Clinical Neurological Findings Research Articles

Skin blood flow and current perception in pentoxifylline-treated diabetic neuropathy.

There are several anecdotal reports of improvement in diabetic sensory neuropathy following a course of pentoxifylline therapy. Pentoxifylline theoretically could improve skin blood flow, thus reducing ischemia at axonal endings. The authors used laser Doppler techniques to measure skin blood flow and measured sine wave current perception thresholds (CPTs) in pentoxifylline-treated diabetic patients with sensory neuropathy. Twenty-four patients completed a six-month course of treatment. These patients had a predominantly "stocking" neuropathy; all the major abnormalities on clinical, laser Doppler, and current perception testing were found on the lower extremity. Seventeen of the 24 patients reported symptomatic improvement. A careful, graded neurologic examination confirmed that improvement, with a decrease in symptom score on the lower extremity (SSDW) from a baseline of 5.0 +/- 0.7 to 3.5 +/- 0.7 (p < 0.01) and of physical score (PSDW) from baseline 22.0 +/- 2.0 to 16.0 +/- 1.9 (p < 0.01) after six months. On the lower extremity, there was an increase in laser Doppler measured flow score (FS) both at 35 degrees and at 44 degrees C. FSDW (35 degrees) increased from 10 +/- 2 to 14 +/- 3 at six months (p < 0.05). FSDW (44 degrees) increased from 58 +/- 5 to 77 +/- 7 at six months (p < 0.01). There was an improvement in sine wave current perception measured by current perception threshold score (TS). TSDW dropped from 150 +/- 32 to 84 +/- 28 at six months (p < 0.03). In patients with diabetic sensory neuropathy, pentoxifylline appears to improve skin blood flow. Current perception thresholds improve in tandem, corroborating improvement in clinical neurologic findings.(ABSTRACT TRUNCATED AT 250 WORDS)

Neuropathologic Findings after Long-term Intrathecal Infusion of Morphine and Bupivacaine for Pain Treatment in Cancer Patients

Epidural or intrathecal infusions of morphine and bupivacaine mixtures are presently used for the treatment of "refractory" cancer pain even though the neurotoxic potential of such mixtures is unknown. The pathologic findings of the spinal column, the meninges, the nerve roots, and the spinal cord, and the clinical neurologic deficits were recorded in 15 patients (5 men and 10 women), aged 26-83 (median 68) yr, treated for 4-274 (median 81) days with intrathecal infusions of morphine (with preservatives [sodium metabisulfite and sodium edetate]) and bupivacaine mixtures, given through open, subcutaneously tunneled nylon catheters. Six patients had been subjected to radiation therapy (20-96 Gy), applied over the spinal column, and four had been treated with antineoplastics believed to be neurotoxic. Ten patients had various neurologic deficits before the intrathecal treatment. The cumulative doses (ranges) given intrathecally were: morphine 33-11,900 mg, sodium metabisulfite 3.3-1,050 mg, sodium edetate 0.33-105 mg, and bupivacaine 10-41,400 mg; cumulative volumes were 16-9,400 ml. The concentrations of the drugs in the mixtures were: morphine 0.25-4.0 mg/ml, sodium metabisulfite 0.025-0.40 mg/ml, sodium edetate 0.0025-0.04 mg/ml, and bupivacaine 3.0-4.75 mg/ml. The osmolality of the mixtures in vitro ranged from 282 to 286 mOsm/kg and the pH from 4.1 to 4.6. The pathologic findings consisted of vertebral metastases (n = 6), epidural and/or intrathecal tumor masses (n = 8), focal subdural fibrosis (n = 6), infiltration of mononuclear cells in the subarachnoid space (n = 10), and discrete injuries (nerve fiber degeneration or fibrosis) to the anterior (five patients) and posterior (seven) nerve roots, and spinal cord (tumor compression [one], slight thickening of the leptomeninges [one], and thrombosis of a spinal artery and medullary infarction [one]). In none of the cases was any reaction against the nylon catheter within its subarachnoid course recorded. The neuropathologic findings were not related to the duration or cumulative doses of the intrathecal treatment. No new neurologic deficits that could be attributed to the intrathecal administration of the opiate-bupivacaine mixtures were recorded. The neuropathologic and clinical neurologic findings in cancer patients treated with intrathecal morphine-bupivacaine mixtures appeared similar to those in animals and humans reported with either intrathecal morphine or bupivacaine alone.

