Neurological Physical Examination Research Articles

Horner’s Syndrome in a Child With Otitis Media: An Unusual Complication

Figure 1. Fat-saturated, contrast-enhanced T1 magnetic resonance image of the base of the skull. Avid contrast enhancement of the left petrous apex (arrow) is consistent with apicitis, along with thickening and enhancement of the left petrous internal carotid artery wall (black arrow). A pulsation artifact is present. A 7-year-old, previously healthy girl presented to her family physician with a 1-day history of rhinorrhea and mucoid discharge from the left ear. She was diagnosed with otitis externa and received topical antibiotics. The child was brought to the emergency department of our hospital on day 3 of her illness with a unilateral earache and discharge from the ear. Her temperature at presentation was 37.9 C. She was subsequently afebrile, and her blood pressure was normal. Examination of her ears presented evidence of inflammation of the left eardrum. No postauricular redness or swelling, no mastoid tenderness, and no protrusion of the ear were evident. She manifested ptosis of the left eye and a constricted left pupil. The drooping of her left eye had been observed by her parents on day 2 of her illness, 1 day before presentation at the hospital. Neurologic (including the cranial nerves) and general physical examinations were otherwise unremarkable. She was diagnosed with partial left Horner’s syndrome, secondary to acute otitis media. An otorrhea culture was positive for Streptococcus pyogenes (group A streptococci). She received oral amoxicillin and clavulanic acid (Augmentin; GlaxoSmithKline, Middlesex, UK) for 2 weeks. No previous history of otitis media was reported. Neuroimaging was requested. The child underwent a magnetic resonance imaging scan, followed by a computed axial tomography scan, 2 weeks after her initial presentation. Imaging revealed enhancing soft tissue material within the opacified mastoid air cell complex, middle ear cleft, and petrous apex surrounding the carotid canal on the left side, suggestive of complicated otitis media with mastoiditis, petrous apicitis, and secondary carotid involvement (Figs 1 and 2). Clinically, the partial Horner’s syndrome was unchanged, and the otorrhea had subsided. In view of the neuroimaging results, she received intravenous antibiotics for 14 days, i.e., cefotaxime for 1 week, changed because of mild thrombophlebitis to cefepime and vancomycin for the second week. A further 4-week course of oral cephalexin was prescribed (total duration of antibiotics, 8 weeks, consisting of 2 weeks oral, 2 weeks intravenous, and 4 weeks oral). A repeated magnetic resonance imaging scan 6 weeks later demonstrated a reduction in inflammatory activity in the left petrous temporal bone and a resolution of the narrowing of her

Angst und Panik im Notarztdienst - Richtig diagnostizieren und handeln

Fearful patients are in emergency situation often inattentive, unable to concentrate, agitated or even aroused. They show reduced perception and restricted willingness to cooperate. In severe conditions these patients are strongly tending towards more hazardous behavior: refusal of necessary therapy, break out or even high suicidal risk. Within disaster situations (mass accidents, fires) fearful patients with their agitated and persuasive behavior can influence other victims and with that trigger a situation of mass panic that has to be avoided at any cost. Therefore these patients must be swiftly identified and separated from the event. A diligent diagnosis process including physical-neurological examination is necessary. The recommended treatment within the emergency situation consists of a close continuous personal contact through assuring and encouraging conversations. A sense of security should be created by explaining the planned therapeutic interventions in simple, easy-to-follow and understandable words. If this necessary psycho-therapeutic intervention can not be applied a short term psychopharmacological treatment is required preferably with Benzodiazepines. Still a longterm specific therapy is highly advised, since these disturbances, if left untreated, will lead to a chronic manifestation and with that to considerable psychosocial impairments.

