Unsteady Gait Research Articles

Risk factors of readmission after geriatric hospital care: An interRAI-based cohort study in Finland

PurposeTo identify risk factors for readmission after geriatric hospital care. MethodsA retrospective cohort study of 1,167 community-dwelling patients aged ≥70 years who were hospitalised in two geriatric hospitals and discharged to their homes over a three-year period. We combined the results of the interRAI-post acute care instrument (interRAI-PAC) with hospital discharge records. Factors associated with readmissions within 90 days following discharge were analysed using logistic regression analysis. ResultsThe patients' mean age was 84.5 (SD 6.2) years, and 71% (n = 827) were women. The 90-day readmission rate was 29.5%. The risk factors associated with readmission in the univariate analysis were as follows: age, admission from home vs. acute care hospital, Alzheimer's disease, unsteady gait, fatigue, unstable conditions, Activities of Daily Living Hierarchy Scale (ADLH) score, Cognitive Performance Scale (CPS) score, body mass index (BMI), frailty index, bowel incontinence, hearing difficulties, and poor self-rated health. In the multivariable analysis, age of ≥90 years, ADLH ≥1, unsteady gait, BMI <25 or ≥30 kg/m 2 , and frailty remained as risk factors for readmission. Surgical operation during the treatment period was associated with a lower readmission risk. Conclusions and implicationsInterRAI-PAC performed upon admission to geriatric hospitals revealed patient-related risk factors for readmission. Based on the identified risk factors, we recommend that the patient's functional ability, activities of daily living (ADL) needs, and individual factors underlying ADL disability, as well as nutritional and mobility problems should be carefully addressed and managed during hospitalization to diminish the risk for readmission.

Effective treatment of osmotic demyelination syndrome with plasmapheresis: a case report and review of the literature

BackgroundTreatment options for chronic osmotic demyelination syndrome are limited to case reports and only a very few show complete recovery. We report a case of complete recovery of chronic osmotic demyelination syndrome with plasmapheresis.Case presentationA 43-year-old Sri Lankan man presented with fever, repeated vomiting, unsteady gait, increased tonicity of his right upper limb and paucity of speech for three days. He was treated in the local hospital with antibiotics and antivirals as per central nervous system infection. He had hyponatraemia, which was rapidly corrected with hypertonic saline from 97 to 119 mmol/L. He was transferred to our hospital because of progressive reduction of consciousness, rapidly worsening rigidity and bradykinesia of all four limbs and worsening dysarthria and bradyphrenia. Magnetic resonance imaging of the brain was compatible with osmotic demyelination syndrome. He was commenced on plasmapheresis twenty-two days after rapid correction of sodium. He regained independent mobility with complete resolution of rigidity, bradykinesia and speech dysfunction after five cycles of alternate day plasmapheresis.ConclusionPlasmapheresis can be considered as an effective treatment modality in chronic osmotic demyelination syndrome.

Acute toxic encephalopathy following bromadiolone intoxication: a case report

BackgroundClinically, bromadiolone poisoning is characterized by severe bleeding complications in various organs and tissues. Bromadiolone-induced toxic encephalopathy is extremely rare. Here, we report a special case of bromadiolone-induced reversible toxic encephalopathy in a patient who had symmetrical lesions in the deep white matter.Case presentationA 23-year-old woman mainly presented with dizziness, fatigue, alalia and unsteady gait after the ingestion of bromadiolone. The laboratory examinations showed normal coagulation levels. Brain magnetic resonance imaging (MRI) showed apparent diffusion restriction in the bilateral deep white matter. The clinical manifestations and MRI alterations were reversible within one month of treatment with vitamin K. The neuropsychological assessment showed no neurodegenerative changes at the 2-year follow-up.ConclusionWith the increased use of bromadiolone as a rodenticide, more cases of ingestion have been reported annually over the past several years. Bromadiolone-induced toxic encephalopathy has no special clinical manifestations and is potentially reversible with timely treatment. Because of the reversible restricted diffusion on diffusion-weighted images (DWI) and low apparent diffusion coefficient (ADC) values, transient intramyelinic cytotoxic oedema is thought to be the cause rather than persistent ischaemia. The underlying pathophysiological mechanism is still unknown and may be coagulant-independent. This clinical case extends the current knowledge about neurotoxicity in cases of bromadiolone poisoning and indicates that MRI is useful for the early detection of bromadiolone-induced toxic encephalopathy.

