Merritt - Neurology 10th Ed

Merritt's Neurology 10th Edition (June 2000): by H. Houston Textbook of Neurology Merritt (Editor), Lewis P.
Rowland (Editor), Randy Rowland By Lippincott

Williams & Wilkins Publishers
By OkDoKeY
Merritt's Neurology
CONTENTS
Contributing Authors Preface Abbreviations
SECTION I. SYMPTOMS OF NEUROLOGIC DISORDERS
Chapter 1. Delirium and Dementia

Scott A. Small and Richard Mayeux
Chapter 2. Aphasia, Apraxia, and Agnosia

J. P. Mohr
Chapter 3. Syncope and Seizure

Timothy A. Pedley and Dewey K. Ziegler
Chapter 4. Coma
John C.M. Brust
Chapter 5. Diagnosis of Pain and Paresthesias

Lewis P. Rowland
Chapter 6. Dizziness and Hearing Loss

Jack J.Wazen
Chapter 7. Impaired Vision

Myles M. Behrens
Chapter 8. Headache
Neil H. Raskin
Chapter 9. Involuntary Movements

Stanley Fahn
Chapter 10. Syndromes Caused by Weak Muscles

Lewis P. Rowland
Chapter 11. Gait Disorders

Sid Gilman
Chapter 12. Signs and Symptoms in Neurologic Diagnosis

Lewis P. Rowland
SECTION II. HOW TO SELECT DIAGNOSTIC TESTS
Chapter 13. Computed Tomography and Magnetic Resonance Imaging

Robert DeLaPaz and Stephen Chan
Chapter 14. Electroencephalography and Evoked Potentials

Ronald G.Emerson,Thaddeus S.Walczak, and Timothy A.Pedley
Chapter 15. Electromyography and Nerve Conduction Studies in Neuromuscular Disease

Dale J. Lange and Werner Trojaborg
Chapter 16. Neurovascular Imaging

J. P. Mohr and Robert DeLaPaz
Chapter 17. Lumbar Puncture and Cerebrospinal Fluid Examination

Robert A. Fishman
Chapter 18. Muscle and Nerve Biopsy

Arthur P. Hays
Chapter 19. Neuropsychologic Evaluation

Yaakov Stern
Chapter 20. DNA Diagnosis

Lewis P. Rowland
SECTION III. INFECTIONS OF THE NERVOUS SYSTEM
Chapter 21. Bacterial Infections

James R.Miller and Burk Jubelt
Chapter 22. Focal Infections

Gary L. Bernardini
Chapter 23. Viral Infections

Burk Jubelt and James R. Miller
Chapter 24. Acquired Immunodeficiency Syndrome

Carolyn Barley Britton
Chapter 25. Fungal and Yeast Infections

Leon D.Prockop
Chapter 26. Neurosarcoidosis

John C.M. Brust
Chapter 27. Spirochete Infections: Neurosyphilis

Lewis P.Rowland and Leonidas Stefanis
Chapter 28. Spirochete Infections: Leptospirosis

James R. Miller
Chapter 29. Spirochete Infections: Lyme Disease

James R. Miller
Chapter 30. Parasitic Infections

Burk Jubelt and James R. Miller
Chapter 31. Bacterial Toxins

James R. Miller
Chapter 32. Reye Syndrome

Darryl C. De Vivo
Chapter 33. Prion Diseases

Burk Jubelt
Chapter 34. Whipple Disease

Elan D Louis
SECTION IV. VASCULAR DISEASES
Chapter 35. Pathogenesis, Classification, and Epidemiology of Cerebrovascular Disease

Ralph L. Sacco
Chapter 36. Examination of the Patient with Cerebrovascular Disease

Randolph S.Marshall
Chapter 37. Transient Ischemic Attack

John C.M.Brust
Chapter 38. Cerebral Infarction

John C.M.Brust
Chapter 39. Cerebral and Cerebellar Hemorrhage

J. P. Mohr and Christian Stapf
Chapter 40. Genetics of Stroke

Alexander Halim and Ralph L. Sacco
Chapter 41. Other Cerebrovascular Syndromes

Frank M. Yatsu
Chapter 42. Differential Diagnosis of Stroke

Mitchell S.V. Elkind and J.P. Mohr
Chapter 43. Stroke in Children

Arnold P. Gold and Abba L. Cargan
Chapter 44. Treatment and Prevention of Stroke

Frank M. Yatsu
Chapter 45. Subarachnoid Hemorrhage

Stephan A. Mayer, Gary L. Bernardini, John C.M. Brust, and Robert A. Solomon
Chapter 46. Cerebral Veins and Sinuses

Robert A. Fishman
Chapter 47. Vascular Disease of the Spinal Cord

Leon A. Weisberg
SECTION V. DISORDERS OF CEREBROSPINAL AND BRAIN FLUIDS
Chapter 48. Hydrocephalus

Leon D. Prockop
Chapter 49. Brain Edema and Disorders of Intracranial Pressure

Robert A. Fishman
Chapter 50. Superficial Siderosis of the Central Nervous System

Robert A. Fishman
Chapter 51. Hyperosmolar Hyperglycemic Nonketotic Syndrome

Leon D.Prockop and Stephan A.Mayer
SECTION VI. TUMORS
Chapter 52. General Considerations

Casilda M. Balmaceda
Chapter 53. Tumors of the Skull And Cranial Nerves

Jeffrey N.Bruce, Casilda M.Balmaceda, and Michael R.Fetell
Chapter 54. Tumors of the Meninges

Casilda M. Balmaceda , Michael B. Sisti, and Jeffrey N. Bruce
Chapter 55. Gliomas

Casilda M. Balmaceda and Robert L. Fine
Chapter 56. Lymphomas

Chapter 57. Pineal Region Tumors

Jeffrey N. Bruce, Casilda M. Balmaceda, Bennett M. Stein, and Michael R. Fetell
Chapter 58. Tumors of the Pituitary Gland

Jeffrey N. Bruce, Michael R. Fetell, and Pamela U. Freda
Chapter 59. Congenital and Childhood Central Nervous System Tumors

James H. Garvin Jr. and Neil A. Feldstein
Chapter 60. Vascular Tumors and Malformations

Robert A. Solomon, John Pile-Spellman, and J. P. Mohr
Chapter 61. Metastatic Tumors

Chapter 62. Spinal Tumors

Paul C. McCormick, Michael R. Fetell, and Lewis P. Rowland
SECTION VII. TRAUMA
Chapter 63. Head Injury

Stephan A. Mayer and Lewis P. Rowland
Chapter 64. Spinal Injury

Joseph T.Marotta
Chapter 65. Intervertebral Disks and Radiculopathy

Paul C. McCormick
Chapter 66. Cervical Spondylotic Myelopathy

Lewis P.Rowland and Paul C. McCormick
Chapter 67. Lumbar Spondylosis

Lewis P. Rowland and Paul C. McCormick
Chapter 68. Peripheral and Cranial Nerve Lesions

Dale J. Lange, Werner Trojaborg, and Lewis P. Rowland
Chapter 69. Thoracic Outlet Syndrome

Lewis P. Rowland
Chapter 70. Neuropathic Pain and Posttraumatic Pain Syndromes

James H. Halsey
Chapter 71. Radiation Injury

Casilda M. Balmaceda and Steven R. Isaacson
Chapter 72. Electrical and Lightning Injury

Lewis P. Rowland
Chapter 73. Decompression Sickness

Leon D. Prockop
SECTION VIII. BIRTH INJURIES AND DEVELOPMENTAL ABNORMALITIES
Chapter 74. Neonatal Neurology

M. Richard Koenigsberger and Ram Kairam
Chapter 75. Floppy Infant Syndrome

Thornton B.A. Mason, II and Darryl C. De Vivo
Chapter 76. Static Disorders of Brain Development

Isabelle Rapin
Chapter 77. Laurence-Moon-Biedl Syndrome

Melvin Greer
Chapter 78. Structural Malformations

Melvin Greer
Chapter 79. Marcus Gunn and Mbius Syndromes

Lewis P. Rowland
SECTION IX. GENETIC DISEASES OF THE CENTRAL NERVOUS SYSTEM
Chapter 80. Chromosomal Diseases