The Future of Neurology

Yogi Berra, the former New York Yankees baseball manager, known for his interesting phraseology, famously once said, “It's tough to make predictions, especially about the future.” While this has become somewhat of a tired cliche, there is an inherent validity to the argument that makes us somewhat cautious and humble in any discussion regarding the future of Neurology. At the risk of fumbling our way toward the truth, we remind ourselves that in order to find the truth, we need to ask the right questions. Other colleagues have written eloquently about the changing role of neurologists (Engstrom and Hauser, 1994; Bradley, 2000; Freeman and Vatz, 2010), and the fundamental changes facing Child Neurology (Ridel and Gilbert, 2010). A continuous stream of advances in basic neuroscience research, gene identification, neurogenomics, cutting-edge genetic techniques, neurodiagnostic tools including advanced neuroimaging technologies (Masdeu and Bakshi, 2005), and longitudinal biomarkers, coupled with new treatment modalities and paradigms for neurologic disease, suggests increased demands on available practitioners. In view of the growing aging population, associated with declines in infant mortality and treatment of infectious disease, more people will suffer from age related neurologic disorders such as stroke, dementia, Parkinson's disease, epilepsy, and autoimmune disorders (Engstrom and Hauser, 1994; Bradley, 2000; Freeman and Vatz, 2010; Weiner, 2007). In the past, a neurologist was recognized particularly for skilled diagnoses using clues derived from a thorough and elaborate history and physical examination, but treatment options were limited. Colloquially, the neurologist would “diagnose and adios.” With the advent of advanced neuroimaging and laboratory techniques, there has been much lament about the disappearance of the neurologists’ much vaunted skill in clinical diagnosis. And yet, the various tests, coupled with advanced treatment techniques, have certainly led to an explosion of opportunity, with both increased demand for neurologists and an increased number of people interested in the field. In the near future, the role of diagnostic testing in clinical neurology (as in all of medicine) will only further accelerate. There will be some value to the diagnostic prowess of neurologists in determining the appropriateness and meaning of complex and potentially unnecessary tests and procedures. As noted by Gooch and Amato (2010), in a discussion of the utility of anti-ganglioside antibodies in the diagnosis of multifocal motor neuropathy: “In this era of limited resources, the judicious exercise of sound clinical judgment in crafting a logical and efficient diagnostic evaluation has never been more important. Careful selection of the best path to the final diagnosis will not only most benefit our patients but will also as health reform continues to advance, insure that our precious (and finite) medical resources are not necessarily wasted” (Gooch and Amato, 2010). Still, academicians simply become Luddites if they lament how testing has superseded the neurologic history and physical examination which were never as accurate as we cared to admit. We respectfully suggest that the future of neurology will be critically dependent on harmonizing the tensions between clinical skills and an over-reliance on testing paradigms. The future of Neurology will also be reflected in the greater opportunities to develop therapeutic interventions, delay, or ideally prevent progressive neurodegenerative diseases, and the roles to be played by the new breed of neurologists in providing these interventions. There will likely be explosive growth in potential medical therapies including novel drugs, human pluripotent stem cell technology and gene therapies, and new immunosuppressant modalities in the near future (Mallarkey, 2008). There will also be an increased role for neurologists in interventional fields such as stroke, pain, neurostimulation, and even neuroregeneration. There will also be a continued separation between the practice of intensive and hospital-based neurology and office-based general and specialty neurology. The parallels with Cardiology/Internal Medicine combined with the growth of procedural non-surgical focused specialists in these fields are both obvious and inevitable given the profound shift toward a treatment oriented focus for neurology in the near future. The challenge for neurology will be whether we can satisfy the need for neurologic expertise in providing these treatments or whether others will pick up the slack for this pent-up demand for aggressive treatment of neurologic disease. The field of neurology remains one of the most dynamic areas of medicine, with advances on many fronts. Frontiers in Neurology offers an unprecedented opportunity for a more accessible, more manageable, and more useful dynamic interactive seminal exchange between the world community of neurologists and neuroscientists striving toward a common goal of excellence. Only by sharing your expertise and knowledge with the neurological community, can we achieve our ultimate goal of improving the quality of life and outcomes for patients with neurological disorders.

Unusual penetration of a construction nail through the orbit to the cranium: a case report

Penetrating head and neck trauma with construction nails are uncommon life-threatening injuries and an important problem in developing countries. Assessment of the neurovascular and systemic physical status is a first requirement, and the decision concerning which surgical approach to perform for the removal of the nail is of critical importance. A 10-year-old girl was presented one hour after a fall injury with complaint of a swelling and foreign body lodgment on the left forehead. Neurological and systemic physical examinations were normal except for weak direct pupillary light reflex on the left side and the patient's state of uneasiness. Radiological investigations showed that the head of the nail had entered from the left infra-orbital region and become lodged through the orbital roof, below the frontal bone. Surgical extraction of the nail in the operating room was performed successfully using left pterional craniotomy and lateral orbitotomy technique, and there was no complication after surgery. Here, we report a case with a rare craniocerebral penetrating wound and type, with the head of the nail lodged in the anterior fossa through the orbital roof, which may be defined as 'reverse penetration of the nail'.

