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Central or atypical skull base osteomyelitis (CSBO) often presents with severe unrelenting headache and progressive mono or polyneuritis cranialis. MRI and CT are used as initial imaging techniques but have a poor specificity and sensitivity.To analyze our cohort of CSBO.Over a 5-year period [2015-2020], we retrospectively analyzed the records of all patients with CSBO who had undergone a 3T MRI Brain, MR angiography, regional FDG PET-CT, and skeletal scintigraphy with 99mTc MDP/SPECT-CT. Surgical biopsy specimens were sent for bacterial and fungal cultures.In total, 17 patients with CSBO were identified. Typically, 88% of patients presented with severe unilateral headache. All patients had at least a cranial mono or polyneuritis. The majority of patients were diabetic [64%]. MRI was normal in 42% of patients, whereas PET-CT and with 99mTc MDP scan and SPECT-CT were abnormal in all patients.Our series of CSBO showed a 40% mortality rate with significant morbidity and relentless progression. Patients required repeated PET CT and bone scans to detect regression of disease activity. The average duration of IV therapy ranged from 3 weeks to 9 months and oral therapy for around 2-3 months. Cure was defined after taking into account the original diagnosis, symptom resolution, and concordant reduction of tissue uptake on PET CT and 99mTc bone scan. The combination of MRI, FDG PET CT, and 99mTc bone scan with concurrent SPECT CT was able to detect disease and disease progression in all patients. more...

The differential diagnosis of generalized weakness in ICU patients is quite broad. Although neuromuscular disorders are the most common causes of generalized weakness, a thorough evaluation is necessary to delineate the underlying cause of weakness. Biochemical studies, neuroimaging, and electrophysiologic studies help to delineate most of the common disorders associated with weakness. Prompt identification of a neurologic disorder and initiation of therapy speeds up recovery and reduces morbidity and mortality in these patients. more...

There are no data on pulmonary complications in an selected population of patients with intracerebral hemorrhages (ICH). At present, most data is extrapolated from series of patients with stroke that combine patients with both ischemic and hemorrhagic strokes. The purpose of this study was to determine the frequency, types of pulmonary complications in patients with ICH, their association with clinical variables, and contribution to hospital stay.A total of 144 consecutive patients with ICH between January 1999 and October 2003 were analyzed for pulmonary complications such as pneumonia, pulmonary edema, pulmonary embolism, or miscellaneous complications.Overall, 41 patients (28%, 95% confidence interval, 22-36%) developed pulmonary complications. The most common events were pneumonia (19%) and pulmonary edema (8%). Complications were most often encountered immediately after the onset of ICH (63% detected on the day of admission). Pulmonary complications lengthened the duration of hospital stay among survivors.Our study provides data on pulmonary complications after acute ICH. Almost one-third of patients with ICH develop pulmonary complications. Pulmonary complications increased morbidity, mortality, and duration of hospital stay. Aggressive management of these complications can potentially reduce the morbidity, mortality, duration of hospital stay, and financial expenditure incurred in this group of patients. more...

✓ The discovery of either a dermatomal cutaneous nevus or a spinal arteriovenous malformation (AVM) should raise the suspicion of Cobb syndrome. The Cobb syndrome is a neurocutaneous syndrome in which there are metameric cutaneous and spinal AVMs. The authors present the case of a patient with acute cervical myelopathy and subtle cutaneous hemangiomas in whom a cervical perimedullary fistula was discovered. They also acknowledge Harvey Cushing's contribution to the recognition of this syndrome. more...

Although acute intermittent porphyria presents with dramatic neurological findings, the diagnosis is difficult. An 18-year-old woman had a clinical picture of porphyric encephalopathy. Magnetic resonance (MR) imaging demonstrated multiple large contrast-enhancing subcortical white matter lesions, which regressed with glucose and hematin infusions. Diffusion-weighted MR imaging was normal, and MR spectroscopy excluded acute demyelination or tissue necrosis. MR findings of acute intermittent porphyria can differ from those in posterior reversible encephalopathy syndrome by virtue of intense contrast enhancement. Because diffusion-weighted MR imaging and spectroscopy were normal, the lesions are likely caused by reversible vasogenic edema and transient breakdown of the blood-brain barrier. more...

The authors studied 24 patients admitted to the neurointensive care unit because of clinical deterioration to drowsiness or stupor and midline shift after complete middle cerebral artery infarction (coMCAI) stroke. Fourteen (58%) experienced further deterioration and either underwent hemicraniectomy or refused surgery and died. These patients were significantly more likely to be female (72% vs 20%) and to have additional vascular territorial infarction (72% vs 0%) on initial CT. These features may help to identify patients at high risk for further deterioration after coMCAI. more...