Ching H. Wang
Chapter 81. Disorders of Amino Acid Metabolism

John H. Menkes
Chapter 82. Disorders of Purine Metabolism

Lewis P. Rowland
Chapter 83. Lysosomal and Other Storage Diseases

William G. Johnson
Chapter 84. Disorders of Carbohydrate Metabolism

Salvatore DiMauro
Chapter 85. Glucose Transporter Protein Syndrome

Darryl C. De Vivo
Chapter 86. Hyperammonemia

Rosario R. Trifiletti and Douglas R. Nordli, Jr.
Chapter 87. Peroxisomal Diseases: Adrenoleukodystrophy, Zellweger Syndrome, and Refsum Disease
Mia MacCollin and Darryl C. De Vivo
Chapter 88. Organic Acidurias

Stefano Di Donato and Graziella Uziel
Chapter 89. Disorders of Metal Metabolism

John H. Menkes
Chapter 90. Acute Intermittent Porphyria

Lewis P. Rowland
Chapter 91. Neurological Syndromes with Acanthocytes

Timothy A. Pedley and Lewis P. Rowland
Chapter 92. Xeroderma Pigmentosum

Lewis P. Rowland
Chapter 93. Cerebral Degenerations of Childhood

Eveline C. Traeger and Isabelle Rapin
Chapter 94. Diffuse Sclerosis

Lewis P. Rowland
Chapter 95. Differential Diagnosis

Eveline C. Traeger and Isabelle Rapin
SECTION X. DISORDERS OF MITOCHONDRIAL DNA
Chapter 96. Mitochondrial Encephalomyopathies: Diseases of Mitochondrial DNA

Salvatore DiMauro, Eric A Schon, Michio Hirano, and Lewis P. Rowland
Chapter 97. Leber Hereditary Optic Neuropathy

Myles M. Behrens and Michio Hirano
Chapter 98. Mitochondrial Diseases with Mutations of Nuclear DNA

Darryl C. De Vivo and Michio Hirano
SECTION XI. NEUROCUTANEOUS DISORDERS
Chapter 99. Neurofibromatosis

Arnold P. Gold
Chapter 100. Encephalotrigeminal Angiomatosis

Arnold P. Gold
Chapter 101. Incontinentia Pigmenti

Arnold P. Gold
Chapter 102. Tuberous Sclerosis

Arnold P. Gold
SECTION XII. PERIPHERAL NEUROPATHIES
Chapter 103. General Considerations

Norman Latov
Chapter 104. Hereditary Neuropathies

Robert E. Lovelace and Lewis P. Rowland
Chapter 105. Acquired Neuropathies

Dale J. Lange, Norman Latov and Werner Trojaborg
SECTION XIII. DEMENTIAS
Chapter 106. Alzheimer Disease and Related Dementias

Scott A. Small and Richard Mayeux
SECTION XIV. ATAXIAS
Chapter 107. Hereditary Ataxias

Susan B. Bressman, Timothy Lynch, and Roger N. Rosenberg
SECTION XV. MOVEMENT DISORDERS
Chapter 108. Huntington Disease

Stanley Fahn
Chapter 109. Sydenham and Other Forms of Chorea

Stanley Fahn
Chapter 110. Myoclonus

Stanley Fahn
Chapter 111. Gilles de la Tourette Syndrome

Stanley Fahn
Chapter 112. Dystonia

Stanley Fahn and Susan B Bressman
Chapter 113. Essential Tremor

Elan D. Louis and Paul E. Greene
Chapter 114. Parkinsonism

Stanley Fahn and Serge Przedborski
Chapter 115. Progressive Supranuclear Palsy

Paul E. Greene
Chapter 116. Tardive Dyskinesia and Other Neuroleptic-Induced Syndromes

Stanley Fahn and Robert E. Burke
SECTION XVI. SPINAL CORD DISEASES
Chapter 117. Hereditary and Acquired Spastic Paraplegia

Lewis P. Rowland
Chapter 118. Hereditary and Acquired Motor Neuron Diseases

Lewis P. Rowland
Chapter 119. Syringomyelia

Elliott L. Mancall and Paul C. McCormick
SECTION XVII. DISORDERS OF THE NEUROMUSCULAR JUNCTION
Chapter 120. Myasthenia Gravis

Audrey S. Penn and Lewis P. Rowland
Chapter 121. Lambert-Eaton Syndrome

Audrey S. Penn
Chapter 122. Botulism and Antibiotic-Induced Neuromuscular Disorders

Audrey S. Penn
Chapter 123. Acute Quadriplegic Myopathy

Michio Hirano
SECTION XVIII. MYOPATHIES
Chapter 124. Identifying Disorders of the Motor Unit

Lewis P. Rowland
Chapter 125. Progressive Muscular Dystrophies

Lewis P. Rowland
Chapter 126. Familial Periodic Paralysis

Lewis P. Rowland
Chapter 127. Congenital Disorders of Muscle

Lewis P. Rowland
Chapter 128. Myoglobinuria

Lewis P. Rowland
Chapter 129. Muscle Cramps and Stiffness

Robert B. Layzer and Lewis P. Rowland
Chapter 130. Dermatomyositis

Lewis P. Rowland
Chapter 131. Polymyositis, Inclusion Body Myositis, and Related Myopathies
Lewis P. Rowland
Chapter 132. Myositis Ossificans

Lewis P. Rowland
SECTION XIX. DEMYELINATING DISEASES
Chapter 133. Multiple Sclerosis

James R. Miller
Chapter 134. Marchiafava-Bignami Disease

James R. Miller
Chapter 135. Central Pontine Myelinolysis

Gary L. Bernardini and Elliott L. Mancall
SECTION XX. AUTONOMIC DISORDERS
Chapter 136. Neurogenic Orthostatic Hypotension and Autonomic Failure

Louis H. Weimer
Chapter 137. Acute Autonomic Neuropathy

Louis H. Weimer
Chapter 138. Familial Dysautonomia

Alan M. Aron
SECTION XXI. PAROXYSMAL DISORDERS
Chapter 139. Migraine and Other Headaches

Neil H. Raskin
Chapter 140. Epilepsy

Timothy A. Pedley, Carl W. Bazil, and Martha J. Morrell
Chapter 141. Febrile Seizures

Douglas R. Nordli, Jr. and Timothy A. Pedley
Chapter 142. Neonatal Seizures

Douglas R. Nordli, Jr. and Timothy A. Pedley
Chapter 143. Transient Global Amnesia

John C.M. Brust
Chapter 144. Meniere Syndrome

Jack J. Wazen
Chapter 145. Sleep Disorders

June M. Fry
SECTION XXII. SYSTEMIC DISEASES AND GENERAL MEDICINE
Chapter 146. Endocrine Diseases

Gary M. Abrams and Earl A. Zimmerman
Chapter 147. Hematologic and Related Diseases

Kyriakos P. Papadopoulos and Casilda M. Balmaceda
Chapter 148. Hepatic Disease

Neil H. Raskin and Lewis P. Rowland
Chapter 149. Cerebral Complications of Cardiac Surgery

Eric J. Heyer and Lewis P. Rowland
Chapter 150. Bone Disease

Roger N. Rosenberg
Chapter 151. Renal Disease

Neil H. Raskin
Chapter 152. Respiratory Care: Diagnosis and Management

Stephan A. Mayer and Matthew E. Fink
Chapter 153. Paraneoplastic Syndromes

Lewis P. Rowland
Chapter 154. Nutritional Disorders: Vitamin B12 Deficiency, Malabsorption, and Malnutrition
Lewis P. Rowland and Bradford P. Worrall
Chapter 155. Vasculitis Syndromes

Lewis P. Rowland
Chapter 156. Neurologic Disease During Pregnancy

Alison M. Pack and Martha J. Morrell
SECTION XXIII. ENVIRONMENTAL NEUROLOGY
Chapter 157. Alcoholism

John C.M. Brust
Chapter 158. Drug Dependence

John C.M. Brust
Chapter 159. Iatrogenic Disease

Lewis P. Rowland
Chapter 160. Complications of Cancer Chemotherapy

Massimo Corbo and Casilda M. Balmaceda
Chapter 161. Occupational and Environmental Neurotoxicology

Lewis P. Rowland
Chapter 162. Abuse of Children

Claudia A. Chiriboga
Chapter 163. Falls in the Elderly

Lewis P. Rowland
SECTION XXIV. REHABILITATION
Chapter 164. Neurologic Rehabilitation

Laura Lennihan and Glenn M. Seliger
SECTION XXV. ETHICAL AND LEGAL GUIDELINES
Chapter 165. End-of-Life Issues in Neurology

Lewis P. Rowland
CONTRIBUTORING AUTHORS
Gary M. Abrams, M.D.
Associate Professor
Department of Neurology
University of California
505 Parnassus Avenue
San Francisco, California 94143, and
Chief, Department of Neurology/Rehabilitation
University of California, San Francisco/Mt. Zion Medical Center
1600 Divisadero Street
San Francisco, California 94115
Alan M. Aron, M.D.