Acute Cerebellitis Associated with Dengue Fever

Dengue fever is caused by dengue virus of Flavivirus family transmitted by Aedes aegypti. It causes acute febrile illness with various constitutional symptoms with bleeding manifestations and shock in some instances. Neurological involvement has been frequently reported reported. However, cerebellar involvement is very rare. Here we report a case of 32-year-old male patient presented with fever of 8 days, giddiness, unsteadiness of gait with swaying to the right, slurring of speech and incoordination. Diagnosis of acute cerebellitis was made, and involvement of the cerebellum in this patient was attributed to dengue fever. Patient treated for dengue fever, cerebellar symptoms were gradually improved in the course of hospital stay. He got discharged and on follow-up there was complete resolution of cerebellitis.

Acquired Chiari Type 1 Malformation Secondary to Paget’s Disease of the Bone: A Case Report

Chiari type 1 malformations are characterised by caudal descent of cerebellar tonsil into foramen magnum. Usually it is congenital. Paget’s disease causing acquired chiari type 1 malformation is rare with only five reported cases in the literature. The diagnosis is primarily by Magnetic Resonance Imaging (MRI). Authors reported a case of acquired chiari type 1 malformation due to paget’s disease in a 58-year-old male patient diagnosed by MRI and Computed Tomography (CT). The patient presented with complaints of headache, unsteady gait, slow movements with weakness in all the four limbs, difficulty in walking which aggravated since three days and stammering of speech. Initially a diagnosis of motor neuron disease was suspected and the patient was subjected for MRI examination of brain and spine. MRI revealed platybasia with cerebellar tonsillar herniation with calvarial thickening and multiple vertebral collapse. The CT of brain and spine was done to evaluate bones specifically in view of thickened cranial vault and multiple vertebral collapse on MRI which revealed features of paget’s disease in the form of widened sclerotic bone with lytic areas and thickened trabeculae. Hence, diagnosis of paget’s disease causing acquired chiari type 1 malformation was made which correlated with biochemical findings. The management is different in primary and acquired chiari type 1 malformation and hence it is important to diagnose this condition which is relatively rare.

Rehabilitation in Devica’s Syndrome. Case Report

Introduction: Devic’s syndrome also known as neuromyelitis optica is an autoimmune disease of central nervous system (CNS).It has an inflammatory, demyelizatory, chronic and relapsing nature, where ones own immune system attacks the spinal cord and optic nerves. Material and Methods: The authors presented a case report of a 54-year-old woman diagnosed with Devic’s syndrome 2 years ago. The physiotherapeutic examination revealed: visual and balance disturbances, decrease in muscle strength of upper and lower limbs, unsteady and shaky gait with a need to use a zimmer frame. At the start and at the end of a therapy, to objectively monitor the progress of rehabilitation treatment, a number of functional tests were used that included: Barthel Index, Brunnstrom’s test, Rankin Scale, Ashworth’s scale, Lovett’s test and a timed 20m walk. In physiotherapeutic treatment process patterns and techniques of PNF (prioprioceptive neuromuscular facilitation) ware used as well as exercise to correct muscles tone and strengthening exercise of trunk and lower limbs. Results: As a result of applying a comprehensive rehabilitation approach an increase of muscles strength of upper and lower limbs was obtained (Lovett’s scale R/L: shoulder 5/5, elbow 5/5, hand 5/5, hip 4+/4+, knee 4+/4+, foot 4+/4+). In addition all postural muscles gained in strength and an improvement in hands dexterity, body coordination and balance was noticed. Conclusion: Multidisciplinary approach and an individually selected rehabilitation program proves to show beneficial effects in a treatment process of patients with Devic’s syndrome.

