Robert L. Archer

Neurologic complications of gastric bypass surgery for morbid obesity.

Background: The number of bariatric procedures is rapidly growing as the prevalence of obesity in the USA is increasing. Such procedures are not without complications, and those affecting the nervous system are often disabling and irreversible. We now describe our experience with these complications and review the pertinent literature. Methods: We describe 26 patients with major neurologic conditions that seemed causally related to bariatric surgery encountered in the neurology service of a tertiary referral university medical center over a decade. Results: The neurologic complications affected most regions of the nervous system: encephalopathy, optic neuropathy, myelopathy, polyradiculoneuropathy, and polyneuropathy. Myelopathy was the most frequent and disabling problem; symptoms began about a decade after surgery. Encephalopathy and polyradiculoneuropathy were acute and early complications. Except for vitamin B12 and copper deficiencies in patients with myelopathy, we could not correlate specific nutritional deficiencies to the neurologic complications. All patients had multiple nutritional deficiencies, but their correction did not often yield dramatic results. The best result was achieved in one patient after surgical revision to reduce the bypassed jejunum. Conclusions: A wide spectrum of serious neurologic conditions may follow bariatric surgery. These complications may occur acutely or decades later.

Muscle strength and fatigue during isokinetic exercise in individuals with multiple sclerosis.

PURPOSE To compare muscle strength and muscle fatigue of the knee extensors and flexors in individuals with multiple sclerosis (MS) and non-MS control subjects and to evaluate the reliability of muscle strength and muscle fatigue testing in these individuals. METHODS Thirty individuals (13 women and 2 men for both MS and control groups), age (mean +/- SD) 38.8 +/- 10 for MS and 33.1 +/- 7.6 yr for controls, participated in this investigation. Peak torque was measured on two occasions separated by approximately 7 d at 30, 60, 90, 120, 180 degrees.s(-1) with 2 min of recovery between each bout. The nondominant leg was tested followed by the dominant leg after 10 min of recovery. Subjects then performed three bouts of 30 flexions and extensions of the dominant leg at 180 degrees.s(-1) with 1 min of recovery between bouts. RESULTS The reliability of muscle torque was very high for individuals with MS (only 1 of 20 measurements with an ICC below 0.900). Total work was also highly reliable for MS, but the Fatigue Index (work during the last 15 contractions/work during the first 15 contractions) x 100 was not. Peak torque adjusted for age, body mass, and fat free mass (measured by whole body plethysmography; the Bod Pod; Life Measurement Instruments; Concord, CA) was significantly greater for controls than for MS for three of four lower body muscle groups tested. For the muscle fatigue test (3 bouts of 30 knee extensions and flexions at 180 degrees.s(-1)), the Fatigue Index was greater (less fatigue) for the knee extensors for controls than MS for the third bout. For flexion, the Fatigue Index was greater for controls than MS over the three bouts (group effect). Total work was significantly greater for controls than MS for the flexors (group effect) and approached significance for the extensors. CONCLUSIONS Individuals with MS were weaker than controls when data were adjusted for age, body mass, and fat free mass. This latter finding (force relative to age and fat free mass) suggests that there is a reduced ability to activate muscle mass in MS and/or the muscle mass of individuals with MS is of lower quality (i.e., reduced force/unit muscle mass) than controls.

Sheehan syndrome: a splinter of the mind.

A 40-year-old woman presented with headache and diplopia after hypotension from postpartum hemorrhage. A noncontrasted cranial magnetic resonance imaging (MRI) showed an enlarged pituitary with a rim of slight increased signal. A repeat gadolinium-enhanced cranial MRI showed peripheral enhancement of the pituitary gland surrounding an isointense central area consistent with infarction of the pituitary and the clinical diagnosis of Sheehan syndrome. The patient was treated with intravenous hydrocortisone. Immediately after treatment, her symptoms remitted and the examination normalized. One month later, a gadolinium-enhanced cranial MRI was normal. The characteristic appearance of the post-gadolinium enhanced cranial MRI helped confirm the diagnosis of Sheehan syndrome and facilitate early treatment with corticosteroids.

Motor neuron disease in methamphetamine abusers

Dear Sir, Environmental factors, including exposure to toxins, may play a causal role in the development of motor neuron disease (MND). The relationship between abuse of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and the development of Parkinsonism has heightened our awareness that recreational drug abuse may impact the nervous system long after the acute effects of intoxication have passed (1). We report six patients with MND and a history of chronic methamphetamine (MET) abuse and propose that the two are not coincidental but may be causally linked.

Progressive multifocal leukoencephalopathy mimicking glioma in a patient with idiopathic CD4 lymphocytopenia

Progressive multifocal leukoencephalopathy (PML) was described for the first time in 1958 by Astrom et al. as a demyelinating disease in patients with leukemia and lymphoma. A viral etiology for this condition was suggested as the oligodendrocytes contained inclusion bodies [1]. MRI features described in classical PML include hyperintense lesions on T2-weighted and FLAIR sequence which are asymmetric, devoid of contrast enhancement or mass effect, and relatively spare periventricular white matter [2]. We are reporting a case of PML in a patient with ICL (idiopathic CD4 lymphopenia) in which MRI brain showed punctate contrast enhancement, gyral swelling, and a pattern on MR spectroscopy concerning for a glioma.

A winged scapula and dropped wrist: an unusual manifestation of copper deficiency

Myelopathy due to copper deficiency closely resembles myelopathy due to vitamin B12 deficiency. This is a treatable form of myelopathy and was recognized for the first time in 2001 [1]. The deficiency of copper may lead to a length-dependent axonal neuropathy, myelopathy, and myelodysplastic syndrome [2]. Due to the concomitant involvement of spinal cord and peripheral nerves in copper deficiency, the disorder is sometimes called as myeloneuropathy. To the best of our knowledge, we are reporting a first case of copper deficiency leading to radiculomyeloneuropathy manifesting as winged scapula, wrist drop, axonal neuropathy, and myelopathy. Case report

Hemiparkinsonism after unilateral traumatic midbrain hemorrhage in a young woman

The relationship between head trauma and parkinsonism has been debated since James Parkinsons first description of the shaking palsy in the late 19th century. We observed in our outpatient clinic a young woman in whom hemiparkinsonism developed within 3 weeks of sustaining closed head trauma with loss of consciousness. The patient had a discrete unilateral midbrain hemorrhage on head MRI which involved the contralateral substantia nigra. The condition responded well to carbidopa/levodopa. This patient is a convincing example of posttraumatic midbrain hemorrhage causing parkinsonism.