Professor of Pediatrics and Clinical Neurology
Departments of Neurology and Pediatrics
Mount Sinai-New York University Medical Center, and
Director, Attending Neurologist, and Attending Pediatrician
Department of Pediatric Neurology
Mount Sinai Hospital
One Gustave Levy Place
New York, New York 10029
Casilda M. Balmaceda, M.D.

Assistant Professor of Neurology
Columbia University College of Physicians and Surgeons
Assistant Attending Neurologist
New York-Presbyterian Hospital
Neurological Institute
Columbia-Presbyterian Medical Center
710 West 168th Street
Carl W. Bazil, M.D., Ph.D.

Myles M. Behrens, M.D.

Professor of Clinical Ophthalmology
Attending Ophthalmologist
Eye Institute Room 114
635 165th Street, Box 71
Gary L. Bernardini, M.D., Ph.D.

Associate Professor of Neurology
Albany Medical College
Director
Neurological Intensive Care Unit
Albany Medical Center
47 New Scotland Avenue
Albany, New York 12208
Susan B. Bressman, M.D.

Chair
Beth Israel Hospital
Phillips Ambulatory Care Center
10 Union Square East, Suite 2Q
Carolyn Barley Britton, M.D.

Associate Professor of Clinical Neurology
Associate Attending Neurologist
Jeffrey N. Bruce, M.D.

Associate Professor of Neurological Surgery
Associate Attending Neurological Surgeon
John C. M. Brust, M.D.

Professor of Clinical Neurology
Attending Neurologist
New York, New York 10032, and
Director, Department of Neurology
Harlem Hospital Center
506 Lenox Avenue
Robert E. Burke, M.D.

Professor of Neurology
Black Building
650 West 168th Street, 3rd Floor
Abba L. Cargan, M.D.

Stephen Chan, M.D.

Assistant Professor of Radiology
Assistant Attending Neurologist (Neuroradiology)
Milstein Hospital Building
177 Fort Washington Avenue
Claudia A. Chiriboga, M.D.

Massimo Corbo
San Raffaele Hospital
Scientific Institute of Milan
20132 Milan, Italy
Darryl C. De Vivo, M.D.

Sidney Carter Professor of Neurology
Professor of Pediatrics
Attending Neurologist and Pediatrician
Chief, Division of Pediatric Neurology
Robert DeLaPaz, M.D.

Professor of Radiology
Attending Radiologist
Director, Division of Neuroradiology
Stefano Di Donato, M.D.

Istituto Nazionale Neurologico C. Besta
Via Celoria, 11
Milano, 20133
Italy
Salvatore DiMauro, M.D.

Lucy G. Moses Professor
Mitchell S.V. Elkind, M.D.

Ronald G. Emerson, M.D.

Professor of Clinical Neurology and Clinical Pediatrics
Stanley Fahn, M.D.

H. Houston Merritt Professor of Neurology
Chief, Division of Movement Disorder
Neil A. Feldstein, M.D.

Assistant Professor of Neurological Surgery
Assistant Attending Neurosurgeon
Michael R. Fetell, M.D.

Professor of Clinical Neurology and Neurosurgery
Robert L. Fine, M.D.

Herbert Irving Associate Professor of Medicine
Director, Medical Oncology Division
Associate Attending Physician in Medicine
Matthew E. Fink, M.D.

Albert Einstein College of Medicine
President, Chief Executive Officer, and Attending Neurologist
Beth Israel Medical Center
First Avenue at 16th Street
Robert A. Fishman, M.D.

Professor Emeritus
University of California, San Francisco, and
University of California, San Francisco Hospitals
505 Parnassus Avenue
Pamela U. Freda
Associate Professor of Clinical Medicine
Department of Medicine
Assistant Attending Physician
Department of Medicine
June M. Fry M.D., Ph.D.

Professor
MCP Hahnemann University
3200 Henry Avenue
Philadelphia, Pennsylvania 19129, and
Director of Sleep Medicine
Medical College of Pennsylvania Hospital
3300 Henry Avenue
Philadelphia, Pennsylvania 19129
James H. Garvin Jr., M.D., Ph.D.

Professor of Clinical Pediatrics
Attending Pediatrician
Sid Gilman, M.D.

William J. Herdman Professor and Chair
University of Michigan, and
Chief, Neurology Service
University of Michigan Hospitals
1500 East Medical Center Drive
Ann Arbor, Michigan 48109-0316
Arnold P. Gold, M.D.

Professor of Clinical Neurology and Professor of Clinical Pediatrics
Attending Neurologist and Pediatrician
Paul E. Greene, M.D.

Melvin Greer, M.D.

Professor and Chairman
University of Florida College of Medicine
Box 100236
Gainesville, Florida 32610
Alexander Halim, Ph.D.

James H. Halsey, M.D.

Arthur P. Hays, M.D.

Associate Professor of Clinical Neuropathology
Department of Pathology
Associate Attending in Pathology
Department of Pathology
New York Presbyterian Hospital
Eric J. Heyer, M.D.

Associate Professor of Clinical Anesthesiology and Clinical Neurology
Associate Attending Anesthesiologist
Michio Hirano, M.D.

Herbert Irving Assistant Professor of Neurology
Stephen R. Isaacson
Associate Professor
Department of Radiation Oncology
William G. Johnson, M.D.

University of Medicine and Dentistry of New Jersey
Robert Wood Johnson Medical School
675 Hoes Lane
Piscataway, New Jersey 08854-5635
Burk Jubelt, M.D.

Professor
Department of Microbiology/Immunology
SUNY Upstate Medical University
Chief
University Hospital
750 East Adams Street
Syracuse, New York 13210
Ram Kairam, M.D.

Assistant Professor of Clinical Pediatrics and Clinical Neurology
Lincoln Hospital
234 E. 149th Street
Bronx, New York 10451
M. Richard Koenigsberger, M.D.

Professor of Clinical Neurosciences
University of Medicine and Dentistry of New Jersey
185 S. Orange Avenue
Newark, New Jersey 07103
Dale J. Lange, M.D.

Norman Latov, M.D., Ph.D.

Director, Peripheral Neuropathy Division
710 West 168th St.
Robert B. Layzer, M.D.

Professor of Neurology Emeritus
University of California, San Francisco
Box 0114
Laura Lennihan, M.D.

Chief, Department of Neurology
Helen Hayes Hospital
Route 9W
West Haverstraw, New York 10993
Elan D. Louis, M.D.

Robert E. Lovelace, M.D.

Timothy Lynch, M.R.C.P.I., M.R.C.P. (London)

Consultant Neurologist
The Mater Misericordiae Hospital
Eccles Street
Dublin 7, Ireland
Mia MacCollin, M.D.

Assistant Professor
Harvard Medical School
Boston, Massachusetts 02115, and Assistant Professor
Massachusetts General Hospital
Neuroscience Center, MGH East
Building 149, 13th Street
Charlestown, Massachusetts 02129
Elliott L. Mancall, M.D.