Sport-related concussion adopt a more conservative approach to straight path walking and turning during tandem gait

It is currently unknown what specific neuronal deficits influence postural instability following SRC; however, the modulation of postural control relies heavily on the appropriate integration of sensory information from the visual, vestibular, and somatosensory system. It is possible symptom provocation of vestibular or ocular function is related to unsteady gait patterns during tandem gait. The purpose of this study was to evaluate the differences in temporal and center of pressure (CoP) metrics during discrete events of instrumented tandem gait (iTG) among those with sport-related concussion (SRC) compared to healthy controls. Secondarily, this study attempted to evaluate the relationship between iTG CoP metrics and the Vestibular/Ocular Motor Screening (VOMS) Exam. 30 collegiate athletes with SRC and 30 healthy controls completed three single task (ST) iTG trials on an instrumented walkway and the VOMS. All individuals with SRC were assessed within 24-48 h post-injury while all controls were measured during pre-participation physicals. CoP metrics in the anteroposterior (AP) and mediolateral (ML) directions and time to completion were evaluated during the first, turn and second pass of iTG between groups. VOMS score was correlated to the CoP metrics across the discrete events. Athletes with SRC took longer to complete tandem gait (P<0.001) along with the first pass, second pass but not the turn when compared to the control group. SRC had slower velocity in the AP direction during both the first (P<0.001) and second pass (P<0.001) with increased postural sway in the ML direction during the first pass (P=0.014). During the turn, athletes with SRC had postural sway in the ML direction (P=0.008). Finally, VOMS score was weakly negatively related to CoP velocity in the AP direction during first (r=-0.39) and second (r=-0.36) pass while being weakly positively related to postural sway during the turn (r=-0.30). Athletes with SRC adopted a more conservative walking pattern and the presence of vestibular and/or ocular symptoms influence the ability to perform heel-to-toe walking. Individuals with SRC will walk slower during heel-to-toe walking and move more in the ML direction with great movement in the ML direction while en pointe turning. This may increase given the total amount of vestibular or vision symptoms following the SRC.

Oral Cladribine is Effective in the Treatment of Tumefactive Demyelination in Relapsing Remitting Multiple Sclerosis – A Case Report

This case report describes a 32-year old Emirati patient with tumefactive multiple sclerosis (TMS) treated with a short course of cladribine tablets. The patient presented initially with acute onset of progressive gait unsteadiness, lower limb weakness, associated with numbness of four days duration. Neurological examination of right arms and both legs weakness with sensory level at T10. Contrast-enhanced magnetic resonance imaging (MRI) of the brain showed a large tumefactive demyelination with multiple demyelinating lesions in the brain, consistent with a diagnosis of multiple sclerosis. MRI of the spine cervical and dorsal revealed multiple enhancing lesions as well. Cerebrospinal fluid oligoclonal bands were positive, and IgG index was high. Magnetic resonance spectroscopy showed elevation of lactate on short echo time (TE) and elevation of choline on long TE. The patient was treated with pulse steroid followed by oral cladribine as immune reconstitution therapy in the acute phase. The patient showed significant improvement clinically and radiologically to the treatment. The patient was followed up for 2 years and showed excellent resolution of the tumefactive lesion with no new lesions. Immune reconstitution therapy can be an option for treatment of tumefactive demyelination in multiple sclerosis in the acute setting. To our knowledge, there are no reports of the use of immune reconstitution therapies for the treatment of tumefactive lesions in multiple sclerosis.

Endoscopic Fenestration of Arachnoid Cysts Through Lateral Pontomesencephalic Membranotomy: Technical Note and Case Series

The ideal treatment method for cranial arachnoid cysts stills controversial, each of endoscopic and microscopic techniques has its pros and cons. We described cystocisternostomy technique for arachnoid cysts through fenestration medial to the edge of tentorium through lateral pontomesencephalic membrane and illustrated it's outcomes. We performed endoscopic lateral pontomesencephalic membranotomy in nine children with zero angled rigid endoscope (STORZ).The age ranged from eight months up to nine years. The cysts were Galassi type III in eight cases (five of them giant hemispheric) and Galassi type II in one case. Clinical presentations were delay in milestones, seizures, loss of consciousness, unsteady gait, and persistent headache. The cysts decreased in size in five cases after three months and nearly disappeared after three and 15 months in two cases, and in 18 months in the other two. Preoperative symptoms improved in all cases. Insignificant subdural hygroma was found in five cases, one case developed hydrocephalus four months later treated with a ventriculoperitoneal shunt; contralateral massive subdural hematoma occurred in one case four months after surgery evacuated with two burr holes with good clinical outcome. There was neither cerebrospinal fluid leakage, cranial nerve palsy nor mortality. The fenestration through the lateral pontomesencephalic membrane created a shortcut of cerebrospinal fluid flow to the basal cisterns especially cerebellopontine cistern and represents a reliable option with an acceptable success rate. It creates a good drainage to the large cysts.

