Massey Ew

Silent aspiration following stroke

Neurogenic dysphagia following stroke is not limited to brainstem involvement. Among 21 patients with stroke, one-third demonstrated only unilateral signs. In eight patients with silent aspiration, less subjective complaints, weaker cough, and dysphonia occurred more often. Videofluoroscopy must be used liberally in unilateral and bilateral strokes.

Aspiration following stroke Clinical correlates and outcome

Among 47 patients with stroke evaluated clinically and videofluoroscopically, one-half aspirated. Patients with combined cerebral-brainstem strokes with bilateral cranial nerve signs were at greatest risk, but aspiration also occurred in the context of unilateral signs. Dysphonia was the common clinical characteristic of aspirating patients. Single chest roentgenograms were of limited value in predicting aspiration. Outcome was favorable following compensatory oral feeding programs.

Treatment of radiation‐induced nervous system injury with heparin and warfarin

When radiation is used to treat nervous system cancer, exposure of adjacent normal nervous system tissue is unavoidable, and radiation-induced injury may occur. Acute injury is usually mild and transient, but late forms of radiation-induced nervous system injury are usually progressive and debilitating. Treatment with corticosteroids, surgery, and antioxidants is often ineffective. We treated 11 patients with late radiation-induced nervous system injuries (eight with cerebral radionecrosis, one with a myelopathy, and two with plexopathies, all unresponsive to dexa-methasone and prednisone) with full anticoagulation. Some recovery of function occurred in five of the eight patients with cerebral radionecrosis, and all the patients with myelopathy or plexopathy. Anticoagulation was continued for 3 to 6 months. In one patient with cerebral radionecrosis, symptoms recurred after discontinuation of anticoagulation and disappeared again after reinstitution of treatment. We hypothesize that anticoagulation may arrest and reverse small-vessel endothelial injury–the fundamental lesion of radiation necrosis–and produce clinical improvement in some patients.

Natural history of cerebral complications of coronary artery bypass graft surgery

We reviewed 1,669 patients who survived coronary artery bypass graft surgery between 1969 and 1981. A total of 75 cerebral complications were identified, including (1) altered mental state, (2) stroke, and (3) seizure in 64 patients (3.8%). Altered mental state (delirium, hypoxic-metabolic encephalopathy) occurred in 57 (3.4%). Postoperative arrhythmias were associated with an increased risk of altered mental state. Cerebral infarction occurred in 13 (0.8%). Patients who suffered stroke had a higher occurrence of carotid bruits and history of peripheral vascular disease. Seizures occurred in five patients (0.3%). Mortality in patients with a neurologic complication was 29%.

Neurologic manifestations of essential thrombocythemia.

Essential thrombocythemia is a clonal myeloproliferative disorder, characterized predominantly by a markedly elevated platelet count without known cause. We report a case that was recognized during investigation of a transient ischemic attack, and review the neurologic findings in 33 patients with unequivocal essential thrombocythemia under prospective study by the Polycythemia Vera Study Group. Twenty-one patients had neurologic manifestations at some point during their course, including headache (13 patients), paresthesiae (10), posterior cerebral circulatory ischemia (9), anterior cerebral circulatory ischemia (6), visual disturbances (6) and epileptic seizures (2). All patients with neurologic symptoms responded satisfactorily to treatment, although continuous or repeated treatment was often required. Therapeutic recommendations include plateletpheresis for major thrombo-hemorrhagic phenomena, or megakaryocyte suppression with radioactive phosphorus, alkylating agents (such as melphalan), or hydroxyurea; minor symptoms may respond to platelet antiaggregating agents.

Aspiration in bilateral stroke patients

Seventy patients with bilateral strokes underwent neurologic and videofluoroscopic barium swallowing examinations; 34 (48.6%) aspirated. Patients with aspiration were more likely to have posterior circulation strokes, abnormal cough, abnormal gag, and dysphonia. However, patients likely to aspirate can be identified best by the presence of an abnormal voluntary cough, an abnormal gag reflex, or both. The prediction of patients at risk for aspiration was not improved by additional clinical information (ie, presence of dysphonia or bilateral neurologic signs).