Professor and Interim Chairman
Jefferson Medical College
Thomas Jefferson University Hospital
1025 Walnut Street, Suite 310
Philadelphia, Pennsylvania 19107
Joseph T. Marotta, M.D., F.R.C.P. (C)

Professor Emeritus of Neurology
Department of Neurological Sciences
University of Western Ontario
London Health Sciences Centre
London, Ontario N6A 5C1
Canada
Randolph S. Marshall
Assistant Professor
Thornton B.A. Mason, II, M.D.

Assistant Professor of Neurology and Pediatrics
Assistant Attending Neurologist and Pediatrician
Stephan A. Mayer, M.D.

Assistant Professor of Neurology (in Neurological Surgery)
Director, Columbia-Presbyterian Neuro-Intensive Care Unit
Richard Mayeux, M.D.

Gertrude H. Sergievsky Professor of Neurology, Psychiatry, and Public Health
Sergievsky Center
Paul C. McCormick, M.D.

Associate Professor of Clinical Neurological Surgery
Associate Attending Neurosurgeon
John H. Menkes, M.D.

Professor Emeritus
Departments of Neurology and Pediatrics
University of California, Los Angeles
Director of Pediatric Neurology
Cedars Sinai Medical Center
Los Angeles, California 90212
James R. Miller, M.D.

Director, Multiple Sclerosis Care Center
J. P. Mohr, M.D.
Sciarra Professor of Clinical Neurology
Director, Columbia-Presbyterian Stroke Unit
Martha J. Morrell, M.D.

Attending Neurologist and Director
Comprehensive Epilepsy Center
Douglas R. Nordli, Jr., M.D.

Director of Pediatric Epilepsy
Childrens Memorial Hospital
Northwestern University
2300 Childrens Plaza, Room 51
Chicago, Illinois 60614
Alison M. Pack, M.D.

Fellow in Neurology
710 West 168th St.
Kyriakos P. Papadopoulos, M.D.

Assistant Professor of Medicine
Division of Medical Oncology/Hematology
Columbia University College of Physicians and Surgeons, and
Assistant Attending Physician
Timothy A. Pedley, M.D.

Henry and Lucy Moses Professor of Neurology
Chairman of Neurology
Director, Neurological Service
Audrey S. Penn, M.D.

Deputy Director
National Institute of Neurological Disorders and Stroke
National Institutes of Health
31 Center Drive, MSC 2540, Room 8A52
Bethesda, Maryland 208922540
John Pile-Spellman
Professor of Radiology
Vice Chair of Research
Director of Interventional Neuroradiology
Leon D. Prockop, M.D.

Professor
College of Medicine, University of South Florida
12901 Bruce B. Downs Boulevard, Box 55
Tampa, Florida 33629
Serge Przedborski, M.D., Ph.D.

Associate Professor of Neurology and Pathology
Isabelle Rapin, M.D.

Professor of Neurology and Pediatrics (Neurology)
Albert Einstein College of Medicine
Room 807 Kennedy Center
1410 Pelham Parkway South
Bronx, New York 10461
Neil H. Raskin, M.D.

Professor
University of California, San Francisco, and
Attending Physician
Moffitt/Long Hospital
505 Parnassus Ave.
Roger N. Rosenberg, M.D.

Zale Distinguished Chair and Professor
University of Texas Southwestern Medical Center
5323 Harry Hines Boulevard
Dallas, Texas 75235-9036, and
Zale-Lipsky University Hospital and Parkland Hospital
5300 Harry Hines Boulevard
Dallas, Texas 75235
Lewis P. Rowland, M.D.

New York, New York 10032-2603
Ralph L. Sacco, M.S., M.D.

Associate Professor of Neurology and Public Health (Epidemiology)
New York, New York 10032-2603
Eric A. Schon, Ph.D.

Professor of Genetics and Development (in Neurology)
Glenn M. Seliger, M.D.

Director of Head Injury Services
Helen Hayes Hospital
Route 9W
West Haverstraw, New York 10993
Michael B. Sisti, M.D.

Assistant Professor of Clinical Neurological Surgery
Assistant Attending Neurosurgeon
Scott A. Small, M.D.

Robert A. Solomon
Byron Stookey Professor and Chairman
Department of Neurological Surgery
Director of Neurosurgery
Christian Stapf, M.D.

Visiting Research Scientist in Neurology
Fellow, Stroke Center
Clinical Fellow
Stroke Unit/Department of Neurology
Universitaetsklinikum Benjamin Franklin
Hindenburgdamm 30
D-12203 Berlin, Germany
Leonidas Stefanis, M.D.
Bennett M. Stein, M.D., F.A.C.S.

Chairman and Professor Emeritus
Department of Neurosurgery
Director Emeritus
Department of Neurosurgery
Yaakov Stern, Ph.D.

Professor of Neurology and Psychiatry
Columbia University
College of Physicians and Surgeons
Professional Neuropsychologist
Eveline C. Traeger, M.D.

Assistant Professor
Departments of Pediatrics and Neurology
Robert Wood Johnson School of Medicine
University of Medicine and Dentistry of New Jersey, and
Attending Physician
Robert Wood Johnson University Hospital
New Brunswick, New Jersey 08903
Rosario R. Trifiletti, M.D.

Assistant Professor of Neurology, Neuroscience, and Pediatrics
Weill Medical College of Cornell University
Assistant Attending Neurologist and Pediatrician
Cornell-New York Center
525 East 68th Street, Box 91
Werner Trojaborg, M.D.

Special Lecturer in Neurology
Graziella Uziel, M.D.

Assistant
Istituto Nazionale Neurologico C. Besta
Via Celoria, 11
Milano, 20133
Italy
Thaddeus S. Walczak, M.D.

University of Minnesota, Twin Cities Campus
5775 Wayzata Boulevard
Minneapolis, Minnesota 55416
Ching H. Wang, M.D., Ph.D.

Assistant Professor
Department of Neurology and Biochemistry
University of Missouri, and
Department of Neurology and Child Health
University Hospitals and Clinics
M741, MSB
One Hospital Drive
Columbia, Missouri 65212
Jack J. Wazen, M.D.

Associate Professor
Department of Otolaryngology-Head and Neck Surgery
Atchley Pavilion (AP 5512)
Louis H. Weimer, M.D.

Assistant Professor
Leon A. Weisberg, M.D.

Director
Vice-Chairman
Department of Psychiatry and Neurology
Tulane Medical School
1430 Tulane Avenue, SL 28
New Orleans, Louisiana 70112
Bradford P. Worrall, M.D.

Clinical Instructor
Department of Neurology and Health Evaluation Sciences
University of Virginia
Health System #394
Charlottesville, Virginia 22908
Frank M. Yatsu, M.D.

Professor and Chairman Emeritus
University of Texas
6431 Fannin Street
Houston, Texas 77030
Dewey K. Ziegler, M.D.

Professor Emeritus
University of Kansas Medical School
3901 Rainbow Boulevard
Kansas City, Kansas 66103
Earl A. Zimmerman, M.D.