A Retrospective, Matched Case-Control Study on the Risk Factors of Falls and Varying Severities of Fall-Related Injuries in Inpatients.

This study was to investigate the factors that influence falls and the severity of fall-related injuries in inpatients. We adopted a retrospective, matched case-control design and conducted this study at a teaching hospital in Taiwan. Our study period ran from January 2016 to December 2019. We searched for inpatients with official fall records and obtained data from 823 patients, and then established a control group comprising 331 matching patients based on age, sex, length of hospital stay at time of fall incident, and ward type, thereby resulting in 1154 patients in all. A cumulative logistic regression model was applied to the data collected from medical records and fall incident reports to identify the factors that influence falls and the severity of fall-related injuries in inpatients. The results indicated that the use of sedatives (B = 0.49, P < 0.001), impaired consciousness (B = 0.64, P < 0.001), normal weight versus obese (B = -0.59, P = 0.008), low hemoglobin levels (B = -0.08, P = 0.003), an unsteady gait versus a normal gait (B = 1.82, P < 0.001), and history of falling within the past year (B = 0.56, P < 0.001) were correlated with the falls and the severity of fall-related injuries. Our results indicate that the use of sedatives, impaired consciousness, obesity, low hemoglobin levels, poor gait function, and history of falling within the past year are all independent factors that influence falls and the severity of fall-related injuries. This study can provide medical personnel with a reference for the identification of patients with a high risk of falling and implementation of fall prevention measures.

Current Management of Cervical Spondylotic Myelopathy.

Cervical spondylotic myelopathy (CSM) develops insidiously as degenerative changes of the cervical spine impact the spinal cord. Unfortunately, CSM is a form of spinal cord injury in older patients that often experiences delayed treatment. This summary evaluates the pathophysiology, natural history, diagnosis, and current management of CSM. Frequently, patients do not appreciate or correlate their symptomatology with cervical spine disease, and those with radiographic findings may be clinically asymptomatic. Providers should remember the classic symptoms of CSM-poor hand dexterity, new unsteady gait patterns, new onset and progressive difficulty with motor skills. An magnetic resonance imaging is required in patients with suspected CSM, but computerized tomography myelography is an alternative in patients with implants as contraindications to magnetic resonance imaging. The management of those with CSM has continued to be a controversial topic. In general, patients with incidental findings of cervical cord compression that are asymptomatic can be managed conservatively. Those with daily moderate-severe disease that significantly affects activities of daily living should be treated operatively.

Anti-GFAP neuroinflammation with synchronous bilateral papillitis and characteristic imaging

A 50-year-old female marine ecologist presented to the emergency department following 3 weeks of persistent headache, nausea, vomiting, disturbed vision, intermittent aural pulsations, unsteady gait and acroparesthesias. She had previously...

Long-term persistence of infectious Zika virus: Inflammation and behavioral sequela in mice.

The neurodevelopmental defects associated with ZIKV infections early in pregnancy are well documented, however the potential defects and long-term consequences associated with milder infections in late pregnancy and perinatal period are less well understood. To model these, we challenged 1 day old (P1) immunocompetent C57BL/6 mice with ZIKV. The animals developed a transient neurological syndrome including unsteady gait, kinetic tremors, severe ataxia and seizures 10–15 days post-infection (dpi) but symptoms subsided after a week, and most animals survived. Despite apparent recovery, MRI of convalescent mice show reduced cerebellar volume that correlates with altered coordination and motor function as well as hyperactivity and impulsivity. Persistent mRNA levels of pro-inflammatory genes including Cd80, Il-1α, and Ifn-γ together with Cd3, Cd8 and perforin (PrfA), suggested persistence of low-grade inflammation. Surprisingly, the brain parenchyma of convalescent mice harbor multiple small discrete foci with viral antigen, active apoptotic processes in neurons, and cellular infiltrates, surrounded by activated astrocytes and microglia as late as 1-year post-infection. Detection of negative-sense strand viral RNA and isolation of infectious virus derived from these convalescent mice by blinded passage in Vero cells confirmed long-term persistence of replicating ZIKV in CNS of convalescent mice. Although the infection appears to persist in defined reservoirs within CNS, the resulting inflammation could increase the risk of neurodegenerative disorders. This raises concern regarding possible long-term effects in asymptomatic children exposed to the virus and suggests that long-term neurological and behavioral monitoring as well as anti-viral treatment to clear virus from the CNS may be useful in patients exposed to ZIKV at an early age.