A C-fiber–mediated neuropathic brachioradial pruritus

A 56-year-old man presented to the outpatient clinic with a 3-year history of itch within the innervation territory of C-6 of the left arm. Sudden neck movements induced intermittent paresthesias in the same dermatome. No dermatological diseases, allergies, or trauma to the affected extremity or the spine or a history of familial pruritus were reported. Neurological physical examination and electromyography revealed normal findings. Quantitative sensory testing demonstrated selective C-fiber dysfunction at C6-8 on the left, and cervical MR imaging revealed multilevel degenerative cervical spine pathology with neuroforaminal stenoses. Brachioradial neuropathic pruritus caused by cervical neuroforaminal stenosis was the final diagnosis. Treatment consisted of 2 cervical epidural steroid applications that resulted in clinical disappearance of the itch and improvement in C-fiber function on quantitative sensory testing.

Initial Presentation of an Accessory Left Ventricle in a Patient With Syncope

A 39-year-old woman was referred for a transthoracic echocardiogram after presenting to her primary care provider following an episode of unexplained loss of consciousness. Her past medical history was notable for fibromyalgia and migraine headaches. She had a normal cardiac and neurological physical examination with no extra heart sounds or murmurs. Her transthoracic echocardiogram (Movie I of the online-only Data Supplement) revealed a large outpouching of the lateral wall of the left ventricle (LV) that contracted in synchrony with the ventricle (Figure 1A and 1B). The initial differential for this finding included an LV diverticulum or an accessory ventricle. An LV pseudoaneurysm was considered unlikely because of the synchronous contraction of the outpouching with the rest of the ventricle. Figure 1. Transthoracic echocardiogram demonstrating the apical 4-chamber view of the LV. The outpouching (arrow) originating from the lateral aspect of the midventricular wall is shown in both diastole (A) and systole (B). The outpouching contracted synchronously with the LV. To further evaluate this …

Scheduled Repeat CT Scanning for Traumatic Brain Injury Remains Important in Assessing Head Injury Progression

Scheduled repeat brain CT (SRBCT) is used to monitor progression of traumatic brain injury (TBI). Previous studies have suggested that routine SRBCT can be replaced by an unscheduled repeat brain CT after deterioration on serial neurological examination. In this study, we evaluated if SRBCT has a role in the management of TBI. Retrospective observational study of 1,019 consecutive adult patients admitted to a Level I trauma center with CT evidence of TBI on initial brain CT (IBCT). All patients with intracranial pathology on IBCT were scheduled for SRBCT and underwent sequential neurological physical examinations. Interventions (surgical or medical) after IBCT, SRBCT, or neurological change were recorded. One thousand nineteen patients with IBCT evidence of TBI were identified from the trauma registry during a 50-month study period beginning in November 2001. Eighty-six (8.9%) of these patients went directly for craniotomy. After exclusions, 887 patients were analyzed. A total of 692 (78%) patients had a no worse first SRBCT and neurologic changes requiring intervention later developed in 11 (1.6%) of these patients. One hundred ninety-five (22%) patients had a worse first SRBCT, with 14 (7.2%) requiring immediate intervention. Seven (3.6%) worse first SRBCT patients had a subsequent SRBCT that worsened, leading to an intervention. A neurologic change that precipitated an intervention developed subsequently in an additional 19 (9.7%) patients with a worse first SRBCT. Chi-square analysis demonstrated that a first SRBCT that was worse was more likely to result in an intervention than if the first SRBCT was no worse. A worse SRBCT is more likely to result in neurologic intervention. SRBCT remains useful in assessing patients with TBI.