Oregon Health Sciences University, and
Chief, Neurology Service
Oregon Health Sciences University Hospital
3181 S.W. Sam Jackson Park Road
Portland, Oregon 97201-3098
PREFACE
H. Houston Merritt first published this Textbook of Neurology in 1955. He was the sole author. The book became popular, and he revised it himself through the fourth
edition. As the mass of information increased, he finally accepted contributions from colleagues for the fifth edition. Even then, he wrote most of the book himself, and
he continued to do so for the sixth edition despite serious physical disability. He died in 1979, just as the sixth edition was released for distribution.
The seventh edition, published in 1984, was prepared by seventy of Merritts students. Thirty of them headed neurology departments and others had become
distinguished clinicians, teachers, and investigators. That edition was a landmark in the history of neurology. It documented the human legacy of a singular and great
leader whose career set models for clinical investigation (when it was just beginning), clinical practice, teaching, editing books and journals, administering schools and
departments, and commitment to national professional and voluntary organizations.
We now provide the tenth edition. The list of authors has changed progressively, as a dynamic book must do. Yet the ties to Merritt persist. Many of his personal
students are still here and their students, Merritts intellectual grandchildren, are appearing in increasing numbers.
Merritts Neurology is intended for medical students, house officers, practicing neurologists, non-neurologist clinicians, nurses, and other healthcare workers. We
hope it will be generally useful in providing the essential facts about common and rare diseases or conditions that are likely to be encountered.
We have tried to maintain Merritts literary attributes: direct, clear, and succinct writing; emphasis on facts rather than unsupported opinion (now called
evidence-based medicine); and ample use of illustrations and tables.
The book now faces competition from other books, including electronic textbooks, but its success is based on several attributes. A book, unlike a computer, can be
taken and used almost anywhere. A one-volume textbook is handier, more mobile, and less expensive than the multivolume sets that now dot the scene. Briefer
paperbacks provide less information and fewer references.
This edition includes comprehensive revisions demanded by the progress of research in epilepsy, Parkinson disease and other movement disorders, stroke,
dementia, critical care, multiple sclerosis, ataxias, neurology of pregnancy, prion diseases, mitochondrial diseases, autonomic diseases, neuro-oncology,
neurotoxicology, peripheral neuropathies, muscular dystrophies, cerebral complications of cardiac surgery, transplantation and imaging. New chapters have been
added on prion diseases, CSF hypotension, superficial siderosis, glucose transporter deficiency, and end-of-life issues.
In almost every chapter, the impact of molecular genetics has left its mark in much updating. The progress of medical science has produced monographs on each of
these subjects; a challenge to our authors has been the need to transmit the essential information without unduly enlarging the textbook.
We have retained the general organization of previous editions, including arbitrary decisions about the placement of some subjects. Does the discussion of seizures
or multiple sclerosis in pregnancy belong in chapters on pregnancy, epilepsy or multiple sclerosis? Is the Lambert-Eaton syndrome best described in a chapter on
neuromuscular disorders or one on paraneoplastic syndromes? We have opted for redundancy on these issues. It makes the book a bit longer than it might be
otherwise, but the reader does not have to keep flipping pages to find the information.
The impact of molecular genetics has left other marks. Do we continue to organize the book by clinical syndromes and diseases or do we group by the nature of the
mutation? Channelopathies or neuromuscular disease for Lambert-Eaton disease? Channelopathy for familial hemiplegic migraine or a form of headache?
Nondystrophic myotonia or periodic paralysis for the hyperkalemic type? Triplet repeat or ataxia or spinobulbar muscular atrophy? We have opted for the clinical
classification while recognizing that we are on the verge of understanding the pathogenesis of these increasingly scrutable diseases.
Another uncertainty involves eponyms: use apostrophe or not? There is no consensus in medical publishing because not everyone recognizes there is a problem.
Neurology journals and the influential New England Journal of Medicine have not changed, but journals devoted to genetics or radiology have dropped the apostrophe
and even the AMA journals are coming around. The Council of Biology Editors has taken a strong stand against the use of the possessive form.
It is not only the possessive inference that is objectionable. The legendary humorist A. J. Liebling once wrote: I had Brights disease and he had mine. In other
usage, the nominal adjective is not the possessive; no one objects to Madison Avenue, Harvard University, Nobel Prize, or Kennedy Center. And there are other
challenges, including the grating sibilance of Duchennes dystrophy and the inconsistency of people who use that term, sometimes with the apostrophe and
sometimes without. In the neuromuscular community, Duchenne dystrophy is surely preferred. And consider our hapless heroes whose names end in an s: Graves,
Kufs, Gowers, Menkes and others become incorrectly singular when the apostrophe is inserted (creating the nonexistent Kufs disease). If the possessive is added
at the end, something sounds wrong in Gravess disease.
We have therefore followed the general rules of Victor McKusick in dealing with eponyms, giving general preference to the nonpossessive form without being totally
rigid about it. Often, an inserted the can smoothly precede the eponym, especially in hyphenated compounds such as the Guillain-Barr syndrome. Nevertheless,
as McKusick states: some nonpossessive terms, because of long usage in the possessive, roll off the tongue awkwardlye.g., the Huntington disease, the Wilson
disease, the Hodgkin disease, etc. I myself have a hard time saying Bell palsy. But Huntington disease, Alzheimer disease, Parkinson disease, and Hodgkin
disease are heard with increasing frequency, even without a preceding the. Once the nonpossessive form is used in conversation, it is more likely to sound natural.
In another tribute to the tremendous impact of Victor McKusick, we have retained the practice of giving his catalog numbers for genetic diseases. Readers can then
find the history of the syndrome and current research data in the catalog, which is now online. In this day of gender-neutral writing, it is awkward to use the acronym
MIM for Mendelian Inheritance in Man. It seems too late to change that historic title, but Human Mendelian Inheritance would be euphonic.
On the other hand, the stiff-man syndrome remains a problem. Papers entitled stiff-man syndrome in a woman or in a boy ought to be fixed and stiff-person
syndrome is just plain awkward. My personal attempts to use the eponym, Moersch-Woltman syndrome have had zero success, partly because the names do not
trip lightly off the lip, and reversing the order is no better.
We thank all the authors for their devoted and skillful work. In the editors office, Sheila Crescenzo has once again kept her head when I was losing mine, and she
remained patient when I misplaced pages. She has been remarkably skillful in tracking correspondence and keeping multiple revisions of the same chapter in order.
Terrance Gabriel was again a valuable resource in updating references throughout the book. At Lippincott Williams & Wilkins, Joyce Murphy supervised editing and
production. Robin Cook was an excellent production editor. Charles Mitchell has had overall responsibility for the publisher. Their combined efforts have resulted in
the handsome volume.
We formally dedicate the book to H. Houston Merritt. I personally dedicate it also to all the spouses and children of all the contributors, especially to Esther E.
Rowland; our children, Andrew, Steven, and Joy; and our grandchildren, Mikaela, David Liam, Cameron Henry, and Mariel Rowland. All of them, Rowlands and
others, have suffered neglect because of the contributors clinical research and writing that provide the substance and content of this book.
CHAPTER REFERENCES
American Medical Association. Manual of style. A guide for authors and editors, 9th ed. Chicago: American Medical Association, 1998:469472.
McKusick VA. Mendelian inheritance in man. A catalog of human genes and genetic disorders. 12th ed. Baltimore, Johns Hopkins University Press, 1998.
McKusick VA. On the naming of clinical disorders, with particular reference to eponyms. Medicine 1998;77:12.
ABBREVIATIONS
AchR Acetyl choline receptor
AIDS Acquired immunodeficiency syndrome
ALS Amyotrophic lateral sclerosis
BAER Brainstem auditory evoked response
BMD Becker muscular dystrophy
C3 A specific component of complement
CIDP Chronic inflammatory demyelinating Polyneuropathy
CJD Creutzfeldt-Jakob disease
CK Creatine kinase
CMT Charcol-Marie-Tooth disease
CMV Cytomegalovirus
CNS Central nervous system
CPS Complex partial seizures
CSF Cerebrospinal fluid
CT Computed tomography
DMD Duchenne muscular dystrophy
DNA Deoxyribonucleic acid
ECG Electrocardiogram
EEK Electroencephalography
EMG Electromyography
ESR Erythrocyte sedimentation rate
FSH Facioscapulohumeral muscular Dystrophy
GBS Guillain-Barr syndrome
GM1 A specific neural ganglioside
GSS Gerstmann-Strussler-Scheinker Disease
HD Huntington disease
HIV Human immunodeficiency virus
IVIG Intravenous immunoglobulin therapy
KSS Kearns-Sayre-syndrome
LHON Leber hereditary optic neuropathy
MAG Myelin-associated glycoprotein
MELASMitochondrial encephalopathy with lactic acidosis and stroke
MERRFMyoclonus epilepsy with ragged red fibers
MRA Magnetic resonance angiography
MRI Magnetic resonance imaging
MS Multiple sclerosis
mtDNA Mitochondrial DNA
MyD Myotomic muscular dystrophy
NARP Neuropathy, ataxia, retinitis pigmentosa
NPH Normal pressure hydrocephalus
PET Positron emission tomography
PML Progressive multifocal leukoencephalopahy
POEMSSyndrome of polyneuropathy, organomegaly, endocrinopathy, monoclonal paraproteinemia, and skin changes
RNA Ribonucleic acid
SPECT Single-photon emission computed tomography
SSER Somatosensory evoked response
TIA Transient ischemic attack
VER Visual evoked response
CHAPTER 1. DELIRIUM AND DEMENTIA
MERRITTS NEUROLOGY
SECTION I. SYMPTOMS OF NEUROLOGIC DISORDERS

