Robert G. Siekert

Neurologic manifestations of bacterial endocarditis.

Abstract Twenty-nine percent of patients (110 of 385) with bacterial endocarditis had neurologic involvement. In 60% (65 of 110 patients) the neurologic finding was either the chief complaint or on...

Central nervous system manifestations of periarteritis nodosa

PERIARTERITIS or polyarteritis nodosa is a disease of unknown etiology characterized by focal disseminated inflammatory lesions involving the medium-size and small arteries. A great variety of clinical features results from the variable distribution of these arterial lesions. Neurological manifestations are common; peripheral neuropathy, in particular, has been well known.l.2 However, relatively little attention has been paid to the central nervous system manifestations of the disease. The frequency and type of involvement of the central nervous system in periarteritis nodosa have varied among different According to Arkin,j central nervous system manifestations occur in 8% of cases. Malamud and Foster6 reviewed 300 reported cases and found that central nervous system involvement occurred in 20%. Parker and Kernohan? reported 16 necropsy-proved cases of periarteritis nodosa, in which 7 of the patients (44%) had had prominent and early clinical manifestations of central nervous system involvement, and an additional 4 (25%) had had such involvement late or terminally. Specimens from these 11 patients showed appropriate microscopic changes in the cerebral arteries. Clinical evidence of central nervous system involvement was noted by Griffith and Vurals in 5 of 17 cases and by Rose9 in 9 of 24 cases of periarteritis nodosa. Drachmanlo reviewed 104 reported cases of Wegener’s granulomatosis and found involvement of the central nervous system or cranial structures in 30 (29%). The differences in the percentages of reported central nervous system manifestations are probably related, in part, to the manner of the selection of cases for inclusion in the review; that is, cases based on necropsy

Discoloration of the teeth in alkaptonuria (ochronosis) and parkinsonism.

The patient, a 5%year-old woman, was seen in June, 1967, because of parkinsonism. Her father had had parkinsonism when he was about 56 years old and had died when he was 70 years of age. There was no history of encephalitis. The patient had the typical features of this illness, but in a very minimal amount; these included bradykinesia, minimal rest tremor of all limbs, and loss of associated movements. This illness had appeared during the previous 1 or possibly 2 years. It was rather rapidly progressive, for when she was examined again in November, 1967, she was unable to walk or to dress herself without assistance. At the examination in June, 19867, it was noted that the teeth were discolored; the patient believed that the discoloration had been present for about 2 years. This abnormality had not been observed before in parkinsonism. Trihexyphenidyl (Artane) and chlordiazepoxide hydrochloride (Libm phenothiazines had never been used. A bluish discoloration of the cartilages of the external ear had been present for many years (Fig. 1, A). The color of the ear cartilages and of the teeth was the same. The patient had excreted dark urine all of her life, and homogentisie acid was present in the urine. The characteristic changes of ochronosis were observed in roentgenograms of the spinal column. The bluish discoloration of the teeth also had not been observed previously in alkaptonuria and ochronosis. The patient was referred for dental examination. On the crown of the tooth there was a bluish discoloration (Fig. 1, 6). The density of the dentine vias increased, and this yellowto-brown change was visible on the gingival half of the crowns, giving the impression of dentinal sclerosis. Except for the pigmentation, the dentition appeared sound. The oral soft tissues did not show any increased pigmentation or any abnormality, although a mild (and presumably unrelated) gingivitis was present. Roentgenograms of the teeth revealed no abnormalities. Adequate enamel formation and normal tooth form were present. A slight in-

Syndrome of Intermittent Insuffiency of the Basilar Arterial System

TRANSIENT EPISODES of focal neurologic abnormalities occurring in the middle or older age groups and attributed variously to so-called vasospasm or small strokes are common and have been known to neurologists for many years. Despite considerable study, the exact pathogenesis of these has not been made clear. It is not the purpose of this communication to deal at length with data concerning the causation of these transient states of dysfunction of the central nervous system, although ischemia is assumed to be the factor fundamental to the actual production of symptoms. Rather, we wish to point out that there is a group of patients who, for one reason or another, have transient episodes presumably due to insufficient blood 00w through various portions of the basilar arterial system. These phenomena have never been adequately grouped. This complex of periodic transient symptoms might be termed “the syndrome of intermittent insufficiency of the basilar arterial system.”’ Although in some cases the diagnosis can only be suspected, in many instances the diagnosis can be made if one is alert to the possibility. It is our impression that these periodic phenomena due to insufficiency of the basilar artery may be more common than is generally believed. It also appears that this symptom complex is a common historic feature in patients who succumb to closure of the basilar artery by thrombosis. Once the diagnosis of occlusion of the basilar artery is established, serious neurologic abnormalities are usually present and the prognosis is grave. If treatment is to be adequate, it must in a sense be preventive or anticipatory, since there is no replacement for infarcted cerebral tissue. The first requisite for any treatment is early diagnosis. The transitory episodes under discussion may occur for months or years. They may be brief, lasting several minutes, or they may last several hours. Most last about 15 to 30 minutes. Between these spells the patient is well. Examination between the episodes reveals normal findings, while during an attack objective abnormalities are demonstrable. Although there are instances in which minor residual neurologic difficulty remains, we have chosen to look on most

