Hypertensive encephalopathy after successful treatment of eclampsia.

The association between acute rise of blood pressure and encephalopathy with early recognition, and therapy reversibility has been reported. We reported a case of a young lady in postnatal period, presented with acute rise of blood pressure, encephalopathy, quadriparesis, and apraxia. Magnetic resonance imaging of the brain showed hyperintense lesions in occipital, parietal and right temporal areas. Cerebral angio showed multiple segmental vasoconstriction and narrowing of intracerebral vessels. Immediate control of blood pressure enhanced recovery but it is incomplete.

Saudi Medical Journal. Two Decades of Success.

Full text is available as a scanned copy of the original print version.

New features in the Saudi Medical Journal.

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New features in the Saudi Medical Journal.

Full text is available as a scanned copy of the original print version.

New Horizons in management of Alzheimer's disease.

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Acute transverse myelitis. A localized form of postinfectious encephalomyelitis.

We analysed the clinical, imaging, electrophysiological, laboratory findings, course and prognostic factors in 31 patients with acute transverse myelitis (20 men and 11 women; mean age, 30 years; range, 18-51 years). All patients were assessed for maximal clinical deficit 'deficit score'; pattern-shift visual, auditory and somatosensory evoked potentials were measured, CSF was examined, and neuroimaging of the spinal cord and brain (MRI or CT myelography) was carried out. The myelitis was preceded by febrile illness in 25 (81%) of the patients. The site of the lesion was cervical in 11 (36%), upper thoracic in two (6%), lower thoracic in 16 (52%). MRI of the spinal cord was abnormal in 10 out of the 20 patients examined (50%); in the remaining 11 patients, only CT was carried out and it was normal in all of them. Somatosensory evoked potentials were abnormal in 19 (61%), while pattern-shift visual and brainstem auditory evoked potentials were normal in all patients. CSF was abnormal in 94% of patients with pleocytosis, increased protein or both. Eighteen patients (58%) had good outcome. All patients had monophasic illness. Three variables have emerged as being associated with significant worsening of the outcome: (i) abnormal somatosensory evoked potentials; (ii) abnormal imaging and (iii) high 'deficit score' at onset. Acute transverse myelitis affects a complete segment of the spinal cord, is monophasic and represents a localized form of postinfectious acute encephalomyelitis.

Nocturnal epilepsies in adults.

We evaluated the clinical characteristics and the electroencephalographic (EEG) findings by long video-EEG monitoring in 64 successive patients with definite nocturnal seizures. Mental state, neurological examination, neuroimaging and EEG background were normal in all patients. Classification of epilepsies was possible in 42 out of 64 (66%) patients according to the revised Classification of Epilepsies and Epileptic Syndromes by the Commission on Classification and Terminology of International League Against Epilepsy (1989). Out of those 42 patients, 33 (79%) had partial epilepsies, while 9 (21%) had generalized epilepsies. Response to antiepileptic drugs was excellent and only 4 (6%) patients had one seizure attack per year, two of them were on two antiepileptic drugs while the others were free of seizure on a single drug during the 2 years of follow-up. It seems that nocturnal seizures in adults form a new distinctive partial epileptic syndrome of a benign entity.

Subacute sclerosing panencephalitis (SSPE): early diagnosis, prognostic factors and natural history.

We studied the value of long video-split electroencephalographic monitoring (VSEEG) in detecting myoclonus in nearly SSPE and evaluated the natural history and outcome-affecting factors. The 32 newly diagnosed patients had VSEEG to detect myoclonus and its correlations with EEG periodic complexes. Disease progression was monitored by a special "outcome score'; the chi-square test and multi-variable statistics analysed the outcome score in relation to different variables, such as age at onset, sex, duration of symptoms at presentation, CSF measles antibody titre, type and interval between periodic complexes (EEG discharges). Myoclonus or atonia occurred in all patients and was time-related to the EEG periodic complexes; in 32% of patients, myoclonus or atonia were not clinically evident. The EEG periodic complexes were of 3 types: Type I (16 patients) periodic giant delta waves; Type II (10 patients) periodic giant delta waves intermixed with rapid spikes or fast activity; and Type III (6 patients), long spike-wave discharges interrupted by giant delta waves. Outcome score was associated with symptoms duration (P < 0.01) and EEG periodic complexes (P < 0.05). Symptom duration was inversely related to final outcome (multi-variable analysis). Long VSEEG monitoring greatly improves early diagnosis and detection of subtle atonia or segmental myoclonus. Prognostic factors were the type of EEG periodic complexes and duration of symptoms at presentation.