CHAPTER 1. DELIRIUM AND DEMENTIA
SCOTT A. SMALL AND RICHARD MAYEUX
Delirium
Dementia
Suggested Readings
Delirium and dementia are two of the most common disorders of elderly patients, although both conditions may occur at any age. Delirium is the acute confusional
state that may accompany infections, fever, metabolic disorders, and other medical or neurologic diseases. Dementia, in contrast, is usually chronic and progressive,
and is usually caused by degenerative diseases of the brain, multiple strokes, or chronic infection. The most significant difference, however, is that delirium manifests
itself by a fluctuating mental state, whereas patients suffering from dementia are usually alert and aware until late in the course of the disease.
DELIRIUM
The features of delirium were originally described by Hippocrates. Delirium refers to a global mental dysfunction marked by a disturbance of consciousness,
especially reduced awareness of the environment and inability to maintain attention. Associated features include disruption of the sleepwake cycle, drowsiness,
restlessness, incoherence, irritability, emotional lability, perceptual misinterpretations (illusions), and hallucinations. Symptoms appear within hours or days and
fluctuate, often worsening at night. Other characteristics that lead to the classification of a mental state as delirium include impairment of memory and intellectual
function, the presence of a medical or neurologic condition to which the mental impairment is secondary, the disappearance of mental impairment if the primary
medical or neurologic disorder is reversed, and the effect of the primary disorder on the brain, which is diffuse rather than focal.
Delirium is involved in a wide range of clinical states. Almost any severe acute medical or surgical condition, under the right circumstances, can cause delirium.
Common causes can be divided into primary cerebral disease and systemic illness. Primary brain disorders include head injury, stroke, raised intracranial pressure,
infection, and epilepsy. Systemic illnesses may be infectious, cardiovascular, endocrine, or toxic-metabolic.
Delirium tremens occurs only in people addicted to alcohol. It develops 24 to 48 hours after withdrawal from alcohol. Onset is marked by confusion, agitation, and
hyperactivity. Memory is affected, and hallucinations are prominent. Autonomic hyperactivity results in tachycardia and high fever. If untreated, delirium tremens can
be fatal.
The following drugs can cause delirium:
Atropine and related compounds Barbiturates

