Mark L. Dyken

Sleep abnormalities in patients with brain stem lesions

Seven patients with “locked-in” syndrome were studied by prolonged polygraphic recordings. Severe alterations in the sleep pattern were observed in five patients who had bilateral extensive pontine lesions resulting in tetraplegia, facial and pseudobulbar paralysis, and absence of conjugate horizontal gaze. Rapid eye movement (REM) sleep was entirely absent while non-rapid eye movement (NREM) sleep was absent, reduced, or altered. The remaining two patients, both of whom had relative sparing of horizontal gaze and apparently either no or minimal pontine tegmental involvement, showed both REM and NREM sleep with only a minimal alteration in the sleep pattern. The study suggests that, in human beings as in animals, pontine structures near the midline are essential for control of sleep states.

An electromyographic diagnostic screening test in McArdle's disease and a case report

IN 1951, McArdlel described a patient with the disease that now bears his name. No further cases were reported until 1959, when Schmid and associates~--4 and Pearson, Mommaerts, and associates5-7 described additional cases and established the enzymatic defect as a deficiency of muscle phosphorylase. To the present, only 20 patients with this defect have been described in the English literature: 1 by McArdle in 1951,l 1 by Pearson and associates in 1959,6 3 by Schmid and associates in 1959 and 1961,3g4 1 by Mellick and associates in 1962,s 2 by Engel and associates in 1963,g 2 by Rowland and associates in 1963,lO 1 by Thomson and associates in 1963,11 1 by Hatcher and associates in 1964,12 1 by Hockaday and associates in 1964,l3 3 by Tobin and Coleman in 1965,14 1 by Ratinov and associates in 1965,15 1 by Salmon and Turner in 1965,lG and 2 by Rowland and associates in 1966.17 All 20 were reported from centers where advanced chemical, electrical, and pathological studies could be performed. Therefore, the disease may be much more frequent than the number reported indicates. The complaints of muscle cramping and fatigue with exercise are so common that in some patients the myophosphorylase deficiency may not be diagnosed when the routine examination is within normal limits. The purpose of this paper is to describe a simple electromyographic test which might be used to screen large numbers of patients suspected of having myophosphorylase deficiency and to report an additional case. In this patient, repetitive supramaximal nerve stimulation produced a unique decrement in the amplitude of the evoked potentials in the muscles supplied.

Electroencephalographic lateralization in chronic infantile hemiplegia

Abstract In 20 of 40 patients with chronic infantile hemiplegia, EEGs failed to lateralize cerebral dysfunction as determined clinically. Patients with “concordant” clinical EEG lateralization were compared to those with “discordant” or non-localizing findings. There was no difference between these groups as to sex, age, cerebral vascular resistance and cerebral oxygen consumption. However, cerebral blood flow was significantly lower in the group with discordant lateralization suggesting the existence of generalized bilateral brain damage.

I. Epidemiology for stroke facilities planning

The Major factors known to be associated with stroke include increasing age, hypertension, cardiovascular disease and diabetes. However, many additional data are required to substantiate the role of other risk factors. The incidence, prevalence and mortality figures in this paper are presented in a form to be useful for palnning health facilities and manpower resources required in the proper management of stroke problems.

FOUR CASES OF CAROTID-BASILAR ANASTOMOSIS ASSOCIATED WITH CENTRAL NERVOUS SYSTEM DYSFUNCTION

Various anomalous anastomoses between the carotid and basilar arteries have been reported. Krayenbuhl and Yasargil (1957) classify three types. The first and by far the most frequent type is a persistent primitive trigeminal artery. The second in frequency is a persistent hypoglossal artery. The third type is a persistent primitive acoustic artery. We have found only the first type in our angiographic review. Persistence of the primitive trigeminal artery was first reported by Quain (1844). The first report of angiographic demonstration was not until 1950 (Sutton). In a review of the literature in 1960 (Jackson and Garza-Mercado), only 33 case reports were found. Krayenbuhl and Yasargil in their book on angiography describe four cases demonstrated by angiography. Their first case may be an anomaly other than a persistent trigeminal artery, since the vessel appears to originate at the junction of the C1 to C2 portion of the carotid artery. The vessel illustrated in their last case, described in a discussion of an arteriovenous malformation, may be a branch of the external carotid artery. Lindgren (1954) also reproduced angiograms of two cases. The incidence of this lesion reported in the literature has varied from 1 % to 0-001 % (Jackson and Garza-Mercado, 1960). As pointed out by Harrison and Luttrell (1953), the true incidence of this lesion is very difficult or impossible to ascertain. We found an incidence of approximately 01 % at the Indiana University Medical Center, and in a series of 76 angiograms at the New Castle State Hospital, three cases were demonstrated for an incidence of 4%.

