuride can be an excellent drug in the treatment of this disabling disorder.

Involuntary movements and abnormal spontaneous EMG activity in syringomyelia and syringobulbia.

OBJECTIVE: To describe different types of involuntary movements and abnormal spontaneous electromyographic (EMG) activity in patients with syringomyelia. BACKGROUND: A comprehensive study on involuntary movements in patients with syringomyelia has not yet been undertaken, to these authors' knowledge. METHODS: One hundred adult patients with syringomyelia were examined over the last 15 years. Involuntary movements were videotaped and evaluated by two independent observers. Electromyographic recordings were made using bipolar surface electrodes. The H-reflex recovery curve was obtained after stimulation of the median nerve at the elbow and recording from the flexor carpi radialis. RESULTS: Involuntary movements or abnormal postures were observed in 22 patients. Three patients showed segmental spinal myoclonus, nine minipolymyoclonus, and four propriospinal myoclonus. Five patients had unilateral or bilateral hand postural tremor (8-10 Hz). Focal or segmental dystonia was observed in three patients. Electromyography showed spontaneous bursts of grouped action potentials synchronous in muscles innervated by the same spinal segment, synchronous firing of neurogenic motor unit potentials, or continuous motor unit activity. Increased H-reflex responses to conditioning stimuli were found in patients with spinal myoclonus. Long latency responses were obtained during peripheral nerve stimulation in four patients. Four patients had rigidity and abnormal upper limb posture. Respiratory synkinesis was observed in three patients. One patient developed inverse masticatory muscle activity. CONCLUSIONS: Patients with syringomyelia showed a wide spectrum of involuntary movements. An increased excitability of spinal motor neurons was probably the basic underlying mechanism.

Neuropsychological and neuroradiologic correlates of emotional prosody comprehension.

We examined a series of 59 patients with acute stroke lesions for the presence of comprehension emotional aprosody. Based on a standardized assessment of comprehension of emotional intonation, 29 patients (49%) showed emotional aprosody (17% "mild" aprosody [n = 10] and 32% "severe" aprosody [n = 19]). Patients with comprehension emotional aprosody showed a higher frequency of extinction on double-simultaneous stimulation, anosognosia, and deficits in facial emotion comprehension. Patients with comprehension emotional aprosody also showed a higher frequency of right-hemisphere lesions involving the basal ganglia and the temporoparietal cortex and more severe frontal and diencephalic atrophy. Comprehension emotional aprosody was not necessarily associated with poststroke depression (PSD) since patients with and without PSD showed similar impairments in emotional prosody comprehension.

Use of antiepileptic drugs in nontraumatic neurosurgical procedures. Is there any best route and time of administration?

We assessed in 15 consecutive patients the best route and time of administration for phenytoin (PHT) prophylaxis in neurosurgical procedures. We also correlated PHT levels in serum and cerebrospinal fluid after oral and parenteral loading doses. The mean PHT level was 13.9 micrograms/ml in serum and 2.03 micrograms/ml in cerebrospinal fluid (CSF), with a significant correlation between levels in both compartments (r = 0.73, p < 0.01). Mean PHT levels among the different groups were not statistically significant. We conclude that therapeutic levels of PHT in CSF can be achieved independently of the route of administration, as long as accepted loading doses are used.

Neurological features in overlap syndrome.

We report the frequency of neurological findings in 33 patients with overlap syndrome and describe 2 patients presenting unusual neurological involvement. Five of the 33 patients (15%) had one or more neurological findings. Unilateral trigeminal sensory neuropathy was presents, in 4 patients, in 3 of whom this was the only neurological feature. In the other patient it was associated with other manifestations of central as well as peripheral nervous system involvement, with an overall clinical pattern highly suggestive of a demyelinating disorder. The fifth patient, after an aseptic meningitis-like illness, developed a slowly progressive paraparesis, likewise pointing to a demyelinating disease. Our findings suggest that neurological manifestations, mainly trigeminal neuropathy, are frequent features in overlap syndrome; occasionally, central nervous system involvement mimicking a demyelinating disease may also be observed.

Time distribution of epileptic seizures during video-EEG monitoring. Implications for health insurance systems in developing countries.

An attempt was made to identify guidelines to help establish epilepsy monitoring units in developing countries. We assessed the time distribution of seizures during video-EEG monitoring and we also estimated the minimum time required for such a procedure and the impact of these variables upon the health insurance system. Mean time for recording five stereotyped clinical events was 72 hours, with a significant number of events recorded between midnight and 0600 hours (P < 0.05). This pilot study may help to establish local policies that will warrant an adequate work-up for our patients.