Quantitative Sensory Testing and Mapping

Despite a growing interest in neuropathic pain, neurologists and pain specialists do not have a standard, validated, office examination for the evaluation of neuropathic pain signs to complement the neurologic, musculoskeletal, and general physical examinations. An office neuropathic pain examination focused on quantifying sensory features of neuropathic pain, ranging from deficits to allodynia and hyperalgesia, and evoked by a physiologically representative array of stimuli, will be an essential tool to monitor treatment effectiveness and for clinical investigation into the mechanisms and management of neuropathic pain. Such an examination should include mapping of areas of stimulus-evoked neuropathic pain and standardized, reproducible quantitative sensory testing (QST) of tactile, punctuate, pressure, and thermal modalities. We review quantitative sensory testing methodology in general and specific tests for the evaluation of neuropathic pain phenomena. Numerous quantitative sensory testing techniques for dynamic mechanical, pressure, vibration, and thermal sensory testing and mapping have been described. We propose a comprehensive neuropathic pain evaluation protocol that is based upon these available techniques. A comprehensive neuropathic pain evaluation protocol is essential for further advancement of clinical research in neuropathic pain. A protocol that uses tools readily available in clinical practice, when established and validated, can be used widely and thus accelerate data collection for clinical research and increase clinical awareness of the features of neuropathic pain.

Neurologic signs and symptoms in fibromyalgia

To determine the type and frequency of neurologic signs and symptoms in individuals with fibromyalgia (FM). Persons with FM (n = 166) and pain-free controls (n = 66) underwent systematic neurologic examination by a neurologist blinded to disease status. Neurologic symptoms lasting at least 3 months were assessed with a standard questionnaire. We used logistic regression to evaluate the association of neurologic symptoms and examination findings with FM status. Within the FM group we examined the correlation between self-reported symptoms and physical examination findings. Age- and sex-adjusted estimates revealed that compared with the control group, the FM group had significantly more neurologic abnormalities in multiple categories, including greater dysfunction in cranial nerves IX and X (42% versus 8%) and more sensory (65% versus 25%), motor (33% versus 3%), and gait (28% versus 7%) abnormalities. Similarly, the FM group had significantly more neurologic symptoms than the control group in 27 of 29 categories, with the greatest differences observed for photophobia (70% versus 6%), poor balance (63% versus 4%), and weakness (58% versus 2%) and tingling (54% versus 4%) in the arms or legs. Poor balance or coordination, tingling or weakness in the arms or legs, and numbness in any part of the body correlated with appropriate neurologic examination findings in the FM group. This blinded, controlled study demonstrated neurologic physical examination findings in persons with FM. The FM group had more neurologic symptoms than did the controls, with moderate correlation between symptoms and signs. These findings have implications for the medical evaluation of patients with FM.

Determinants of functional disability in stage IV breast cancer

9567 Background: Functional disability degrades cancer patients' quality of life, exhausts caregivers and incurs significant expense yet little is know of the factors that contribute to disablement or whether the impact of these factors differs across functional domains. Better understanding of the influence that symptoms, physical impairments, and disease characteristics exert on disablement is needed in order to develop service delivery models that preserve function. Methods: To identify factors that influence functional performance in community dwelling people with stage IV breast cancer we conducted a cross-sectional study in a tertiary medical center outpatient cancer clinic. A consecutive sample of 163 community-dwelling patients with stage IV breast cancer were administered self- and clinician-rated functional metrics covering multiple domains including overall functioning, mobility, and self care. Self report measures included the Medical Outcomes Study Physical Function Subscale (PF-10) and the Older Americans Resource Study (OARS) Activities of Daily Living (ADL) and Instrumental ADL (IADL) subscales, and clinician report measures included the Karnofsky Performance Scale (KPS) and the Functional Independence Measure (FIM) Total and Mobility scores. Pain and mental health were assessed through administration of the Brief Pain Inventory (BPI) and Mental Health Inventory-17 (MHI-17), respectively. Electronic medical record review provided cancer-related and demographic information. The presence of physical impairments was determined through a comprehensive musculoskeletal and neurological physical examination including the 6 minute walk test. Linear and ordinal logistic regression models were constructed with function metrics as dependent variables. Results: Total number of physical impairments, BPI scores, and the presence of pleural effusions were highly significant in all models (p<0.01). Exertional intolerance and age were associated with PF-10 and OARS-ADL scores (p<0.01), while the presence of a pre-morbid disability was associated compromised mobility. Conclusions: Potentially remediable factors; pain intensity, cumulative impairment burden and pleural effusions, degrade all functional domains in patients with stage IV breast cancer. No significant financial relationships to disclose.