Differences in the Occurrence of Carotid Transient Ischemic Attacks Associated With Antiplatelet Aggregation Therapy

Twenty-six of 117 consecutive patients with a provisional diagnosis of transient ischemic attacks answered the following criteria: (1) transient hypofunction of an area supplied by a branch of an internal carotid artery, (2) no evidence of infarction, (3) carotid and vertebral arterial systems visualized angiographically, (4) cerebral blood flow and metabolism studies performed, (5) followed a minimum of three months, (6) other causes of transient dysfunction had been ruled out, and (7) no carotid arterial system surgery. Only six (23%) had occlusion greater than 50% and 21 (81%) had evidence of irregularity or ulceration of an atherosclerotic plaque in the appropriate internal carotid artery. It was noted in retrospect that 15 of the patients were treated with aspirin (300 mg b.i.d.) and 11 were not. No difference in ultimate infarction or death was noted, but only two (13%) of those treated with aspirin had an additional attack compared to nine (82%) of those who had no aspirin. These findings suggest that fibrin-platelet emboli may be a major contributor to transient ischemic attacks in the carotid circulation. The authors stress that this is a retrospective study and its importance is to further support the need for prospective studies before antiplatelet aggregating drugs are used indiscriminately.

Report of the Joint Committee for Stroke Facilities VII. Medical and Surgical Management of Stroke

Because it contains material concerned with the many critical problems of diagnosis, differential diagnosis, and treatment which arise when a patient presents with a possible stroke, Medical and Surgical Management is one of the most important Sections to appear in this series of publications from the Joint Committee for Stroke Facilities. Practical aspects of the management of transient ischemic attacks (TIA), strokes-inevolution, completed strokes, and the comatose patient are discussed in detail, and attempts made to distinguish between ischemic and hemorrhagic stroke. Recommendations of the study group are listed.

Internal Carotid Artery Occlusion Diagnosed by Doppler Ultrasound

Using a transcutaneous Doppler ultrasonic blood velocity detector, retrograde ophthalmic artery blood flow was demonstrated in four patients, all of whom had angiographically confirmed occluded internal carotid arteries. In three, compression of the facial artery obliterated the ophthalmic artery signal. In a fourth patient compression of the superficial temporal artery produced the same result. The technique presently used to monitor ophthalmic artery blood flow and to detect retrograde ophthalmic flow is described. This simple method appears to be at least as useful as ophthalmodynamometry in the routine evaluation of patients for extracranial occlusive disease, is easier to perform, and has a wider range of application.

Precipitating Factors, Prognosis, and Demography of Cerebrovascular Disease in an Indiana Community: A Review of All Patients Hospitalized from 1963 to 1965 With Neurologica Examination of Survivors

As an initial step in studying the characteristics of cerebrovascular disease in a geographically limited segment of population, the hospital records of 285 patients coded as “CNS vascular” in the Elkhart General Hospital (Indiana) were reviewed for the years 1963, 1964 and 1965 by a team of neurology residents, under the supervision of the author. Information from examination of almost half the group by a team of neurologists and data from relatives, family physicians, hospital records and death certificates concerning the remainder led to the conclusion that the original diagnosis of “CNS vascular” could not be substantiated in 25 patients (9%), was cerebral infarction in 125 (53%), cerebral hemorrhage in 40 patients (14%), subarachnoid hemorrhage in 21 patients (7%), generalized atherosclerosis in 24 patients (8%), and transient focal cerebral ischemic attacks in 25 patients (9%). Disorders such as diabetes, hypertension, heart disease, myocardial infarction, auricular fibrillation and genitourinary disease were significantly more frequent in patients with cerebral infarction than in a group of similar age and sex patients collected from the same hospital in an attempt to form a “contrast group.” However, hypertension was the only disorder significantly more often associated with cerebral hemorrhage. Cigarette consumption was increased at a highly significant level in the males who had infarction and the prognosis was, in general, unfavorably affected by older age, further cerebrovascular events, and abnormal electrocardiograms. Eighty-three percent of the patients with cerebral hemorrhage died during initial hospitalization.

INCREASED EARLY RADIONUCLIDE ACTIVITY IN THE NASOPHARYNGEAL AREA IN PATIENTS WITH INTERNAL CAROTID ARTERY OBSTRUCTION: HOT NOSE.

Abstract In of 900 radionuclide angiograms obtained with 99m Tc pertechnetate, the nasal area contained marked activity prior to or coincidental with activity in major cerebral arteries. All but one showed anatomical or functional occlusion of one or both internal carotid arteries with a patent external carotid artery. In 4, brain death proved at autopsy was present, while contrast angiography demonstrated obstruction of one internal carotid artery in 11 and obstruction of both carotid arteries in one. Only 3 with proved internal carotid artery obstruction failed to display a “hot nose” on angiography. Its presence suggests obstruction of an internal carotid artery with increased blood flow in the external carotid artery.