Limb apraxias: higher-order disorders of sensorimotor integration.

Limb apraxia comprises a wide spectrum of higher-order motor disorders that result from acquired brain disease affecting the performance of skilled, learned movements. At present, limb apraxia is primarily classified by the nature of the errors made by the patient and the pathways through which these errors are elicited, based on a two-system model for the organization of action: a conceptual system and a production system. Dysfunction of the former would cause ideational (or conceptual) apraxia, whereas impairment of the latter would induce ideomotor and limb-kinetic apraxia. Currently, it is possible to approach several types of limb apraxia within the framework of our knowledge of the modular organization of the brain. Multiple parallel parietofrontal circuits, devoted to specific sensorimotor transformations, have been described in monkeys: visual and somatosensory transformations for reaching; transformation of information about the location of body parts necessary for the control of movements; somatosensory transformation for posture; visual transformation for grasping; and internal representation of actions. Evidence from anatomical and functional brain imaging studies suggests that the organization of the cortical motor system in humans is based on the same principles. Imitation of postures and movements also seems to be subserved by dedicated neural systems, according to the content of the gesture (meaningful versus meaningless) to be imitated. Damage to these systems would produce different types of ideomotor and limb-kinetic praxic deficits depending on the context in which the movement is performed and the cognitive demands of the action. On the other hand, ideational (or conceptual) apraxia would reflect an inability to select and use objects due to the disruption of normal integration between systems subserving the functional knowledge of actions and those involved in object knowledge.

Pupillary sparing in oculomotor palsy from temporal lobe astrocytoma. Report of two cases.

Two cases are reported of pupillary sparing in oculomotor palsy from temporal lobe astrocytoma. In one of them it was the first manifestation of recurrence of tumour. Tumour infiltration with resultant nerve ischemia is suggested to be the responsible pathological process.

Mismatch between electrophysiologically defined and ventriculography based theoretical targets for posteroventral pallidotomy in Parkinson's disease.

OBJECTIVES: Over the past few years many reports have shown that posteroventral pallidotomy is an effective method for treating advanced cases of Parkinson's disease. The main differences with earlier descriptions were the use of standardised evaluation with new high resolution MRI studies and of single cell microrecording which can electrophysiologically define the sensorimotor portion of the internal globus pallidus (GPi). The present study was performed on a consecutive series of 40 patients with Parkinson's disease who underwent posteroventral pallidotomy to determine localisation discrepancies between the ventriculography based theoretical and the electrophysiologically defined target for posteroventral pallidotomy. METHODS: The tentative location of the posteroventral GPi portion was defined according to the proportional Talairach system. Single cell recording was performed in all patients. The definitive target was chosen according to the feasibility of recording single cells with GPi cell features, including the presence of motor drive and correct identification of the internal capsule and of the optic tract by activity recording and microstimulation. RESULTS: In all 40 patients the electrophysiologically defined sensorimotor portion of the GPi was lesioned, with significantly improved cardinal Parkinson's disease symptoms as well as levodopa induced dyskinesias, without damage to the internal capsule or optic tract. Significant differences between the localisation of the ventriculography based theoretical versus electrophysiological target were found in depth (p<0.0008) and posteriority (p<0.04). No significant differences were found in laterality between both approaches. Difference ranges were 8 mm for laterality, 6.5 mm for depth, and 10 mm for posteriority. CONCLUSIONS: Electrophysiologically defined lesion of GPi for posteroventral pallidotomy, shown to be effective for treating Parkinson's disease, is located at a significantly different site from the ventriculography based theoretical target.

Transient epileptic amnesia in dementia: a treatable unrecognized cause of episodic amnestic wandering.