Post radical hysterectomy urinary incontinence: A prospective study of transurethral bulking agents injection

Objective(s) The aim of the present study is to prospectively investigate the efficacy and complications of macroplastique transurethral implantation in cervical cancer patients affected by stress urinary incontinence (SUI) after radical hysterectomy (RH). Methods Patients affected by de novo SUI post type 3 RH were considered for eligibility in this study. Preoperative and postoperative assessment included a standardized urogynecological history, urogynecological and neurological physical examination, evaluation of severity of SUI symptoms, a 3-day voiding diary, urine culture and urodynamic assessment. All patients underwent transurethral implantation using Macroplastique Implantation System (MIS). Patient follow-up was performed 6 and 12 months after surgery. Results A total of 24 consecutive patients were enrolled. At the 12 month follow up SUI cure rate was 42% (10 of 24 patients), the improvement rate was 42% (10 of 24) and the failure rate was 16% (4 of 24). The overall success rate was 84% (10 patients cured and 10 improved). No intraoperative or postoperative early complications were found. The 4 patients in whom treatment was not a success had preoperative urethral hypermobility. Subjective patient perception of SUI symptom severity showed significant improvement (mean severity of urinary loss perception 6.6 ± 1.8 vs 2.3 ± 3.3, p < 0.05). The frequency of incontinence on the 3-day voiding diary was significantly reduced at the follow up (14.5 ± 5.8 vs 4.3 ± 7.9 episodes per 3 days, p < 0.05). Conclusion(s) Bulking agents urethral injection could be a valid option having no surgical complications. This therapeutic strategy is able to treat SUI and improve well being of cervical cancer patients after radical surgery.

Diagnosis and initial management of cerebellar infarction

Cerebellar infarction is an important cause of stroke that often presents with common and non-specific symptoms such as dizziness, nausea and vomiting, unsteady gait, and headache. Accurate diagnosis frequently relies on careful attention to patients' coordination, gait, and eye movements--components of the neurological physical examination that are sometimes omitted or abridged if cerebellar stroke is not specifically being considered. The differential diagnosis is broad, and includes many common and benign causes. Furthermore, early-stage posterior fossa ischaemia is rarely seen with brain CT--the most commonly available initial imaging test that is used for stroke. Insufficient examination and imaging can result in misdiagnosis. However, early correct diagnosis is crucial to help prevent treatable but potentially fatal complications, such as brainstem compression and obstructive hydrocephalus. The identification and treatment of the underlying vascular lesions at an early stage can also prevent subsequent occurrences of stroke and improve patients' outcomes. Here, we review the clinical presentation of cerebellar infarction, from diagnosis and misdiagnosis to patients' monitoring, treatment, and potential complications.

Chronische Quecksilberintoxikation bei Kindern aus zwei Familien durch kosmetische Anwendung einer Bleichcreme seitens der Mütter

We report about two families (A: n = 4, B: n = 5) from the Kosovo-Albanian region where the mothers had been using a skin bleaching cream for cosmetic reasons from a rural market containing 12 % elementary mercury. Elevated mercury levels in urine had first been detected in a survey of school pupils in one son of each family; this led to screening of all family members. Medical history showed no abnormalities in family A. In family B unspecific symptoms occurred such as headache, fatigue and bowel pain. In both families, no symptoms of Feer-syndrome (acrodynia) were observed. Nephrotic syndrome or anemia were excluded by blood analyses. Neurological examination, EEG and physical examination were normal. Using flameless atomic absorption spectroscometry, 24 h urine samples revealed elevated mercury levels with highest values in those female family members who had used the cream for cosmetic purposes (family A, A1: 226, A2: 86, A3: 25, A4: 14 μg/l; family B, B1: 363; B2: 192; B3: 61; B4: 41; B5: 29 μg/l). Reference values for adults are < 7 μg/l in 24 h urine. After antidote treatment with DMPS (2,3 -dimercaptopropane-1-sulfonate, Sodium salt, Dimaval®) with 5 mg/kg bodyweight for 7 days, biomonitoring revealed a mercury level lower than the reference value and the symptoms ceased. In sensitive individuals, a symptom-complex (micromercuralism) with sporadic weakness, fatigue, gastrointestinal disorders, intention tremor (tremor mercuralis), alterations of the personality and memory loss (Erethrismus mercuralis) occur at a concentration of 100 μg/l mercury in urine and 35 μg/l in blood in adults. In the two families, absorption of the mercury in the boys might have occurred through the skin, by breathing or by ingestion.