Neurological complications of infective endocarditis.

We reviewed the files of 80 successive patients with native and prosthetic valve endocarditis admitted to Riyadh Armed Forces Hospital. Neurological complications (NC) occurred in 28 (35%) patients. The valves involved were mitral in 12 (43%), aortic in eight (29%), combined mitral and aortic lesions in six (21%), and others in two (7%). The common causative organisms were Stretococci in 12 (43%), Staphylococcus aureus and Staphylococcus epidermides, both occuring in four (14%). Compared to the 52 infective endocarditis patients with no neurological complications (NNC), the NC occurred more frequently in male patients, those with aortic valve lesion, those with atrial fibrillation, those with delayed therapy and those with causative organisms being Streptococci or Staphylococci. Eleven patients died (39%), 12 (43%) recovered with motor sequelae, six (21%) had seizure disorder, and five (18%) had full recovery. The frequency of neurological complications and mortality is comparable to those reported in the literaturel; however, the frequency of strokes was higher in our patients.

Multiphasic disseminated encephalomyelitis presenting as alternating hemiplegia.

Two cases of alternating hemiparesis are reported, one in a black Sudanese woman, the other in a Saudi man, who had two episodes of alternating hemiparesis separated in time by six and three years respectively. Based on the typical appearance of the MRI and the results of brain biopsy, the diagnosis of multiphasic disseminated encephalomyelitis was made rather than that of multiple sclerosis. This entity is also differentiated from recurrent disseminated encephalomyelitis, where the relapses are symptomatically stereotyped although the appearance of the MRI is similar and in which new lesions do not occur. Because of the unusual appearance of these MRI lesions, brain biopsy is often performed but recognising their relevance should obviate that need.

Electroclinical seizures in Lennox-Gastaut syndrome.

We analyzed electroclinical seizures observed by long video split-screen recording in 21 patients with Lennox-Gastaut syndrome (LGS). All patients had atypical absence seizures, 18 (81%) had tonic seizures, and 4 (21%) had myoclonic-atonic seizures. Tonic seizures were axial with flexion or extension of the head or trunk, or global with generalized tonic spasm mimicking infantile spasm, or involved the eyeballs only (either brief, with upward deviation of eyeballs or long, with oscillatory nystagmus). EEG showed either a bilateral 10-13-Hz rhythm or generalized synchronous spike wave at 3 Hz. Myoclonic-atonic seizures involving limbs, trunk, or neck were either brief or massive; the discharges were 2-3.5-Hz spike wave. Atypical absence seizures evolved gradually, terminated abruptly, and manifested alone or with subtle motor activity or oral automatism. EEG discharges were variable and of different types: (a) Diffuse irregular spike wave at 2-2.5 Hz with or without fragmentation (consciousness was regained during fragmentation or when spike wave discharges were < 2 Hz), (b) irregular diffuse fast activity at 10-13 Hz, or (c) a combination of fast spike wave or sharp waves of increasing amplitude followed by synchronous spike wave discharges at 3 Hz.

Diagnostic role of brain-stem auditory evoked potentials in neurobrucellosis.

Evoked potential audiometry and brain-stem auditory evoked potentials were evaluated in 15 patients with systemic brucellosis in whom brucella meningitis was suspected clinically. In 8 patients cerebrospinal fluid (CSF) was abnormal with high brucella titre, and evoked potentials were abnormal in all of them. In 7 patients the CSF was normal and evoked potentials were also normal. Brain-stem auditory evoked potential abnormalities were categorised into 4 types: (1) abnormal wave I, (2) abnormal wave V, both irreversible, (3) prolonged I-III interpeak latencies, and (4) prolonged I-V interpeak latencies, both reversible. These findings are of important diagnostic value and correlate well with the clinical features, aetiopathogenesis and final outcome.

Neurotuberculosis: a review.