A stent graft was deployed to treat a postcarotid endarterectomy pseudoaneurysm in a 52-year-old man. One and a half years later, he developed asymptomatic extrusion of the stent graft. CT angiography showed stent extrusion with occlusion of the right carotid artery ([figure][1]). The stent was more...

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) and hyponatremia is a well known side effect of older selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, sertraline, fluoxetine, citalopram, escitalopram, and fluvoxamine.1,2 The frequency of hyponatremia is around 8 per 1,000 among elderly women receiving fluoxetine.2 Although the second-generation dual blockers, selective serotonin–norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine, are touted to have a wider therapeutic index, hyponatremia is encountered even with venlafaxine. To date, Medline searches do not reveal any reports of hyponatremia associated with duloxetine. We describe a woman who developed severe hyponatremia on exposure to duloxetine and recurrence on inadvertent rechallenge, suggesting the causative relationship of this drug to hyponatremia. A 48-year-old woman was hospitalized for acute severe headache and treated with IV fluids and analgesics. Over the next few days, she had multiple aches and pains and … more...

OBJECTIVE To determine the incidence of cardiac troponin T (cTnT) elevation, electrocardiographic (ECG) changes, and arrhythmias in supratentorial intracerebral hemorrhage (ICH) and their association with early mortality. PATIENTS AND METHODS Patients with supratentorial ICHs admitted to Mayo Clinic, Rochester, Minn, from March 1998 to October 2003 were studied. We excluded moribund patients with ICHs who died within 12 hours of hospital admission. Cardiac troponin T levels measured on admission and day 2 were determined by a third-generation enzyme-linked immunosorbent assay. Continuous ECG monitoring was performed in all patients. Computed tomographic scans were graded and correlated with abnormal cardiac variables. RESULTS Peak levels of cTnT were elevated at 0.035 to 1.2 μg/L (mean ± SD, 0.27±0.38 μg/L) in 10 (20%) of 49 patients and were not associated with changes in creatine kinase MB fraction or ECG results. The cTnT levels did not correlate with location or side of hemorrhage or mortality at 30 days. Seventy (64%) of 110 patients displayed ECG abnormalities. The ECG changes did not correlate with the location or side of ICH, hydrocephalus, midline shift, or extension to the ventricles. CONCLUSION The cTnT elevations in survivors of acute ICH are frequent but without confirmatory ECG changes that suggest mild myocardial injury. One-month mortality is not influenced by such cTnT elevations. In addition, ECG abnormalities are common but likely benign in patients with supratentorial ICH who survive the initial insult. more...

Over the last few years, this 12-year-old boy had chewed off his lips and tongue, bitten his left arm, and eroded his nose by rubbing it on the floor …

The Glasgow Coma Scale (GCS) has been widely adopted. Failure to assess the verbal score in intubated patients and the inability to test brainstem reflexes are shortcomings. We devised a new coma score, the FOUR (Full Outline of UnResponsiveness) score. It consists of four components (eye, motor, brainstem, and respiration), and each component has a maximal score of 4. We prospectively studied the FOUR score in 120 intensive care unit patients and compared it with the GCS score using neuroscience nurses, neurology residents, and neurointensivists. We found that the interrater reliability was excellent with the FOUR score (kappa(w) = 0.82) and good to excellent for physician rater pairs. The agreement among raters was similar with the GCS (kappa(w) = 0.82). Patients with the lowest GCS score could be further distinguished using the FOUR score. We conclude that the agreement among raters was good to excellent. The FOUR score provides greater neurological detail than the GCS, recognizes a locked-in syndrome, and is superior to the GCS due to the availability of brainstem reflexes, breathing patterns, and the ability to recognize different stages of herniation. The probability of in-hospital mortality was higher for the lowest total FOUR score when compared with the lowest total GCS score. more...

Pituitary apoplexyis a potentially fatal neuroendocrinologic emergency that requires early clinical recognition, confirmation with specialized CT or MR imaging, and early medical and surgical intervention. more...

Background Cardiac arrest has a high mortality rate. Postresuscitation encephalopathy is commonly associated with significant morbidity. Review summary Among those patients who achieve a return to spontaneous circulation, more than half die during the subsequent hospital course. Few survivors recover without significant neurologic disability. Clinical examination is often used for predicting subsequent neurologic outcome in these patients. The role of ancillary investigations and the judicious combination of these parameters with the findings on clinical examination to achieve accurate prognostication is discussed in this review. Only a few parameters have a strong predictive value in coma after cardiac arrest. These include pupillary light reflexes and motor responses at 3 days, absent somatosensory evoked potential, and possibly diffuse magnetic resonance imaging changes. Conclusion The authors discuss the physiology, pathology, and consequences of cardiac arrest to the central nervous system, and the use of various parameters in prognostication. Induced hypothermia is a new therapeutic development. more...