A case of neuropathic brachioradial pruritus caused by cervical disc herniation

A 64-year-old woman presented to an outpatient clinic with a 2-year history of itch, burning sensation and intermittent paresthesias within the innervation territory of the sixth cervical nerve root on the right dorsal forearm. No dermatological diseases, trauma to the affected extremity or the spine, or familial pruritus were reported. Dermatological examination, skin biopsy, laser Doppler imaging, neurological physical examination and cervical MRI scan. Brachioradial pruritus caused by cervical disc herniation. Ventral spinal fusion with cage implantation.

Combination testing in orthopedic and neurologic physical examination: a proposed model

Objective This article suggests a 4-part model for teaching and using orthopedic and neurologic physical testing. Discussion Four methods of combining and sequencing orthopedic and neurologic physical tests are described. The descriptions are followed by examples including test names, test performance, and the relationships between the tests in each group. The principles of the methods originated in the lead author's private practice and were refined while teaching chiropractic students and graduate doctors. Conclusion This model offers one possible method of combining and sequencing the orthopedic and neurologic examination in an effort to provide a more complete picture portraying the mechanisms, results, pathologies, differential diagnosis, and clinical thought processes associated with common orthopedic and neurologic physical tests.

Precipitation of long duration hypnic headaches after ACE inhibitor withdrawal

Sirs: Hypnic headache is a rare headache disorder characterised by recurrent attacks of pain occurring during sleep. Headaches tend to occur in the middle or later stages of the night and patients are abruptly awakened from sleep. We present an unusual case of an 84-year-old female who developed hypnic headaches, although lasting longer than classically described, after stopping her angiotensin converting enzyme (ACE) inhibitor. These resolved completely when the ACE inhibitor was re-started. An 84-year-old female had her ACE inhibitor (enalapril, 5 mg) and a benzodiazepine (flurazepam) stopped abruptly. She immediately developed a distinctive pattern of headache, which would wake her from sleep at 3 a. m. each night. The pain was bi-temporal and it would last approximately 10 hours. Paracetamol and ibuprofen were not effective, and indomethacin was not tried. There were no other symptoms associated with the headache; in particular there were no autonomic features. Her consumption of tea and coffee had not changed, and she did not drink alcohol. There was no previous history of headache and the only significant past medical history was hypertension for which she had been taking enalapril for four years. She had also taken flurazepam and chlordiazepoxide. The enalapril had been stopped by her general practitioner as her blood pressure was considered acceptable at approximately 150/85. Her daytime blood pressure off the enalapril did rise to approximately 180/100. Although we think it unlikely that this rise is significant enough to cause the headache, this does remain a possibility. Neurological and general physical examination was otherwise normal. A biochemical profile, full blood count and computed tomography head scan were normal. Benzodiazepine re-prescription for 2 months did not alleviate the headache, therefore her enalapril was restarted. Her headache responded immediately and one week after recommencing enalapril, her headache had completely resolved. There is general agreement that the mechanisms that underlie sleep regulation and nociception are fundamentally linked although the specific nature and underlying neurochemical processes are poorly defined [4]. The pathogenesis of hypnic headache as a specific sleep related headache, however, remains speculative. There is evidence for a role for the renin-angiotensin system (RAS) in the aetiology of some headache types. The ACE inhibitor lisinopril has been shown to have a prophylactic effect in migraine [5] and migraineurs with a DD genotype have both a higher ACE activity and frequency of attacks than other migraineurs [3]. It has also been shown that dialysis headache, where the headache is not related to blood pressure changes or a ‘dysequilibrium syndrome’, can improve after treatment with ACE inhibitors [2]. We feel that our case report suggests that the RAS may be implicated in the aetiology of hypnic headache. It is not clear how ACE inhibitors mediate the beneficial effect in migraine. Angiotensin II is a neuropeptide produced within the central nervous system (CNS) and may function as a neurotransmitter, influencing neurotransmission and excitability of neurons via glutaminergic and GABAergic neurons [3]. As well as inhibiting the conversion of angiotensin I to angiotensin II, ACE inhibitors also increase prostacyclin synthesis and inhibit the breakdown of bradykinin, encephalin and substance P. Hypnic headache is considered by many to be a rapid-eye movement (REM) sleep-phase phenomenon. In a meta-analysis of 71 cases of hypnic headache, four had headache during polysomnography, three emerging from REM sleep and one from slow wave sleep. The reason for the association with REM sleep is unknown, but it has been suggested that certain areas of the brain of fundamental importance to antinociception, for example the locus coeruleus, an area which is normally inactive during REM sleep, might be impaired [1]. This may perhaps provide a link with the RAS as this is one area of the brain in particular which has been demonstrated to possess high numbers of angiotension receptors [3]. In conclusion, a potential association between hypnic headache and the RAS is suggested. The posLETTER TO THE EDITORS