Bromides
Chlordiazepoxide (Librium)
Chloral hydrate
Cimetidine and related compounds
Clonidine
Cocaine
Diazepam
Digitalis
Dopamine agonists
Ethanol
Flurazepam
Glutethimide
Haloperidol and other neuroleptics
Lithium
Mephenytoin (Mesantoin)
Meprobamate
Methyldopa
Opioids
Phencyclidine hydrochloride (PCP)
Phenytoin sodium (Dilantin)
Prednisone
Propranolol
Tricyclic antidepressants
In elderly patients, anticholinergic and hypnotic agents are particularly common causes of drug-induced delirium.
Delirium is a medical emergency because the disease or drug intoxication may be fatal if untreated, especially in the elderly. The appearance of delirium may double
the risk of death within hours or weeks. Successful treatment of delirium eliminates much of this excess mortality. The two best predictors of fatal outcome are
advanced age and the presence of multiple physical diseases.
The diagnostic evaluation is dictated by evidence in the patient's history and physical examination. First-line investigations include electrolytes, complete blood cell
count, erythrocyte sedimentation rate (ESR), liver and thyroid function tests, toxicology screen, syphilis serology, blood cultures, urine culture, chest x-ray, and
electrocardiogram (ECG). If the cause cannot be determined from these tests, additional investigations to consider include neuroimaging, cerebrospinal fluid (CSF)
analysis, electroencephalogram (EEG), human immunodeficiency virus (HIV) antibody titer, cardiac enzymes, blood gases, and autoantibody screen.
The fluctuating state of awareness in delirium is accompanied by characteristic EEG changes. The varying level of attention parallels slowing of the background EEG
rhythms. Triphasic waves may also be present. Appropriate treatment of the underlying disease improves both the patient's mental state and the EEG.
The management of delirium includes general supportive and symptomatic measures, as well as treatment of the specific underlying conditions.
DEMENTIA
Dementia is characterized by progressive intellectual deterioration that is sufficiently severe to interfere with social or occupational functions. Memory, orientation,
abstraction, ability to learn, visuospatial perception, language function, constructional praxis, and higher executive functions, such as planning, organizing, and
sequencing, are all impaired in dementia. In contrast to patients with delirium, those with dementia are alert and aware until late in the disease. Delirium is most often
associated with intercurrent systemic diseases or drug intoxication, but dementia is usually due to a primary degenerative or structural disease of the brain. Alzheimer
disease (AD) (see Section XIII: Dementias) accounts for more than 50% of cases of dementia in both clinical and autopsy series. In a community-based disease
registry in New York City limited to people older than 65 years, the relative frequency of AD was similar to that in other clinical and autopsy series ( Table 1.1).
Parkinsonism (see Chapter 114) is sometimes associated with dementia, and diffuse Lewy body disease (see Chapter 106) is incorporated into this group. Huntington
disease (see Chapter 108) is much less common but is still an important cause in the presenium. Less common degenerative diseases include Pick disease and
frontotemporal dementia (see Chapter 106), progressive supranuclear palsy (see Chapter 115), and the hereditary ataxias (see Chapter 107).
TABLE 1.1. DISEASES THAT CAUSE DEMENTIA
Cerebrovascular dementia may be defined as a clinical syndrome of acquired intellectual impairment resulting from brain injury due to either ischemic or hemorrhagic
cerebrovascular disease. Of cases of dementia, 15% to 20% are attributed to vascular disease. An essential requirement for the concept of cerebrovascular dementia
is that cerebrovascular disease causes the cognitive loss. Features that support causality include a temporal relationship between stroke and dementia; abrupt or,
less commonly, stepwise deterioration in mental function; fluctuating course; or radiologic evidence of damage to regions important for higher cerebral function, such
as angular gyrus, inferomedial temporal lobe, medial frontal lobe, thalamus, caudate, anterior internal capsule, and the border-zone infarction territory between the
superior frontal and parietal convexities.
Intracranial mass lesions, including brain tumors and subdural hematomas, cause dementia without focal neurologic signs in as many as 5% of patients with
dementia. With computed tomography (CT), these patients are rapidly identified and treated. Future series of dementia cases will probably include fewer patients with
dementia caused by intracranial mass lesions.
The frequency of chronic communicating hydrocephalus ( normal pressure hydrocephalus) as a cause of dementia in adults varies from 1% to 5% in different series.
Diagnosis is usually straightforward when the hydrocephalus follows intracranial hemorrhage, head injury, or meningitis, but in idiopathic cases it is often difficult to
differentiate communicating hydrocephalus from ventricular enlargement due to brain atrophy.
At the turn of the 20th century, the most common cause of dementia was neurosyphilis. Today, however, general paresis and other forms of neurosyphilis are rare.
HIV-associated dementia is now among the most common infectious causes of dementia, as well as among the most common causes of dementia in young adults.
Creutzfeldt-Jakob disease (CJD) is another cause of transmissible dementia. Nonviral infections rarely cause chronic rather than acute encephalopathy. Fungal
meningitis occasionally manifests itself as dementia.
Nutritional, toxic, and metabolic causes of dementia are particularly important because they may be reversible. Korsakoff psychosis, usually found in alcoholics and
attributed to thiamine deficiency, remains an important problem in the United States. In contrast, the dementia of pellagra, a disorder produced by niacin and
tryptophan deficiencies, has been almost entirely eliminated in the United States. Vitamin B 12 deficiency occasionally causes dementia without anemia or spinal cord
disease. Among the metabolic disorders that may cause dementia, hypothyroidism is the most important. Inherited metabolic disorders that can lead to dementia in
adults include Wilson disease, the adult form of ceroid lipofuscinosis (Kufs disease), cerebrotendinous xanthomatosis, adrenoleukodystrophy, and mitochondrial
disorders. Finally, prolonged administration of drugs or heavy metal exposure may cause chronic intoxication (due to inability to metabolize the drug or to idiosyncratic
reactions) that may be mistaken for dementia.
Differential Diagnosis
The first symptoms of progressive dementia may be occasional forgetfulness, misplacing objects, or difficulties in finding objects. The distinction between cognitive
decline in old age and early dementia may be difficult. To improve the identification of cognitive changes associated with aging, varying sets of criteria have resulted
in multiple terms, including age-associated memory impairment, age-related cognitive change, and mild cognitive impairment. It is likely that demonstrable changes in
cognition are not an inevitable result of aging and that early dementing illnesses are one contributing cause.
Another difficult diagnostic problem is the differentiation of dementia and secondary depression from depression and a secondary memory problem that will improve
with treatment of the depression. This problem is dramatized by the misdiagnosis rate of 25% to 30% in dementia series; the errors resulted chiefly from failure to
recognize that older depressed people may show cognitive changes in the mental status examination. Furthermore, depression may be an early manifestation of AD.
In depression, the memory problem usually follows the mood change. The onset of memory loss may be more abrupt than it usually is in dementia, and is often mild,
tending to plateau. Neuropsychologic test results may be atypical for dementia.
The differential diagnosis of dementia requires an accurate history and neurologic and physical examinations. In AD, the onset of symptoms is typically insidious and
the course is slowly progressive but relentless in an otherwise healthy person; in contrast, the history of a patient with vascular dementia may include an abrupt onset
of memory loss, history of an obvious stroke, or the presence of hypertension or cardiac disease. A history of alcoholism raises suspicion of Korsakoff psychosis.
Examination of a patient with AD is usually normal, except for the presence of extrapyramidal signs such as rigidity, bradykinesia, and change in posture, and primitive
reflexes, such as the snout reflex. Conversely, a vascular syndrome may include hemiparesis or other focal neurologic signs. Huntington disease is readily recognized
by chorea and dysarthria. Patients with Parkinson disease (PD) show the characteristic extrapyramidal signs. Dementia in PD usually occurs with advanced age and
includes depression and severe motor manifestations. Progressive supranuclear palsy is recognized by the limitation of vertical eye movements and extrapyramidal
signs. Myoclonus occurs most often in CJD but may be seen in advanced AD and other dementias. Unsteadiness of gait is a hallmark of communicating
hydrocephalus, but it may be even more severe in CJD, hereditary ataxias, or Korsakoff psychosis.
Diagnostic tests to differentiate AD from other dementias are still in their infancy. Amyloid-beta protein and tau protein can be measured in CSF, and hypersensitivity
to pupillary dilation in response to tropicamide, a potent cholinergic antagonist, may help identify AD. However, none of these tests has shown improved accuracy
over the clinical criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders
Association (NINCDS-ADRDA). Several genes have been associated with forms of familial dementia, and a single gene has been associated with sporadic AD;
nonetheless, it is difficult to use any particular gene as a diagnostic test, unless the patient is a member of one of the few identified families with that mutation. The
apolipoprotein E genotype alone is insufficient to make the diagnosis, but the haplotype may improve diagnostic specificity in conjunction with NINCDS-ADRDA
clinical criteria. The NINCDS-ADRDA clinical criteria make the diagnosis of AD reasonably accurate and reliable.
Neuropsychologic testing is the best way to establish the presence of dementia. Age, education, socioeconomic background, and premorbid abilities must be
considered in the interpretation of the test scores. CT and magnetic resonance imaging are important for establishing the cause of dementia. Atrophy, strokes, brain
tumor, subdural hematoma, and hydrocephalus are readily diagnosed by neuroimaging. Changes in white matter intensity must be interpreted with caution. Intensity
changes may be due to small-vessel ischemic disease, normal aging, or dilated Virchow-Robin spaces from generalized atrophy in AD. Functional brain imaging with
single-photon emission computed tomography may also be helpful. Bilateral temporoparietal hypometabolism is suggestive of AD or idiopathic PD with dementia.
Bilateral frontal hypometabolism suggests Pick disease, progressive supranuclear palsy, or depression. Multiple hypometabolic zones throughout the brain suggest
vascular dementia or HIV-associated dementia. In addition, the EEG is useful in identifying CJD, which is characterized by periodic discharges.
Blood tests are essential to identify dementia with endocrine disease and liver or kidney failure. Hypothyroidism is a reversible cause of dementia. Vitamin B 12
deficiency may be present without anemia, as determined by serum vitamin B 12 levels. Neurosyphilis is a rare but a reversible cause, so serologic testing for syphilis
is mandatory. Blood levels of drugs may detect intoxication. The ESR and screens for connective tissue disease (e.g., antinuclear antibodies and rheumatoid factor)
are performed if the clinical picture suggests evidence of vasculitis or arthritis. In any young adult with dementia, an HIV titer should be considered, and if an
associated movement disorder is present, a test for ceruloplasmin should be performed.
Details of the differential diagnosis of diseases that cause dementia are provided in subsequent chapters. An exhaustive evaluation of patients with dementia is
warranted. Although effective treatment for the primary degenerative diseases is limited, many other disorders that cause dementia are amenable to treatment that
may arrest, if not reverse, the cognitive decline.
Mental Status Examination
The mental status evaluation is an essential part of every neurologic examination. It includes evaluation of awareness and consciousness, behavior, emotional state,
content and stream of thought, and sensory and intellectual capabilities. Intellectual impairment is obvious in such florid conditions as delirium tremens or advanced
dementia, but cognitive loss may not be evident in early delirium or dementia, unless the physician specifically tests mental status.
Traditionally, mental status examinations test information (e.g., where were you born? what is your mother's name? who is the president? when did World War II
occur?), orientation (e.g., what place is this? what is the date? what time of day is it?), concentration (by use of serial reversals, e.g., spelling world backwards,
naming the months of the year backwards beginning with December), calculation (e.g., doing simple arithmetic, making change, counting backwards by threes or
sevens), and reasoning, judgment, and memory (e.g., identifying three objects and asking the patient to recall their names or telling a short story and asking the
patient to try to recall it after a few minutes). The most important and sensitive items are probably orientation to time, serial reversals, and a memory phrase. The
minimental status examination (MMSE) was introduced as a standard measure of cognitive function for both research and clinical purposes. This short examination
can be administered at the bedside and completed in 10 minutes. Scores are assigned for each function ( Table 1.2); the maximum score is 30 points. A score less
than 24 is considered consistent with dementia. The MMSE, like all other brief mental status examinations, is not precise. Some investigators use a score of 26 as the
cutoff to include milder forms of dementia and improve specificity. The MMSE tends to underdiagnose dementia in well-educated people and overdiagnose it in those
with little schooling. Therefore, the MMSE should be used only as a first step. It does not replace the history or a more detailed examination of neuropsychologic
function (see Chapter 19).
TABLE 1.2. MINI-MENTAL STATUS EXAMINATION
In addition to testing mental status, it is necessary to test higher intellectual functions, including disorders of language (dysphasias); constructional apraxia; rightleft
disorientation; inability to carry out complex commands, especially those requiring crossing the midline (e.g., touching the left ear with the right thumb); inability to
carry out imagined acts (ideomotor apraxia; e.g., pretend that you have a book of matches and show me how you would light a match); unilateral neglect; or
inattention on double stimulation. These abnormalities are often associated with more focal brain lesions but may also be impaired in delirium or dementia.
Examination of aphasia, apraxia, and agnosia is described in detail in Chapter 2.
SUGGESTED READINGS
Arai H, Terajima M, Miura M, et al. Tau in cerebrospinal fluid: a potential diagnostic marker in Alzheimer's disease. Ann Neurol 1995;38:649652.
Cummings JL, Benson DB. Dementia: a clinical approach, 2nd ed. Boston: ButterworthHeinemann, 1992.
Devanand DP, Sano M, Tang MX, et al. Depressed mood and the incidence of Alzheimer's Disease in the elderly living in the community. Arch Gen Psychiatry 1996;53:175182.
Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association, 1994.
Folstein MF, Folstein S, McHugh P. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189198.
Hachinski VC, Iliff LE, Ziljka E, et al. Cerebral blood flow in dementia. Arch Neurol 1975;32:632637.
Jellinger K. Neuropathological aspects of dementia resulting from abnormal blood and cerebrospinal fluid dynamics. Acta Neurol Belg 1976;76: 83102.
Kahn RL, Goldfarb AI, Pollack M, et al. Brief objective measures for the determination of mental status in the aged. Am J Psychiatry 1960;117: 326328.
Katzman R, Brown T, Fuld P, et al. Validation of a short orientation-memory-concentration test of cognitive impairment. Am J Psychiatry 1983;140:734739.
Lipowski ZJ. Delirium (acute confusional state). JAMA 1987;258: 17891792.
Mayeux R, Foster NL, Rosser M, et al. The clinical evaluation of patients with dementia. In: Whitehouse PJ, ed. Dementia. Philadelphia: FA Davis Co, 1993:92117.
Mayeux R, Saunders AM, Shea S, et al. Utility of the apolipoprotein E genotype in the diagnosis of Alzheimer's disease: the Alzheimer's Disease Centers Consortium on Apolipoprotein E and
Alzheimer's Disease. N Engl J Med 1998;338:506511. Erratum: N Engl J Med 1998;30:1325.
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CHAPTER 2. APHASIA, APRAXIA, AND AGNOSIA
MERRITTS NEUROLOGY
CHAPTER 2. APHASIA, APRAXIA, AND AGNOSIA