Optic tract and internal capsule lesion in a patient with Wernicke-Korsakoff syndrome

A 72-year-old man, presented with a one-week history of confusion and an anterograde amnesic disorder accompanied by confabulation, with lack of insight to his symptoms.&#x0D; Medical history included alcohol abuse and admitted twenty-years of alcohol ingestion (approximately 186 gr/day).&#x0D; Neurologic examination was notable for slightly decreased consciousness, disorientation to time, severe anterograde amnesia and unsteadiness of stance and gait with four limb ataxia.&#x0D; A metabolic blood panel including liver profile showed alanine aminotransferase mildly elevated (66 UI/L) with elevated gamma-glutamyl-transpeptidase (gGT: 426 UI/L). Tests for HIV, syphilis and vitamin B12 levels were negative.&#x0D; Review of initial brain MRI showed a symmetrical, increased fluid-attenuated inversion recovery (FLAIR) signal lesion extending through the hypothalamus, periaqueductal area, mamillary bodies, bilateral anterior thalami, chiasm, both optic tracts and posterior limbs of both internal capsules with restricted diffusion and patchy contrast enhancement (figure 1 1a-1b).&#x0D; A possible Wernicke-Korsakoff syndrome diagnosis was achived. Following the initial examination, the patient was initiated on prophylactic parenteral thiamine reposition.&#x0D; CSF analysis showed elevated proteins (174 mg/dl) and lactate concentration (2.9 mmol/L). Cytologic and immunocytochemical study showed no neoplastic processes. Screening of autoimmune antibodies in CSF and paraneoplastic antibodies in serum were negative.&#x0D; EEG and full-body CT scans were unremarkable.&#x0D; Thiamine serum levels were normal (16,5 ug/L) (blood sample collected previous to reposition). &#x0D; Finally, a neurocognitive test indicated malperformance in tasks related to immediate and delayed recall and disturbances in recent and remote memory with confabulation.&#x0D; A new brain MRI after supplementation showed regression of the previous lesion (figure 1 2a-2b).&#x0D; He was discharged one month later with residual anterograde amnesia and gait instability that are still present eleven months later, at the last follow up.&#x0D; &#x0D; &#x0D; Figure 1: (1) Axial FLAIR MRI sequence showing extensive, symmetrical, hyperintense lesion in chiasm and both optic tracts (1.a) and periaqueductal area, hypothalamus and posterior limb of internal capsules (1.b). (2) Axial FLAIR MRI sequence showing regression of the hyperintense lesion one month after thiamine reposition in chiasm and both optic tracts (2.a) and periaqueductal area, hypothalamus and posterior limb of internal capsules (2.b)&#x0D; &#x0D; Wernicke’s encephalopathy (WE) prototypical clinical triad consists of motor problems such as ataxia or gait incoordination, ocular signs (commonly ophthalmoparesis and nystagmus) and mental status changes1-3. Thiamine (vitamin B1) deficiency secondary to alcoholism is the most common etiologic factor3. If left untreated or undertreated, there is an increased risk of developing a chronic sequelae: the Korsakoff’s syndrome (KS), characterized with loss of working memory and confabulation with sparing of remote memories2-4. Both syndromes together are termed Wernicke-Korsakoff syndrome (WKS).&#x0D; Even though diagnosis of WKS remains primarily clinical3, brain MRI findings in previously reported typical locations1-3are highly specific of this syndrome, suggesting MRI is a valuable confirmation tool.&#x0D; Normal thiamine serum levels shouldn’t dismiss the initial suspicion, as its blood concentration does not necessarily reflect brain tissue’s concentration4.&#x0D; Our case suggests that, even when MRI lesions are not characteristic, intravenous thiamine reposition should be immediately initiated if WKS is suspected, considering the patient's outcome depends on prompt diagnosis and adequate treatment.