Mental neuropathy from systemic cancer

Nineteen patients with mental neuropathy secondary to systemic cancer are described. In nine patients, the numb chin was the presenting symptom of a neoplasm. Nine patients had lymphoreticular malignancies, and the others had a variety of solid tumors. Radiograms of the mandible were abnormal in 5 of 12 patients. The cerebrospinal fluid contained malignant cells in two. Resolution, complete or partial, occurred in 16 of 19 patients receiving radiation or chemotherapy, including 8 who received chemotherapy alone. Sixteen of the 19 patients died within 17 months of the onset of the neuropathy. A nontraumatic mental neuropathy should initiate a search for cancer.

Stroke and acute Myocardial Infarction in the Thrombolytic era: Clinical correlates and long-term prognosis

Thirteen (1.8%) of 708 patients with acute myocardial infarction treated with recombinant tissue-type plasminogen activator in the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) I, II and III trials developed a stroke. Four strokes were hemorrhagic and nine were nonhemorrhagic. Of five prespecified risk factors for intracranial hemorrhage (age greater than 65 years, history of hypertension, history of prior cerebrovascular disease, aspirin use and acute hypertension), two patients had two risk factors and one patient had one risk factor. However, 80% of patients without intracranial hemorrhage had at least one risk factor and 31% had two risk factors. No patient with a prior stroke or transient ischemic attack (all greater than 6 months previously) had an intracranial hemorrhage. Of three prespecified risk factors for nonhemorrhagic stroke (atrial fibrillation, prior cerebrovascular disease and large anterior wall infarction), only the occurrence of a large anterior myocardial infarction (with ejection fraction less than 45%) was a predictor (p = 0.0015). The in-hospital death rate was 25% for patients with hemorrhagic stroke versus 11% for patients with a non-hemorrhagic stroke and 6% for those patients without a stroke. Furthermore, the hospital stay was greater than 50% longer in patients who had a stroke than in those who did not. Thus, intracranial hemorrhage remains an unpredictable risk in patients treated with thrombolytic therapy and cerebral infarction is related to anterior myocardial infarction and poor left ventricular function. Both types of stroke are associated with substantial morbidity and mortality.

Neurologic presentation of decompression sickness and air embolism in sport divers.

In a retrospective study of scuba divers with neurologic injuries, we found that mild symptoms were common. Seventy divers had decompression sickness, most often with paresthesias or numbness, rarely with paresis. Thirty-nine divers had air embolism that often caused unconsciousness or mild symptoms of cerebral injury. Many divers with neurologic decompression sickness gave histories of dives that were within conventional limits, and many with air embolism gave no history of breath-holding during ascent. Mild symptoms sometimes regressed spontaneously. Recompression delays were responsible for poor responses to therapy.

Aspartame and susceptibility to headache.

We performed a double-blind crossover trial of challenges with 30 mg of aspartame per kilogram of body weight or placebo in 40 subjects who reported having headaches repeatedly after consuming products containing aspartame. The incidence rate of headache after aspartame (35 percent) was not significantly different from that after placebo (45 percent) (P less than 0.50). No serious reactions were observed, and the incidence of symptoms other than headache following aspartame was also equivalent to that after placebo. No treatment-related effects were detected in vital signs, blood pressure, or plasma concentrations of cortisol, insulin, glucagon, histamine, epinephrine, or norepinephrine. Most of the subjects were well educated and overweight and had a family or personal history of allergic reactions. The subjects who had headaches had lower plasma concentrations of norepinephrine (P less than 0.0002) and epinephrine (P less than 0.02) just before the development of headache. We conclude that in this population, aspartame is no more likely to produce headache than placebo.