Asymmetries of Sleep Spindles and Beta Activity in Pediatric EEG

Unilateral suppression of beta activity, unilateral suppression of sleep spindles, and unilateral delta slowing on EEG have not been previously compared regarding accompanying neuroradiological (NR) and clinical neurological (CN) findings in children. We studied EEGs in children under age 10 years with unilateral beta suppression (n = 80), spindle suppression (n = 51) or unilateral delta slowing (n = 49). There were no significant differences between the three groups of abnormal EEGs in their relationships with NR and CN. Unilateral suppression of sleep spindles and beta activity are at least as accurate as focal slowing in lateralizing NR and CN findings.

Clinical neurological, electrophysiological, and cerebral CT scan findings in systemic lupus erythematosus.

Thirty SLE patients underwent clinical neurological examination, electrophysiological studies, cerebral computer tomographic (CT) scans, and blood sampling. Nineteen patients (63%) had clinical neuropsychiatric and 10 patients (33%) had clinical neuromuscular manifestations. Migrainous headache affecting 11 patients (37%) was the most prevalent clinical manifestation. Electrophysiological testing revealed abnormal electroencephalography in 10 patients (33%). Abnormal electromyography and nerve conduction velocity were found in 13 (43%) and 7 (24%) patients respectively. Abnormal visual evoked response was detected in 2 patients. Cerebral CT scans displayed cerebral atrophy in 20 patients (71%), while 6 patients (21%) had cerebral infractions. Disease activity assessed by two different tests revealed a higher prevalence of cerebral infarctions, classical migraine, muscular weakness, and pathological electromyography and nerve conduction velocity in the higher disease activity groups. Cerebral infarctions were only found among anti-Ro negative patients, but apart from this, no significant association could be found between coagulopathy, circulating immune complexes, cryoglobulins, routine immunological tests, medication, and any clinical, electrophysiological or cerebral CT pathology.

Seamen exposed to organic solvents. A cross-sectional study with special reference to the nervous system.

A cross-sectional study of 85 long-term solvent exposed seamen working on chemical tankers compared to 59 unexposed seamen. Symptoms from the nervous system, clinical neurological findings and neurographic measurements were studied. The examinations were performed at least 2 weeks after the last solvent exposure. A stepwise multiple regression analysis was used to evaluate the dose-response relationship between the registered data on one hand and solvent exposure, employment on chemical tankers, age, alcohol and chloroquine phosphate consumption on the other. A significant correlation was found between increasing solvent exposure and reduced sensory nerve conduction velocities, as well as between increasing solvent exposure and prolonged distal latencies of motor nerves, and between increasing exposure and reduction of action potential amplitudes of sensory nerves. No correlation was found between solvent exposure and symptoms from the nervous system or clinical neurological findings.

Mania following head injury: Case reports and neuropsychological findings

Mania secondary to head injury is reported to be rare. Two cases of florid manic psychoses following head injury are reported along with neurological and neuropsychological investigations. Findings on the Luria Nebraska Neuropsychological Battery (LNNB) suggested residual cognitive deficits, predominantly of right hemisphere. Temporal proximity, clinical neurological findings, EEG changes and deficits on LNNB suggest a causal link between head injury and mania.

Computed tomography, electrodiagnostic and clinical findings in chronic workers' compensation patients with back and leg pain.

One hundred patients with complaints of low-back pain and leg pain, consistent with a diagnosis of sciatica, were evaluated. All patients had complaints for longer than 6 months and had recently undergone electrodiagnostic testing and computed tomography (CT). Correlation was made between symptoms, straight leg raising, clinical neurological deficits, electrodiagnostic and CT findings. The radiation of pain above or below the knee and pain on straight leg raising did not show a high correlation with each other or with neurological deficits or CT findings. Electrodiagnostic studies often defined a radiculopathy in patients with equivocal clinical signs. CT findings did not predict the nature of symptoms or clinical and electrodiagnostic findings. Electrodiagnostic abnormalities showed the greatest ability to predict CT abnormalities. It is concluded that in chronic sciatica patients, no single diagnostic parameter is conclusive and a combination of clinical and laboratory findings is necessary to reach a diagnosis. In addition, many assumptions, valid in patients with acute pain cannot be extrapolated to patients with chronic sciatica.

Urodynamic Assessment of Children With Cerebral Palsy

More than a third of the children with cerebral palsy present with dysfunctional voiding symptoms. Clinical evaluation and urodynamic study of cerebral palsy patients were performed to characterize the symptoms, to define the type of neurological deficit and to document its effect on voiding dynamics.We evaluated flow rate, and cystometrographic and external sphincter electromyographic findings in 57 children with cerebral palsy. Upper and lower motor neuron lesions were defined by standard criteria. Of the children 86 per cent had evidence of a pure upper motor neuron injury and 11 per cent manifested electromyographic findings suggestive of incomplete lower motor neuron sphincteric injury. The latter deficit could not be predicted on the basis of clinical neurological findings but it was suggested by a history of neonatal cyanosis. Treatment protocols achieved continence in more than 75 per cent of the children.The voiding dynamics in children with cerebral palsy have not been assessed previously. We have defined the lower urinary tract dysfunction in these patients, and provide a rational and effective plan of management.