Gadolinium chelates are extensively used in MRI studies. Neurotoxicity due to gadolinium chelates is minimal and uncommon. A 57-year-old woman in renal failure developed a subacute encephalopathy after inadvertent repetitive gadolinium contrast administration. An unusual MRI appearance with CSF hyperintensity due to gadolinium diffusion into the CSF is also shown. more...

Neurotoxicity associated with calcineurin inhibitors cyclosporin A and tacrolimus is established. Sirolimus is a new agent related to tacrolimus, but its mechanism of action differs. The authors reviewed 202 transplant recipients treated with sirolimus from 2001 to 2004. They found no evidence of neurotoxicity with sirolimus therapy for up to 18 months (range, 15 days to 3 years). Sirolimus could be considered a substitute immunosuppressant for patients with cyclosporin A or tacrolimus neurotoxicity. more...

neurosurgical intensive care unit (NICU) and may only be diagnosed with simultaneous electrocardiography (EKG) and electroencephalography (EEG) monitoring. This 67-year-old woman presented to us 1 week after having undergone Guglielmi Detachable Coil embolization of a left supraclinoid internal carotid artery aneurysm. She had experienced two to three episodes of seizures along with severe bradycardia (heart rate 20 bpm). There was no history of cardiac illness or use of cardioactive drugs. On examination, she had a Glasgow Coma Scale score of 15 and mild conductive aphasia. Magnetic resonance studies revealed hyperintensities on T2-weighted images in the left temporal lobe and left basal ganglia, with the aneurysm abutting the temporal lobe on coronal images (Fig. 1). She was started on a regimen of sodium valproate. Simultaneous video EKG/EEG monitoring recorded a left temporal lobe seizure accompanied by severe bradycardia lasting 53 seconds (Fig. 2). The lowest heart rate recorded during monitoring was 22 bpm. The patient refused to undergo implantation of a cardiac pacemaker. She has experienced no other seizure during a 1-year follow-up period. Ictal arrhythmias presumably develop from the propagation of seizure activity to the central autonomic network (CAN), which regulates autonomic visceromotor output.1 The CAN consists of the insular cortex, amygdala, central nuclei, and portions of the hypothalamus. Cardiac pacing may be indicated because seizures are refractory to medication in 40% of patients and bradyarrhythmias are potentially fatal.2 Ictal bradycardia may occur in left hemisphere or temporal lobe seizures.3,4 To our knowledge, this is the first report of ictal bradycardia following endovascular therapy for an aneurysm. The contents of this report emphasize the importance of considering an ictal cause of bradycardia in patients in the NICU. more...

Radiation plexopathy produces numbness, weakness, and reflex changes.1 Excess motor unit activity (EMUA) after irradiation manifests as myokymia and neuromyotonia in affected muscles.2,3 A 65-year-old woman presented with a pulling sensation in the left axilla and intermittent depression of the left arm of 3 to 4 months duration. Ten months earlier she had completed chemotherapy and radiation therapy after a simple mastectomy for breast … more...

Objective The diagnosis of isolated central nervous system angiitis often requires both cerebral angiography and biopsy for diagnosis. Clinical presentation We present a case of gliomatosis cerebri with demonstrated angiographic changes suggestive of a central nervous system vasculitis. Intervention A 47-year-old woman presented with a 2-week history of worsening headache and progressive drowsiness. Magnetic resonance imaging scans revealed confluent nonenhancing T2-weighted hyperintensity involving the frontal white matter bilaterally, hypothalamus, and both thalami. A four-vessel angiogram revealed diffuse arterial beading with stenoses of a right frontal middle cerebral artery branch and the distal posterior cerebral artery and anterior cerebral artery branches, bilaterally. The biopsy revealed a Grade 2 fibrillary astrocytoma consistent with gliomatosis cerebri. Conclusion Gliomatosis cerebri can mimic central nervous system vasculitis angiographically. Perivascular infiltration by tumor cells may be responsible for these changes. more...

An 80-year-old woman had a thunderclap headache. CT scan revealed blood in the left sylvian fissure. The clot took the form of an arrow (figure …

A man aged 67 years developed progressive drowsiness, left-sided weakness, and low-grade fever of 4-day duration. CT of the brain showed hypodensities in the right temporal and inferior frontal …