Tuberculosis is still a major cause of serious illness in many parts of the world. CNS involvement has frequently been found secondary to tuberculosis elsewhere in the body, particularly the lungs. The disease manifests itself as meningitis, tuberculoma and/or spinal tuberculosis. The presence of tuberculosis elsewhere in the body favors the diagnosis although its absence does not exclude it. While tuberculous meningitis is a disease of childhood, tuberculomas and spinal tuberculosis are invariably an adult manifestation. The great majority of patients with neurotuberculosis are diagnosed and treated early because of characteristic clinical, imaging, and CSF findings. Clinical response to antituberculous therapy in all forms of neurotuberculosis is excellent if the diagnosis is made early before irreversible neurological deficit is established.

Effects of methylcobalamin on diabetic neuropathy.

We studied the clinical and neurophysiological effects of methylcobalamin on patients with diabetic neuropathy. In a double-blind study, the active group showed statistical improvement in the somatic and autonomic symptoms with regression of signs of diabetic neuropathy. Motor and sensory nerve conduction studies showed no statistical improvement after 4 months. The drug was easily tolerated by the patients and no side effects were encountered.

Cerebrovascular disease in Saudi Arabia.

We studied the pattern and outcome of strokes in 200 Saudi patients. Cerebral infarction constituted 87% of strokes, subarachnoid hemorrhage 4.5%, cerebral hemorrhage 6.5%, and venous infarction 2%. The vessel most commonly involved was part or all of the middle cerebral artery, constituting 52% (90) of the 174 arterial infarcts. Lacunar infarcts were seen in 21% (37) of the patients with arterial infarcts. Among all 200 patients, 8% died and 8% had secondary generalized seizures. Hypertension occurred in 41% of the 174 patients with arterial infarcts and 62% of the 13 with cerebral hemorrhages. The highest incidence of hypertension as a risk factor was among those with lacunar infarcts (81%), ganglionic cerebral hemorrhages (80%), and infarcts of deep branches of the middle cerebral artery (57%). Embolic infarcts due to rheumatic heart disease constituted 11% of all arterial infarcts. We conclude that our pattern of strokes is similar to that of the west rather than that of the Japanese, but with less frequent arteriovenous malformations and aneurysms.

Bickerstaff brainstem encephalitis. A grave non-demyelinating disease with benign prognosis.

We describe 6 patients with ophthalmoplegia, ataxia and normal or exaggerated deep tendon reflexes. All had been preceded by a febrile illness and had a full recovery without sequelae. The brainstem auditory evoked potentials showed a localised lesion in the upper brainstem while the pattern shift visual evoked potentials were normal and did not show any additional silent lesions. CSF IgG oligoclonal bands were not detected in any of the patients. MRI in 2 patients showed a confluent high intensity lesion in the upper mesencephalon and thalamus involving white and gray matter. Follow-up ranged from 6 to 24 months and showed no relapse.

Neurobrucellosis: clinical characteristics, diagnosis, and outcome.

We report 13 patients with neurobrucellosis categorized into five groups: acute meningoencephalitis; papilledema and increased intracranial pressure, meningovascular, CNS demyelinization, and peripheral neuropathy. We treated the patients successfully, without relapse, with two or more antimicrobials: rifampicin, co-trimoxazole, and doxycycline.

Pure word deafness (acquired verbal auditory agnosia) in an Arabic speaking patient.

A 38-year-old, right-handed Arabic-speaking male developed pure word deafness three days after myocardial infarction. He could recognize Arabic music and instruments but not words of songs; a radio broadcast from the Koran, but not the individual words; a male as opposed to female voice; Arabic and non-Arabic languages; and whether sentences were questions, exclamations, or imperatives. He discerned whether the speaker was emotionally neutral, happy, angry or sad. Contextual cues and reducing the rate of speaking aided verbal comprehension. Pure tone threshhold audiometry revealed mild bilateral sensorineural loss up to 2000 Hz and a moderate high frequency loss. Brainstem auditory evoked potentials were normal, cortical auditory evoked potentials abnormal. CT scan revealed bilateral infarcts subcortically just posterior to the left superior temporal gyrus and the right posterior superior and midtemporal regions. Neurolinguistic tests indicated that the deficit is prephonemic and not due to impairment of linguistic discrimination.