Acute direct and indirect lesions of the brain stem--CT findings and their clinical evaluation.

Since the introduction of computer tomography (CT) (Ambrose 1973, Hounsfield 1973) it has become an essential instrument in the diagnosis of acute intracranial lesions. The precise analysis of the CT and in particular the evaluation of the basal cisterns, yields results which are already wellknown, basically, from post-mortem investigations and clinical findings. However, while these were retrospective analyses and results, serial CT examinations which are free of risk for the patient and can be used in correlation with the clinical neurological findings, allow important assertions intra vitam, as well as a definitely better assessment of the prognosis. In addition to acute supratentorial lesions, acute and subacute infratentorial lesions are analysed and their clinical significance described. In this way, for the first time, the dynamics of the mechanical factors in raised intracranial pressure can be analysed. Important conclusions are drawn for the clinical management of the patients, and even some new indications for operation. Analysis of the acute hyperdense brain stem lesions--pathognomonic for haemorrhages--allows for the first time the diagnosis and continuous observation of traumatic and secondary haemorrhages caused by raised pressure, as well as spontaneous ones. As regards the mortality and morbidity, the results in this large series of traumatic and secondary haemorrhages are in striking contrast to previous analyses based on post mortem findings. Acute hypodense brain stem lesions are not amenable to any definite pathogenetic classification--softening, inflammatory lesions, tumours and oedema must all be considered. With acute lesions we are only dealing with infarcts, which are only incompletely assessable in the computer tomogram, and their diagnosis must still depend on the clinical findings. Secondary ischaemic lesions in acute raised intracranial pressure are identifiable in over 18% as infarcts which involve the entire territory of an artery. These additional space-occupying lesions are only survived by 11% of the patients. Hence the correlation which has been established between the basal cisterns and intracranial pressure is of great clinical significance. From our own research group several reports on different aspects of raised intracranial pressure and lesions of the brain stem have appeared since 1979. Similar analyses of partial aspects of the basal cisterns, have been published only recently, and came essentially to the same conclusions.

Relationship between Stimulant Effect, Electroencephalogram, and Clinical Neurological Findings in Hyperactive Children

Claims have been made that hyperactive children respond better to stimulant treatment if they have clinical indicators of neurological dysfunction. However, studies report conflicting results. The present placebo-controlled study examined the relationship between neurological abnormalities and stimulant medication efficacy in 80 pervasively hyperactive children. Treatment outcome measures, which were adjusted for both age and initial severity of the disorder, included teacher and psychiatric ratings. No evidence was found to indicate that clinical neurological status, including encephalographic and neurological soft signs, was predictive of drug responsivity.

Proton magnetic resonance imaging in ischemic cerebrovascular disease

Proton magnetic resonance imaging (MRI) using a 0.6- or 1.5-Tesla superconductive magnet was compared with high-resolution computed tomography (CT) in 60 patients with transient ischemic attacks (TIAs) or brain infarction. MRI showed focal parenchymal changes in 84% of patients with TIAs, whereas CT showed similar changes in 42%. The sensitivity of MRI was also greater in patients with infarcts, but the difference between CT and MRI was not as great. Infarcts were usually better delineated by MRI regardless of location. However, MRI failed to reveal cortical infarcts that were clearly seen on contrast-enhanced CT scans and was unable to clearly distinguish subacute from chronic hemorrhagic infarcts. MRI changes were best detected with T2-weighted images and usually appeared as multiple areas of increased signal intensity in the subcortical and periventricular white matter. MRI changes often could not be correlated with the clinical history and neurological findings; identical changes have been seen in patients with no history of cerebrovascular disease.

Carpal tunnel syndrome: neurographical parameters in different stages of median nerve compression.

In a series of 47 cases and 55 hands operated upon for carpal tunnel syndrome, the pre-operative electrodiagnostic findings have been compared retrospectively with the morphological findings within the carpal tunnel during operation. As a main result there was no significant correlation between the degree of electrophysiological changes and the degree of median nerve compression. Only the lack of any motor or sensory response seems to indicate a more severe median nerve compression. In about 20% of cases with operatively proven marked median nerve compression, both distal motor latency and motor nerve conduction velocity were well within normal limits and would not have led to the diagnosis of a carpal tunnel syndrome in these cases. The diagnosis, therefore, cannot be made on the basis of electrodiagnostic pathological values only of distal motor latency and motor nerve conduction velocity, but has to take into account as well the sensory nerve conduction velocity as well as the clinical picture and neurological findings.