Effects of level and degree of spinal cord injury on male orgasm

Controlled, laboratory-based analysis. To determine the impact of spinal cord injuries (SCIs) on the ability to achieve male orgasm. US academic medical center. A laboratory-based analysis of the ability of 45 men with SCIs and 16 able-bodied control subjects to achieve orgasm coupled with a detailed neurologic examination, history and physical examination, and administration of the International Index of Erectile Function. Men with SCIs were less likely than controls to achieve orgasm. Mean latency to orgasm, blood pressure and heart rates at orgasm were not significantly different between controls and SCI subjects. Men with incomplete SCIs were more likely to achieve orgasm than those with complete SCIs. A disconnect was noted between the presence of orgasm and the presence of ejaculation. Men with complete lower motor neuron dysfunction affecting their sacral segments were less likely to achieve orgasm than men with any other patterns of SCI. These results document the ability of men with complete SCIs to achieve orgasm. Characteristics of orgasm in men with SCIs as compared to able-bodied subjects are similar. Although orgasm and ejaculation are more likely to occur together, a number of men with SCIs achieve orgasm without ejaculation. Further research should explore the possibility of retraining ejaculatory and orgasmic responses in men with SCIs.

A case of voltage-gated potassium channel antibody-related limbic encephalitis

A 56-year-old man presented to hospital with a 6-month history of recurrent episodes of altered behavior and 'odd' episodes. He had become apathetic and uninterested in his family. He had no relevant past medical or family history. General and physical neurological examinations were unremarkable, as was bedside cognitive testing. Brain MRI scan, 24-h electroencephalogram, serum and cerebrospinal fluid testing for voltage-gated potassium channel antibodies, blood screening for tumors, CT scans of the chest, abdomen and pelvis, whole-body PET scan, neuropsychological examination, brain 18F-fluorodeoxyglucose-PET scan. Voltage-gated potassium channel antibody-related limbic encephalitis. Antiepileptic drugs, immunomodulatory therapy, oral steroids, plasma exchange.

Focal canine tetanus: diagnostic value of electromyography

A four-year-old, male Italian hound was presented with severe spasticity of both thoracic limbs that worsened with external stimuli. The remainder of the neurological and general physical examination was normal. Complete blood cell count, chemistry profile, and serology for protozoal diseases were within normal limits. Survey radiography of the cervicothoracic spine and abdominal ultrasonography showed no abnormalities. Electromyography of the thoracic limbs demonstrated the presence of "doublets" and simultaneous activity in both agonist and antagonist muscles. These abnormalities may be explained by a defective glycinergic inhibition at the spinal cord level. Together with the history, progression of signs, and clinical findings, electromyography supported a presumptive diagnosis of focal tetanus. The dog received tetanus antitoxin and antibiotic treatment and gradually improved over four months.

Cholesteatoma of the Clivus

Cholesteatomas (central nervous system epidermoids) can be found intradurally or extradurally in the central nervous system. Extradural intraosseous lesions are most commonly found in the petrous bone. The authors describe a unique case of a clival cholesteatoma in a 64-year-old woman who presented with headaches. No other neurological complaints or physical examination findings were noted. Magnetic resonance imaging showed an expansile lesion centered in the middle portion of the clivus. A large portion of the clivus was eroded. The lesion was explored via a transnasal trans-sphenoidal approach and granular debris was evacuated. The cystic lining was stripped from the surrounding bone, and the bone opening was widely fenestrated. Pathological examination showed keratinous debris with macrophages and an outer lining of benign epithelial tissue consistent with a cholesteatoma (epidermoid cyst). When surgically accessible, these lesions should be excised to prevent a recurrence. If inaccessible, marsupialization may be considered.