Diagnostic Accuracy of the HINTS Exam in an Emergency Department: A Retrospective Chart Review.

The HINTS exam is a series of bedside ocular motor tests designed to distinguish between central and peripheral causes of dizziness in patients with continuous dizziness, nystagmus, and gait unsteadiness. Previous studies, where the HINTS exam was performed by trained specialists, have shown excellent diagnostic accuracy. Our objective was to assess the diagnostic accuracy of the HINTS exam as performed by emergency physicians on patients presenting to the emergency department (ED) with a primary complaint of vertigo or dizziness. A retrospective cohort study was performed using data from patients who presented to a tertiary care ED between September 2014 and March 2018 with a primary complaint of vertigo or dizziness. Patient characteristics of those who received the HINTS exam were assessed along with sensitivity and specificity of the test to rule out a central cause of stroke. A total of 2,309 patients met criteria for inclusion in the study. Physician uptake of the HINTS exam was high, with 450 (19.5%) dizzy patients receiving all or part of the HINTS. A large majority of patients (96.9%) did not meet criteria for receiving the test as described in validation studies; most often this was because patients lacked documentation of nystagmus or described their symptoms as intermittent. In addition, many patients received both HINTS and Dix-Hallpike exams, which are intended for use in mutually exclusive patient populations. In no case was dizziness due to a central cause identified using the HINTS exam. Our results suggest that despite widespread use of the HINTS exam in our ED, its diagnostic value in that setting was limited. The test was frequently used in patients who did not meet criteria to receive the HINTS exam (i.e., continuous vertigo, nystagmus, and unsteady gait). Additional training of emergency physicians may be required to improve test sensitivity and specificity.

Endoscopic Endonasal Transclival Odontoidectomy for Basilar Invagination: Operative Video and Technical Nuances.

Basilar invagination is a congenital or acquired craniovertebral junction abnormality where the tip of the odontoid process projects through the foramen magnum which can cause severe symptomatic compression of the brainstem and spinal cord. If left untreated, patients can develop progressive quadriparesis. Traditionally, basilar invagination can be treated with cervical traction and posterior stabilization. However, in irreducible cases, anterior decompression via a transoral or endonasal approach may be necessary. In this operative video, we demonstrate an endoscopic endonasal transclival approach for odontoidectomy to successfully treat a 37-year-old female with severe basilar invagination causing symptomatic compression on the cervicomedullary junction resulting in unsteady gait and motor weakness. The patient had Klippel–Feil syndrome where the C1 arch was assimilated to the foramen magnum and transclival drilling was needed to adequately access the odontoid process for removal. A second-stage posterior occipitocervical stabilization and fusion was performed the following day. Immediate postoperative imaging showed excellent decompression of the cervicomedullary junction. Postoperatively, the patient had significant improvement in gait and motor strength in all extremities, and was ambulating independently without assistance at 1 year after surgery. The endoscopic endonasal transclival odontoidectomy is a useful strategy to treat severe irreducible basilar invagination causing symptomatic neural compression. The surgical technique and nuances are described in a step-by-step fashion in this illustrative operative video.The link to the video can be found at: https://youtu.be/HL4K7KqJEJM.

Far Lateral Approach for Disconnection of Craniocervical Junction Dural Arteriovenous Fistula Presented with Myelopathy and Hydrocephalus.

We report a case of craniocervical junction dural arteriovenous fistula (dAVF) presented with myelopathy and normal pressure hydrocephalus, and was treated with hybrid approach of embolization and surgical disconnection. A 68-year-old gentleman presented with 1 year history of unsteady gait and sphincter disturbance. Magnetic resonance imaging (MRI) showed abnormally enlarged and tortuous vessels over right cerebellomedullary cistern. Digital subtraction angiogram (DSA) showed Cognard's type-V dAVF at craniocervical junction. Catheter embolization was performed via external carotid artery and finally surgical disconnection was done with far lateral approach ( Fig. 1 ). Postoperative DSA showed no more arteriovenous shunting ( Fig. 2 ). Clinically the patient improved after a course of rehabilitation. Dural AVF at craniocervical junction is rare and its clinical presentation can be highly variable from subarachnoid hemorrhage to brainstem dysfunction. Identification of the exact fistula site is essential in surgical planning. Surgery is effective and safe to achieve complete obliteration and good clinical outcome. 1 2 3 4 5 6 The link to the video can be found at: https://youtu.be/xI48stSlWpY .