Involvement of the Audiovestïbular System in Multiple Sclerosis an Otoneurologic and Audiologic Study

This study was performed on a material of 70 patients, who fulfilled the criteria of definitive MS. All the patients were examined by an otologist, a neurologist and a neuro-ophthalmologist. A wide range of audiologic and otoneurologic tests were used to obtain a good understanding of the respective disorders in MS, to gain a better knowledge of the role of otology in MS, to correlate the results with the clinical findings in order to find the most useful tests to detect MS lesions and to describe pathophysiologic aspects of central lesions using MS as a model. The material consisted of MS cases representing mild or moderate stages of disability (Hyllested classification 1.-4); 32 belonged to Hyllested group 1., 19 to group 2., 7 to group 3. and 12 to group 4. The age and sex distribution were similar with materials described earlier, as were most of the clinical neurologic findings. The material can thus be considered representative. The neuro-ophthalmologic examination served to rule out causes other than MS for abnormalities observed in the tests. Besides the clinical neurologic and otoneurologic evaluation a number of additional tests were performed. The ENG tests consisted of registration for spontaneous and positional nystagmus, of smooth pursuit and saccadic eye movements, optokinetic nystagmus and caloric reactions. The audiologic evaluation was based on the following tests: pure tone audiograms, speech reception thresholds, discrimination scores, filtered speech test, stapedius reflex thresholds, stapedius reflex decay and auditory brainstem responses. The clinical otologic examination revealed little abnormalities, which is well in accordance with the pathophysiology of MS. In addition the clinical examination ruled out peripheral lesions as reasons for observed abnormalities. Numerous abnormalities were found during the otoneurologic examination of the cranial nerves. The amount of abnormal findings in the otoneurologic examination were surprisingly high: only one patient exhibited normal results in all the tests used. The abnormalities most often encountered were those of smooth pursuit (96%), followed by saccadic eye movements (76%), optokinetic nystagmus (53 %), and abnormalities in the caloric reactions such as dysrhythmia (40%) and defective visual suppression of the nystagmus (43%). When comparing the results obtained with ENG with those of clinical findings seen during the neuro-ophthalmologic examination, a good intercorrelation was found. Yet, in many ENG tests a number of cases with subclinical abnormalities only, were observed, which stresses the importance of exact and objective methods for the registration of eye movements.(ABSTRACT TRUNCATED AT 400 WORDS)

Correlation between the Findings of a Clinical Neurological Examination and the Urodynamic Dysfunction in Children with Myelodysplasia

Clinical neurological findings in 47 children with lumbosacral myelodysplasia did not correlate well with the existing dysfunction of the lower urinary tract as diagnosed by urodynamic studies. The level of intact skin sensation, and the presence or absence of bulbocavernosus and anal reflexes could not significantly predict the function of the detrusor muscle, proximal urethra and striated urethral sphincter. Therefore, one should not rely on a clinical neurological examination to outline the urological management in such patients.

Ataxic Creutzfeldt‐Jakob disease

We studied two cases of ataxic Creutzfeldt-Jakob disease. EEG, CT, evoked responses, and CSF were normal in one purely ataxic patient. Diagnosis was established by cerebellar biopsy. Autopsy demonstrated devastating spongiform changes in the cerebellum, basal ganglia, and thalamus with rare focal changes in cerebral cortex. In the second patient, late generalized changes developed with dementia. Diagnostic studies included abnormal visual evoked responses, CSF with abnormal oligoclonal bands and IgG, and subacute spongiform encephalopathy in frontal lobe biopsy. Early diagnosis is best established by biopsy of brain areas most likely to be involved on the basis of clinical neurologic findings.

Thalidomide Neurotoxicity

Of six patients treated with thalidomide for either prurigo nodularis or discoid lupus erythematosus, four had paresthesias in the hands and feet and one also complained of muscular pain and stiffness. Clinical neurological findings in all four patients were normal. Subsequent electrophysiological examination disclosed a peripheral neuropathy in five of the six patients; two had electrophysiological signs of a polyneuropathy and three of a carpal tunnel syndrome. Symptoms and abnormal electrophysiological findings were still present in one patient one year after the discontinuation of thalidomide therapy. Since reports on thalidomide neurotoxicity have shown that the neurological symptoms are long standing and possibly irreversible, it is obviously important to inform patients of this possible side effect and to evaluate them closely for the symptoms and electrophysiological signs of evolving neurological changes.