Reversed Blood Flow in the Vertebral Arteries

Excerpt In 1961, Baker (1), Toole (2), and Fields (3) each showed arteriograms in which it was observed that, when the subclavian artery was severely narrowed or occluded proximal to the origin of ...

Transient Cerebral Ischemic Attacks Associated With Subacute Bacterial Endocarditis

The case histories are given of 12 patients who had transient cerebral attacks in association with subacute bacterial endocarditis. The attacks are similar to those that accompany atherosclerotic occlusive cerebrovascular disease. All patients had manifestations of general illness, particularly fever, malaise, and elevated sedimentation rate. Subsequently, cerebral infarcts occurred in three patients and cerebral hemorrhages in four patients. A definite relationship between anticoagulant therapy and hemorrhage could not be established.

Results of Surgical Treatment of Incipient Stroke

Recently we have studied the role of surgical treatment of patients having occlusive cerebrovascular disease, particularly incipient stroke (or focal intermittent cerebrovascular insufficiency). This report concerns 35 pa-patients with incipient stroke in whom circulation was restored to normal by operation on an artery in an attempt to prevent transient ischemic episodes and cerebral infarction.Since all of the patients were neurologically normal at the time of the surgical procedure, we were concerned primarily with the risk of[see tablein the PDF file]the procedure, particularly in terms of cerebral infarction. The operative mortality rate was 8.5 per cent (three patients). Six patients (17 per cent) sustained cerebral infarcts. Four of these had mild neurologic deficits, usually consisting of clumsiness and mildly reduced discriminatory sensation in one hand; one had a severe neurologic deficit, and one died. Evidence shows that at least some of these infarcts resulted from emboli arising from the operative site at the time of or shortly after the operation.The results of long-term follow-up revealed that 66 per cent of the surgically treated patients were normal compared to 25 per cent of a contrast group; and 17 per cent of the treated patients had suffered cerebral infarcts compared to 40 per cent of the contrast group. The long-term results are thus similar to the immediate postoperative results. These findings simply indicate that an operated patients prognosis was good over the long term if the cerebral ischemic episodes were relieved and if he sustained no complications from the surgical procedure.

Current indications for the use of anticoagulant drugs in cerebrovascular disease.

Considerable variation exists in the interplay of the factors influencing the occurrence of strokes and their final outcome. A final statement about the usefulness of anticoagulant drugs in the treatment of cerebrovascular disease must await further study. The current indications for their use include: (1) intermittent insufficiency of the basilar arterial system, (2) intermittent insufficiency of the internal carotid system, (3) thrombosis within the basilar arterial system, (4) recurrent cerebral emboli associated with a likely cardiac source and (5) possibly, recurrent cerebral thromboses.

The Stroke Council of the American Heart Association The Early Years

An account of the origin, within the American Heart Association, of a council devoted to vascular disease of the central nervous system, with particular attention to the context in which that occurred, is presented in this article. The forces of a service-charitable organization, political action, medical practice in general, and interested, strong-witted citizens provided the stimuli for the development of the Stroke Council.

Medical considerations of the surgical treatment of ischemic cerebrovascular disease

Abstract Patients with ischemic cerebrovascular disease are divided into three categories of clinical status at the time they are seen by the physician: (1) transient ischemic attacks, (2) progressing stroke, and (3) completed stroke. These categories are used as a framework for discussing which patients are suitable for surgical therapy. Consideration is given to evidence for the presence of extracranial occlusive disease, indications for arteriography and particularly the goals of therapy and the likelihood of obtaining these goals. In patients with transient ischemic attacks, surgical therapy in highly selected cases appears to offer some prophylactic value against the development of cerebral infarcts. It is pointed out, however, that documentation of this conclusion as well as assessment of the effectiveness of surgical therapy for patients who have other types of ischemic cerebrovascular disease remains incomplete.