Spontaneously changing MRI findings of primary central nervous system vasculitis: A case report

Spontaneously disappearing lesions on magnetic resonance imaging (MRI) has been described in primary central nervous system lymphoma. In this case, we report our experience of spontaneously changing MRI findings of primary central nervous system vasculitis (PCNSV) confirmed histopathologically. A 69-year-old man presented with sudden unsteady gait. Fluid-attenuated inversion recovery (FLAIR) images showed high-intensity areas in the right deep white matter. Contrast-enhanced T1-weighted MRI demonstrated a nodular lesion in the white matter of the left occipitoparietal lobe. On repeat MRI 7 days later, FLAIR hyperintense lesions had spontaneously disappeared and contrast-enhanced lesions had progressed, with new contrast lesions in the right corpus callosum. Repeat MRI 14 days after admission demonstrated contrast-enhancing lesions either increased or decreased in intensity in both occipitoparietal lobes. Contrast-enhancing lesions were therefore biopsied. Histopathological examination revealed vasculitis with fibrinoid necrosis. PCNSV was diagnosed without any signs of inflammation in blood vessels other than cerebral blood vessels. Spontaneously changing MRI findings may play an important role in diagnosing PCNSV.

The 14-day repeated-dose toxicity study of a fixed-dose combination, QXOH/levobupivacaine, via subcutaneous injection in beagle dogs.

QXOH-Levobupivacaine (LB) is a fixed-dose combination of 35-mM QXOH and 10-mM LB. It was developed for perioperative analgesia because of its long-acting analgesic effect. The purpose of this study was to evaluate the potential toxicity of QXOH-LB in beagle dogs in accordance with the Guidance on the repeated-dose toxicity published by the China Food and Drug Administration. Groups of five male and five female beagle dogs received normal saline, QXOH-LB (2, 4, and 8mg/kg, calculated as QXOH), QXOH (2, 4, and 8mg/kg), or LB (2mg/kg, equals the concentration of LB in 8-mg/kg QXOH-LB group) at the volume of 1mL/kg once per day for 14days through subcutaneous injection. No mortality was observed. Dogs in the control group as well as animals treated with 2-mg/kg QXOH or QXOH-LB exhibited normal behaviors. Clinical signs of toxicity in dogs treated with 4 and 8mg/kg of QXOH or QXOH-LB included decreased activity, unsteady gait, jerks, tremors, vocalization, emesis, ataxia, lateral/sternal recumbency, deep/rapid respiration, and gasping. Additionally, neurological function was found to be affected by QXOH and QXOH-LB at the doses of 4 and 8mg/kg. All clinical signs were recovered within 24h. The no-observed-adverse-effect level of QXOH and QXOH-LB was considered to be 2mg/kg. Toxicokinetic data showed that exposure to QXOH and LB increased as QXOH-LB doses were increased from 4 to 8mg/kg. There was no evidence of drug accumulation or any effect of gender.

Family history as a clue to the diagnosis of orofacial abnormal movements in a 30-year-old man

A 30-year-old man presented with a two-year history of involuntary movements in the face and mouth. Movements progressively worsened during the previous six months. Born from non-consanguineous parents, he had normal developmental milestones and his past medical history was unremarkable. The patient did not take any medication or had a history of illicit drug use. Family history was positive for unsteady gait of unknown cause. Neurological examination disclosed isolated orofacial dystonia affecting the face, particularly his mouth and eyes, resembling Meige’s syndrome. Dystonic closure of eyelids and dystonic contractions of orbicularis oris and platysma were particularly visible while patient was talking. The Montreal Cognitive Assessment score was 30. There were no other movement disorders or other abnormalities in neurological examination. Of note, cerebellar examination as well as gait assessment were normal.