Non-traumatic intracerebral haemorrhage. Prognostic implications of neurological and computer-tomographical findings in 100 consecutive patients.

One hundred cases of non-traumatic intracerebral haemorrhage were studied retrospectively. The mortality was 41%, although however, the cause of death in 10% of the cases was not directly related to the intracerebral haemorrhage. Clinical neurological and CT findings available in the first few hours after the admission of the patients were selected for the statistical analysis, using a linear stepwise discriminant analysis including jack-knife classification and a simple independence model for the variables. The results indicate that the outcome can be predicted with relatively great accuracy in individual patients, and that the level of consciousness on admission and the age of the patient are the most important factors for prognosis. The addition of CT-based variables did not achieve any significant improvement in the accuracy of the prediction of the outcome.

Intracranial metastases in small cell carcinoma of the lung: correlation of clinical and autopsy findings.

Two hundred-twelve consecutive patients with small cell carcinoma of the lung were included in an evaluation of clinical and diagnostic neurologic findings of intracranial metastases. A correlation of premortem findings to postmortem examination of the brain was obtained in 87 of the patients. Clinical intracranial metastases were diagnosed in 21.2% on the basis of symptoms and signs. At autopsy 44 of the 87 patients (50%) had metastases. Lesions located to the posterior cranial fossa were demonstrated in 53% of the positive autopsies. A correlation of 96% existed between significant premortem clinical findings and positive autopsy, while 33% had clinically "silent" metastases at autopsy. A neuro-oncologic examination was performed in 49 patients at the time of presentation of neurologic symptoms. Twenty-eight patients were considered to have intracranial metastases. Gait disturbances were the presenting signs in more than 50% of the patients. Brain metastases were demonstrated at autopsy in 14 of 15 patients considered to have intracranial metastases by the neuro-oncologist, and clinically "silent" metastases were observed in one out of 10 patients. Radionuclide brain scan was negative in seven of 13 patients in spite of "positive" neuro-oncological examination had a subsequent positive autopsy. Cerebrospinal fluid examination was of no value in the diagnosis of brain metastases. It is concluded that a careful clinical examination by a neuro-oncologist is of great value in early detection of brain metastases, especially in diagnosing metastases to the posterior cranial fossa.

Sensitivity analysis and optimization for a head movement model.

A sixth order nonlinear model for horizontal head rotations in humans is analyzed using an extended parameter sensitivity analysis and a global optimization algorithm. The sensitivity analysis is used in both the direct sense, as a model fitting tool, and in the indirect sense, as a guide to experimental design. Resolution is defined in terms of the sensitivity table, and is used to interpret the sensitivity results. Using sensitivity analyses, the head and eye movement systems are compared and contrasted. Controller signal parameters are the most influential. Their variations and effects on head movement trajectories and accelerations are investigated, and the conclusions are compared with clinical neurological findings. The global optimization algorithm, in addition to automating the fitting of various types of data, is combined with time optimality theory to give theoretical time-optimal inputs to the model.

Neurological picture of organic solvent poisoning in industry. A retrospective clinical study of 37 patients.

A retrospective evaluation of neurological, neuroradiological, neurophysiological, psychological, and laboratory findings on 37 patients, remitted to the Institute of Occupational Health, Helsinki because of suspected poisoning due to organic solvents, was performed. Patient selection was made on the basis of performed pneumoencephalography (PEG). Most of the patients had been exposed to a mixture of solvents (19 cases). Carbon disulphide exposure had occurred in six cases, trichloroethylene in five cases, and the rest of the patients had been exposed to styrene (one case), thinner (two cases), toluene (1 case), methanol (1 case), and carbon tetrachloride (two cases). Clinical neurological findings comprised slight psycho-organic alteration, cerebellar dysfunction, and peripheral neuropathy. The PEG showed changes suggesting brain atrophy in 63% of the patients. Slight asymmetric central atrophy and localized cortical atrophy were the most frequent findings. The main electroencephalographic finding was slight diffuse slow-wave. Electroneuromyography showed slight changes suggesting peripheral neuropathy in 23 of the 28 patients examined. Psychological alterations were seen in all patients: personality changes and psychomotor disturbances were the most common findings. Because individual constitutional differences existed, no clear-cut exposure-effect relationship could be established. Thus, neurological evaluation of all those exposed to neurotoxic agents who present symptoms, regardless of the degree of current exposure, is important.