The authors present two patients with dementia who displayed recurrent transient episodes of amnestic wandering and disorientation characterized by getting lost in familiar environments. At other times these patients did not wander or become disoriented. The inability to recall any information during these episodes, and the marked difference of the episodic amnesia exacerbations from the progressive amnesia characteristic of Alzheimer disease seen in these patients led to their evaluation. These clinical episodes and the bilateral interictal epileptiform electroencephalographic changes found in both patients led to the diagnosis of transient epileptic amnesia, a syndrome that can be diagnostically elusive. These transient amnestic wandering events subsided after treatment with antiepileptic drugs in both patients. The authors suggest that transient wandering of this type may be caused by ictal events or postictal confusional states. This report emphasizes the importance of recognizing transient epileptic amnesia as an easily treatable cause of episodic behavioral abnormalities responsive to antiepileptic therapy, especially in those patients who have a markedly inconsistent pattern of wandering, disorientation in familiar settings, and amnesia exacerbation manifested by no recall of the emotional stress of getting lost or of any information during these episodes. Recognition of this type of behavioral disruption and its proper treatment can lead to improved quality of life for these patients, maintain these patients in their homes and out of chronic care institutions longer, and facilitate the community's and caretaker's interactive roles with the patient.

Dystonia and reflex sympathetic dystrophy induced by ergotamine.

A 59-year-old man developed dystonia and reflex sympathetic dystrophy after receiving high doses of ergotamine for migraine treatment. Ischemia is suggested as the precipitating factor.

Changes in regional cerebral blood flow beyond the temporal lobe in unilateral temporal lobe epilepsy.

PURPOSE: Single photon emission computed tomography (SPECT) is widely used to evaluate functional abnormalities during the epileptic event. Changes in regional cerebral blood flow (rCBF) are well defined in patients with temporal lobe epilepsy (TLE) undergoing surgical resection. Nonetheless, the interpretation of ictal abnormalities in CBF beyond the temporal lobes has not been carefully addressed. METHODS: We assessed 4 patients with pathologically proven unilateral TLE who had significant ipsilateral frontal hypoperfusion in ictal studies with no other abnormalities but chronic epilepsy accounting for such findings. Patients were assessed as candidates for surgery by interictal EEG, neuropsychological studies, brain magnetic resonance imaging, scalp electrode video-EEG monitoring, and ictal SPECT. RESULTS: Characteristic hyperperfusion was evident over the temporal lobe ipsilateral to the EEG focus, with significant hypoperfusion over the frontal region in 3 patients. In patient 4, frontal hypoperfusion was not statistically significant. CONCLUSIONS: SPECT demonstrated relative rCBF changes beyond the epileptogenic zone in unilateral TLE. Our findings provide further insight into the pathophysiological changes underlying this condition.

Apraxia in Parkinson's disease, progressive supranuclear palsy, multiple system atrophy and neuroleptic-induced parkinsonism.

We studied 45 non-demented patients with Parkinson's disease (PD), 12 with progressive supranuclear palsy (PSP), 10 with multiple system atrophy (MSA) and 12 with neuroleptic-induced parkinsonism (NIP) for the presence of apraxia. Our aim was to determine whether a standard comprehensive assessment of different praxic functions would demonstrate specific types of errors not attributable to bradykinesia, rigidity, tremor or any other abnormal elementary motor deficit. PD patients on chronic levodopa treatment were examined in the 'on' and 'off' (treatment) states. Based on apraxia assessment scores, bilateral ideomotor apraxia for transitive movements was found in eight (75%) and 12 (27%) of PSP and PD patients, respectively. Ideomotor apraxia was mainly characterized by spatial errors (i.e., external and internal configuration, body-part-as-object and trajectory). Four PSP but no PD patients exhibited ideomotor apraxia for intransitive movements. PSP as well as PD patients with ideomotor apraxia also had difficulties in imitating hand and finger postures, but none of them failed on pantomime comprehension and pantomime recognition/discrimination. Some PSP patients exhibited, in addition, a limbkinetic type of apraxia and a minority of them displayed deficits on tasks involving multiple steps. Neither MSA nor NIP patients showed any disturbance of praxic functions. There were no differences in age, disease duration, Mini Mental State Examination (MMSE), Unified Parkinson's disease Rating Scale and Hoehn-Yahr scores between apraxic and non-apraxic PD patients, and ideomotor apraxia scores were similar in the 'on' and 'off' states. A correlation was found between ideomotor apraxia scores in PD patients and deficits in frontal lobe-related neuropsychological tasks such as the Tower of Hanoi, verbal fluency and the Trail Making Test. Furthermore, PD patients with apraxia showed higher Hamilton depression scores than non-apraxic PD patients. In PSP patients, ideomotor apraxia scores correlated significantly with cognitive deficit as measured with MMSE. The presence or absence of cortical involvement, and its severity and distribution might determine the presence and type of apraxia in PD and PSP. Apraxia in these conditions would therefore reflect combined cortico-striatal dysfunction.