Paulo Rogério M Bittencourt

Clinical, radiological and cerebrospinal fluid presentation of neurocysticercosis: a prospective study.

The wide clinical spectrum of neurocysticercosis has led to many attempts at clinical, radiological, CSF and other classifications. Based on an objective review of the relevant literature and on a prospective study of 42 patients with active neurocysticercosis, a new classification is proposed, based on clinical, tomographic, magnetic resonance and CSF evidence of viability of cysts. The first step is to define whether the disease is active or not. Inactive disease may be parenchymal calcifications or hydrocephalus. Active disease may be intraparenchymal, extraparenchymal or mixed. Statistical analysis of 42 cases with active disease shows intraparenchymal disease to occur in younger patients, perhaps more frequently in females, and to have a better prognosis than extraparenchymal of mixed disease. The latter appears to have the worst prognosis. Therapeutic implications are that only active disease warrants etiological therapy. There remain doubts about the best therapy for some infrequent subtypes of extraparenchymal and mixed disease.

Síndrome neuroléptica maligna: relato de caso com recorrência associada ao uso de olanzapina

The neuroleptic malignant syndrome (NMS) consists in an idiosyncratic reaction to neuroleptic drugs, probably related to a blockage of dopamine receptors in basal ganglia. Research criteria for diagnosing NMS from DSM-IV require severe rigidity and fever accompanied by 2 of 10 minor features including diaphoresis, dysphagia, tremor, incontinence, altered mentation, mutism, tachycardia, elevated or labile blood pressure, leukocytosis and elevation of creatine phosphokinase. From a clinical point of view, the NMS may range a large spectrum of presentations. Haloperidol is the most frequent drug associated with this syndrome. We report the case of a 30 year-old man who developed NMS at two different occasions, the first related to haloperidol and chlorpromazine and the second related to olanzapine, to our knowledge without previous mention in the indexed literature.The neuroleptic malignant syndrome (NMS) consists in an idiosyncratic reaction to neuroleptic drugs, probably related to a blockage of dopamine receptors in basal ganglia. Research criteria for diagnosing NMS from DSM-IV require severe rigidity and fever accompanied by 2 of 10 minor features including diaphoresis, dysphagia, tremor, incontinence, altered mentation, mutism, tachycardia, elevated or labile blood pressure, leukocytosis and elevation of creatine phosphokinase. From a clinical point of view, the NMS may range a large spectrum of presentations. Haloperidol is the most frequent drug associated with this syndrome. We report the case of a 30 year-old man who developed NMS at two different occasions, the first related to haloperidol and chlorpromazine and the second related to olanzapine, to our knowledge without previous mention in the indexed literature.

Eletrencefalograma digital com mapeamento em demência de Alzheimer e doença de Parkinson: estudo prospectivo controlado

Com o intuito de estudar a atividade eletrencefalografica em vigilia da demencia senil de tipo Alzheimer (DA) e da doenca de Parkinson (DP) foi iniciado estudo prospectivo e controlado. Foram comparados 6 pacientes com DA e 11 pacientes com DP, com um grupo controle composto por 12 pacientes com depressao maior cronica leve a moderada (DSM-III-R, 1987). Nos tres grupos, atraves de analise espectral, foi obtida a mediana da frequencia da energia da atividade dominante posterior. O grupo controle apresentou atividade posterior com frequencia de 8,79 ± 0,52 (m±dp). No grupo com DA este valor foi 6,65 ± 0,80 (m±dp) e no grupo com DP 7,69± 1,39 (m±dp). A hipotese experimental de que pacientes com DA e DP diferem dos controles em relacao a atividade de fundo (definida como anormal sendo <8) foi confirmada pelo teste do qui quadrado (p=0,01) e no teste t a media das frequencias da energia posterior foi significativamente menor nos pacientes com DA (p=0,01) e DP (p=0,05) do que nos controles. Os resultados indicam que esta anormalidade possa ser correlacionada com o grau de comprometimento cortical e a gravidade da evolucao da DA e da DP.

