Incidence of seizures with tricyclic and tetracyclic antidepressants.

One hundred eighty-six depressed psychiatric inpatients were seen at our institution during 1982. Forty-five of these patients were treated with tricyclic antidepressants, 32 received maprotiline hydrochloride, a tetracyclic compound, 20 received other medications, and 82 received no drug treatment. One patient in the tricyclic group (2.2%) and five patients in the maprotiline group (15.6%) developed seizures. In four patients the seizure followed the institution of maprotiline therapy by less than three weeks. These data indicate that depressed patients taking the tetracyclic drug maprotiline are at risk for developing epileptic seizures.

The value of visual evoked potential as a screening test in neurofibromatosis.

Pattern reversal visual evoked potential (VEP) test was performed in 30 asymptomatic patients with neurofibromatosis (NF). All patients had normal visual acuity, visual fields, and ophthalmoscopic examination results. Pattern reversal VEP was abnormal in eight patients (26%). Seven of these patients had computed tomographic scans with reformated orbital views. Orbital computed tomographic scans were abnormal in six patients and in each case showed enlargement of the optic nerve on the side of VEP abnormality. Our data indicate that pattern reversal VEP is a valuable screening test in asymptomatic patients with NF. Because of the high incidence of VEP abnormality in such patients, VEP abnormality must be interpreted cautiously when a patient with NF is suspected of having other diseases or disorders that potentially affect the visual pathways.

Magnetic resonance imaging in partial complex epilepsy.

The yield of magnetic resonance (MR) imaging was investigated in 30 patients with partial complex epilepsy, and the results were compared with those of computed tomography (CT). Magnetic resonance imaging and CT disclosed focal cerebral abnormalities in 13 (43%) and eight (26%) patients, respectively. Two additional focal temporal lesions were identified by double-dose CT scanning, increasing the yield of CT to 33%. Magnetic resonance images were abnormal in all patients with focally abnormal CT scans, and in four patients (50%) they defined the extent of the temporolimbic lesions better than did the CT scans. Two of these patients had gliomas. In addition, MR images were focally abnormal in 85% of the patients in whom scalp electroencephalograms showed focal ictal discharges. These data indicate that MR imaging is more informative than CT in partial complex epilepsy.

The impact of new pharmaceutical agents on the cost of neurologic care.

Since the emergence of the specialty, neurologists have worked with a rather restricted list of relatively inexpensive pharmacologic agents. This is rapidly changing with the development of new agents for the treatment of migraine, multiple sclerosis, Parkinson's disease, Alzheimer's disease, and epilepsy, accelerated in part by designation of the 1990s as the "Decade of the Brain." Exciting as these developments are, they are very costly when applied to the large number of patients who may benefit, perhaps exceeding $6.4 billion. Since this cost exceeds the $1.5 billion income of all practicing neurologists, it enhances the value of the neurologic consultation, which can provide more accurate diagnosis and more expertly directed therapy. Our relationships with the drug manufacturers are changing as our prescribing habits become a more likely determinant of profits.

Carbamazepine-induced orofacial dyskinesia.

Extrapyramidal syndromes have been described after administration of phenytoin and primidone. Although asterixis, dystonia, and tremor have been described with carbamazepine (Tegretol), there is no report of orofacial dyskinesia. We report a case in which a dose-related lingual-facial-buccal extrapyramidal reaction occurred in association with carbamazepine intoxication.

Utilization of nurse clinicians and physician assistants by Active members and Fellows of the American Academy of Neurology.

A study of 343 Active members and Fellows of the American Academy of Neurology revealed that among 285 responders who spent over 10 hours per week in direct patient care, 198 were in private practice, 69 worked exclusively for institutions, and 18 worked part time in each setting. Eighty-three (29%) used extenders in their practice. Institutionally based neurologists were significantly more likely to use extenders than those in private practice.

Improvement of ataxic hemiparesis with trihexyphenidyl.

In a patient with the syndrome of crural paresis and homolateral ataxia, administration of trihexyphenidyl resulted in improvement of disabling unilateral ataxia and gross intention tremor. Symptoms returned when drug therapy was interrupted. CT showed a radiolucent lesion deep in the parietal white matter close to the internal capsule.

Nerve agents: a review.

Nerve agents produce neuromuscular blockade and convulsions in exposed humans. Military personnel in areas of potential exposure take prophylactic pyridostigmine. They are instructed to self-administer atropine and pralidoxime at the first sign of nerve agent toxicity. The key to treatment of nerve agent poisoning is the administration of atropine in doses larger than is customary in most other disorders, repeated as often as needed. Mechanical ventilation may be required. Convulsions are treated with diazepam, but only after atropine has been administered.

The neurology clerkship core curriculum.

Neurologic symptoms are common in all practice settings, and neurologic diseases comprise a large and increasing proportion of health care expenditures and global disease burden. Consequently, the training of all physicians should prepare them to recognize patients who may have neurologic disease, and to take the initial steps in evaluating and managing those patients. We present a core curriculum outlining the clinical neurology skills and knowledge necessary to achieve that degree of preparation. The curriculum emphasizes general principles and a systematic approach to patients with neurologic symptoms and signs. The ability to perform and interpret the neurologic examination is fundamental to that approach, so the curriculum delineates the essential components of the examination in three different clinical settings. The focus of the curriculum is on symptom-based rather than disease-based learning. The only specific diseases selected for inclusion are conditions that are common or require urgent management. This curriculum has been approved by the national organization of neurology clerkship directors and endorsed by the major national professional organizations of neurologists. It is intended as a template for planning a neurology clerkship and as a benchmark for evaluating existing clerkships. It should be especially helpful to clerkship directors, neurology chairs, deans of medical education, and members of external accreditation groups.

The site of the lesion in acute deafness of multiple sclerosis--contribution of the brain stem auditory evoked potential test.

Two patients with multiple sclerosis experienced acute unilateral deafness during an exacerbation. The brain stem auditory evoked potential test (BAEP) of both patients revealed absence of all waves after wave I, on the side of the hearing loss. These findings strongly suggest that acute hearing loss in multiple sclerosis results from involvement of the eighth nerve close to the ponto-medullary junction.

Administrative management of the soldier with seizures.

Based on improvement in our understanding of the prognosis of young adults with new onset seizures, and cumulative experience with the rules in effect for the last 30 years, a substantial change in the regulations affecting the fitness and profiling of these soldiers has been made. In general, these liberalize retention and profiling, set limits on the duration of trials of duty, provide for fitness determinations in soldiers with pseudo-seizures, and specify when neurologic consultation is required.

Impact of the new fitness regulation for epilepsy.

In 1983, a new regulation was prepared, based on clinical reports published at that time, redefining the fitness standards for those applicants to the military who had experienced one or more seizures during childhood or early adult life. The most important change admitted those who had been free of seizures and off medications for 5 years or more and who had normal EEGs. Only 2 of 155 soldiers enlisted in 1986 and 1987 meeting these criteria were separated for seizure-related complaints. Both had problems during basic training and the diagnosis of recurrent epilepsy was tenuous in both. We conclude that the regulation change has given many young adults a chance to serve effectively in the Army without appreciable increase in medical or training costs.