Cognitive functions, epileptic syndromes and antiepileptic drugs

Cognitive function of patients on monotherapy specific for their epileptic syndrome has been studied infrequently. We evaluated 7 patients with symptomatic localised epilepsies (SEL) on phenytoin aged 30 +/- 12 (mean +/- standard deviation) years, 8 with idiopathic generalised epilepsies on sodium valproate aged 18 +/- 4 years, 16 with SEL on carbamazepine aged 28 +/- 11 years, and 35 healthy controls aged 27 +/- 11 years. All subjects were of normal intelligence, educated appropriately to age, and led productive lives in the community. Two of the patients on carbamazepine and one on valproate had less than five partial, absence or myoclonic seizures monthly, the remaining were controlled. Carbamazepine serum concentrations were 12 +/- 5 micrograms/ml, phenytoin were 23 +/- 7, and valproate were 62 +/- 23 (mean +/- sd). Tests included immediate recall and recognition for pictures, Stroop test, delayed recall and recognition of pictures. Patients on phenytoin and valproate performed significantly worse than controls on immediate recall, and patients on carbamazepine performed significantly worse than controls in Stroop test (p < 0.01). The results indicate relatively minor effects of the epileptic syndromes and of phenytoin, carbamazepine and valproate on cognition of patients with controlled epilepsy leading productive lives in the community. We conclude that the cognitive deficit found in chronic epileptic patients on poly-therapeutic drug regimen must be multifactorial, and that future studies need to control for all possible variables in order to achieve meaningful results.

Diabetes Mellitus como fator prognóstico em doença cerebrovascular isquêmica

Como parte de estudo prospectivo de 347 casos de doenca cerebrovascular isquemica (DCVI) internados em um hospital geral, foram avaliados 36 pacientes diabeticos e 36 controles com sexo, idade e pressao arterial semelhantes, com o objetivo de verificar como diabetes mellitus afeta o prognostico em DCVI. Os 72 pacientes apresentavam varios tipos de DCVI (trombose, tromboembolismo ou embolia cardiogenica). Os pacientes diabeticos tiveram estatisticamente mais dias de internamento (p<0,05), mais complicacoes durante o internamento (p<0,05), mais complicacoes infecciosas (p<0,01) e maior numero de obitos ao fim do seguimento (p<0,05). Apos 377 ±429 (media ± desvio padrao) dias de seguimento, em 50% dos diabeticos havia ocorrido o obito, enquanto apos 387±405 dias 25% dos nao diabeticos haviam falecido. Os obitos em ambos os grupos ocorreram em media no oitavo mes apos o evento vascular que motivou a admissao inicial. Nao foram notadas diferencas com respeito ao numero de obitos durante a internacao inicial ou as condicoes neurologicas dos sobreviventes ao fim da admissao inicial e do seguimento.As part of a prospective study about 347 cases of ischemic cerebral vascular disease (DCVI) admitted to a general hospital 36 diabetic and 36 non-diabetic patients with similar sex, age and blood pressure were evaluated with the objective of assessing the effect of diabetes mellitus on prognosis in DCVI. All patients had various types of DCVI (thrombosis, thromboembolism or cardiac embolism). The diabetic patients had statistically longer admissions (p less than 0.05), more complications during admission (p less than 0.05), more infectious complications (p less than 0.01) and a greater number of deaths at the end of follow-up (p less than 0.05). After 377 +/- 429 (mean +/- standard deviation) days of follow-up, 50% of the diabetics had died while after 387 +/- 405 days 25% of the non-diabetics had died. Deaths in both groups occurred in average at the 8th month after the vascular event that led to the first admission. There were no differences with respect to the number of deaths during admission or to neurological conditions of the survivors at the end of the first admission or at the end of follow-up.

Cognitive functions of epileptic patients on monotherapy with phenobarbitone and healthy controls

Quantitative measurements have indicated that heredity, cerebral damage, psycho-social aspects, ictal and inter-ictal phenomena and antiepileptic drugs may interfere in the cognitive dysfunction of epileptic patients. In the present study objective methods included immediate and late recall and recognition of pictures, Stroop test and auditory selection. Twenty patients with symptomatic localized epilepsy aged 17-52 years (27 +/- 10, mean +/- sd) were compared to age and socially matched healthy controls. Patients were on therapeutic serum concentrations (25 +/- 12 mu/ml) of phenobarbitone and had active epilepsy with 1.94 generalized tonic-clonic, 0.85 simple partial and 6.28 complex partial seizures monthly (means). Patients performed worse than controls in all 6 tests (p less than 0.05 to p less than 0.001), indicating a generalized cognitive deficit related to seizures and/or barbiturate therapy. We suggest further studies should be carried out in populations with uniform monotherapeutic regimens and epileptic syndromes in order to isolate factors related to the cognitive dysfunction of epileptic patients.

Epilepsy surgery without invasive EEG: early results of a new program

A total of 42 patients were submitted to a clinical, behavioural and neuropsychological evaluation with the objective of eventual surgical treatment of epilepsy refractory to the usual clinical therapies. Prolonged video-EEG monitoring, MRI hippocampal volume measurement, lateralization of speech and memory using the amobarbital (Wada) test were used. Of 18 operated cases, 12 were submitted to temporal lobectomy, with a follow-up of 6-30 months; 8 patients had significant improvement in seizures control; 2 patients had partial improvement in seizure frequency and intensity; 2 patients had no improvement in seizure control. One patient underwent right frontal lobectomy with total remission of seizures and 5 had callosotomy with varying degrees of success. There was no mortality. Morbidity included one subdural hematoma, one transient hemiparesis, one episode of mania, one lobar pneumonia and frequent immediately post-operative muscular tension headaches. These early results indicate good results of temporal lobectomy patients investigated through a non-invasive presurgical evaluation.

Carbamazepine kinetics in cardiac patients before and during amiodarone

Carbamazepine and amiodarone may often be used together, especially in countries where cardiomyopathies are common. In this study single doses of carbamazepine (400 mg) were given to patients with cardiac disease before and after one month of therapy with amiodarone, 400 mg daily. The kinetic profile of carbamazepine, its free fraction, and serum amiodarone, were measured at the two occasions. There was no statistically significant change in carbamazepine kinetics or free fraction, before and after the introduction of amiodarone. The concentrations of amiodarone after one month of therapy were low. It is suggested that the possible interaction in the hepatic metabolism was not demonstrated because amiodarone concentrations were not enough to inhibit carbamazepine metabolism.

Doses-carga de carbamazepina e difenil-hidantoína: utilizaçäo em pacientes de alto risco

Loading-doses of phenytoin (1000 mg) and carbamazepine (600 mg) were given orally respectively to 10 and 6 patients with uncontrolled epileptic seizures secondary to acute neurological disorders or alcohol withdrawal. In the phenytoin group age varied between 12-73 years and serum concentrations at 2, 4, 6, 8, 12 and 18 hours after drug administration were 7.6, 8.8, 8.7, 8.7, 7.2 and 6.5 micrograms/ml (means). A quantitative method did not detect important side-effects. In the carbamazepine group age varied between 25-56 years and serum concentrations at the same times were 3.9, 5.3, 6.5, 7.5, 7.4 and 8.2 micrograms/ml. Side-effects were discrete. Further medication was not necessary in the 24 hours after drug administration. Although both regimens controlled the clinical situation without relevant side-effects serum concentrations were sub-therapeutic in the case of phenytoin. We suggest the ideal phenytoin oral loading-dose is 1500 mg. The carbamazepine load produced therapeutic concentrations. The stability of serum concentrations for the period of the study shows that those regimens are useful in the subacute control of epileptic seizures in the maintenance treatment of status epilepticus and in alcohol withdrawal.Doses-carga de difenil-hidantoina (lOOOmg) e carbamazepina (600mg) foram administradas oralmente a respectivamente 10 e 6 pacientes com crises epilepticas secundarias a doenca aguda neurologica ou sindrome de abstinencia alcoolica. No grupo da difenil-hidantoina a idade variou de 12 a 73 anos e as concentracoes sericas 2, 4, 6, 8, 12 e 18 horas apos a administracao foram 7,6, 8,8, 8,7, 8,7, 7,2 e 6,5 mg/ml (media). Nao foram anotados efeitos colaterais importantes por um metodo quantitativo. No grupo da carbamazepina a idade variou de 25 a 56 anos e as concentracoes sericas nas mesmas horas foram 3,9, 5,3, 6,5, 7,5, 7,4 e 8,2 mg/ml. Efeitos colaterais foram discretos. Nao foi necessaria medicacao suplementar durante as 24 horas apos a administracao das doses-carga. Embora ambos os esquemas tenham controlado a situacao clinica sem efeitos colaterais relevantes, as concentracoes sericas foram sub-terapeuticas no caso da difenil-hidantoina. Sugerimos que a dosecarga ideal de difenil-hidantoina e 1500mg. A dose-carga de carbamazepina foi eficaz e produziu niveis sericos terapeuticos. A estabilidade dos niveis sericos durante o periodo de estudo torna este esquema util no controle subagudo de crises epilepticas frequentes, no tratamento de manutencao de estado de mal epileptico e na sindrome de retirada alcoolica.

Slowly progressive aphasia followed by Alzheimer' s dementia: a case report

Slowly progressive aphasia has been found in 8 published cases, 2 of whom progressed over a period of years to generalized dementia. Positron emission tomography demonstrated decreased glucose metabolism in the left perisylvian region in 2 cases. We describe a patient who had slowly progressive aphasia and developed generalized Alzheimers dementia 7 years after presentation. There was no clinical or laboratory evidence of concomitant disease. Computerized tomography showed generalized atrophy more marked on the left perisylvian region late in the disease, when EEG showed generalized slowing more marked on the same area. Slowly progressive aphasia of old age should be considered a separate entity until further studies elucidate its relation to Alzheimers dementia.