J. P. MOHR
Aphasia
Apraxia
Agnosia
Suggested Readings
APHASIA
Left-hemisphere dominance for speech and language applies to more than 95% of all populations studied. Right-hemisphere dominance in a right-handed person is
rare enough to prompt case reports in the literature. Most left-handed persons show some disturbance in speech and language from either left- or right-hemisphere
lesions, making predictions for hemisphere dominance for left-handed persons difficult to predict on an individual basis. The most predictable site for disturbances in
speech and language are the regions in and bordering on the sylvian fissure of the hemisphere controlling the hand preferred for skilled movements. The farther from
this zone that the lesion occurs, the less the lesion disturbs speech and language. The disturbances in speech and language resulting from a lesion form a group of
disorders known as the aphasias.
The popular classifications of aphasia are based on classic views that the front half of the brain performs motor or executive functions and the back half sensory or
receptive functions, with the two regions connected by pathways in the white matter. Classically, frontal lesions have been inferred to cause motor aphasia, those
affecting the posterior regions cause sensory aphasia, and those interrupting the pathways between the frontal and posterior regions cause conduction aphasia. This
formulation posits an anatomic functional loop with an afferent portion from the eyes and ears connecting to the visual and auditory system, an intrahemispheral
portion through the white matter connecting the temporal with the frontal lobes (the arcuate fasciculus), and an efferent portion from the frontal lobes to the mouth and
hand permitting, in its simplest function, words heard to be repeated aloud and words seen to be copied manually. Apart from the crude replication of sounds heard
and shapes seen, of which any person even ignorant of the language conveyed by the sounds or forms is capable, meaning is thought to be conveyed to these
shapes and sounds by access of the perisylvian region to the rest of the brain through intrahemispheral and transcallosal pathways. Interruption of these linkage
pathways is postulated to produce transcortical sensory aphasia, in which words heard are repeated aloud or copied without comprehension, or transcortical motor
aphasia, in which words can be repeated and copied but no spontaneous communication by conversation or writing occurs. Other disconnections have also been
proposed for pathways to or from the periphery, which presumably would be in the subcortical white matter. Disconnections of incoming pathways bearing visual
lexical information yield pure alexia; those of pathways conveying auditory material cause pure word deafness. The combination of these two disconnections causes
subcortical sensory aphasia. Disconnections of efferent pathways from the motor speech zones produce pure word mutism or subcortical motor aphasia.
Although these generalizations are widely held to account for the major principles of cerebral organization, uncritical acceptance of the expected effects of certain
lesion locations or prediction of lesion locations by the clinical features, as based on the classical formulas, often proves misleading for clinicians seeking the site and
cause of a clinical disorder of speech and language. To avoid this problem, the material that follows emphasizes the clinical features that aid in local lesion diagnosis,
with less emphasis on the classical concepts.
Motor Aphasias
An acute focal lesion (the most frequent and best known being an infarct) involving any portion of the insula or the individual gyrus forming the upper banks of the
opercular cortex (from the anteroinferior frontal region to the anterior parietal) acutely disrupts the acquired skills involving the oropharyngeal, laryngeal, and
respiratory systems that mediate speech, causing mutism. Writing may be preserved, although it is usually confined to a few simple words. Comprehension of words
heard or seen is generally intact because these functions are largely subserved by posterior regions. The speech that emerges within minutes or days of the onset of
motor aphasia consists mostly of crude vowels ( dysphonia) and poorly articulated consonants ( dysarthria). Disturbed coordination (dyspraxia) of speaking and
breathing alters the rhythm of speech ( dysprosody). This faulty intonation, stress, and phrasing of words and sentences is known collectively as speech dyspraxia.
The language conveyed through this speech is usually only slightly disturbed, but the grammatic forms used in speaking or writing are sometimes simplified.
The more anterior that the lesion is along the operculum, the more speech dyspraxia predominates, especially with involvement of the inferior frontal region (Broca
area) located adjacent to the sensorimotor cortex. When the sensorimotor cortex itself is affected, dysarthria and dysphonia are more prominent than dysprosody and
dyspraxia. The errors in pronunciation may make it impossible to understand the language conveyed by the patient's speech, but they are not, strictly speaking, a
language disorder.
When an acute lesion occurs more posteriorly along the sylvian operculum, the precise sensorimotor control over the positioning of the oropharynx may be impaired,
causing unusual mispronunciations as well as mild dysphasia. The disturbed pronunciation is not simple dysarthria. Instead, the faulty oropharyngeal positionings
yield sounds that differ from those intended (e.g., dip is said instead of top). The errors, analogous to the typing errors of a novice unfamiliar with the typewriter
keyboard, are called literal paraphasias. The listener may mistake the utterances as language errors ( paraphasias) or may be impressed with some of the genuine
paraphasias and give the condition the name conduction aphasia (see the following). The patient's comprehension is intact despite the disordered pronunciation.
Stroke is the most common cause of acute lesions. The arrangement of the individual branches of the upper division of the sylvian artery favors the wide variety of
focal embolic obstructions that produce this remarkable array of syndromes. The more specific that the speech abnormality is, the more limited is the focal infarction.
Because the sensorimotor cortex is part of the same arterial supply of the upper division of the middle cerebral artery, the larger infarcts and other disorders such as
basal ganglia hemorrhages, abscesses, large tumors , and acute encephalitis usually cause accompanying contralateral hemiparesis and hemisensory syndromes,
making the diagnosis of perisylvian disease fairly easy. One disorder, known as primary progressive aphasia, appears to be an unusual form of atrophy, causing
mainly a relentless decline in speech and language function without the accompanying motor, sensory, visual, or other clinical evidence of a large lesion affecting the
main pathways serving these functions.
For speech and language, the smaller and more superficial that the injury is, the briefer and less severe is the disruption. Rapid improvement occurs even when the
lesion involves sites classically considered to cause permanent speech and language disturbances, such as the foot of the third frontal gyrus (Broca area). The larger
the acute lesion, the more evident is dysphasia and the longer is the delay before speech improves. In larger sylvian lesions, dysphasia is evident in disordered
grammar, especially when tests involve single letters, spelling, and subtleties of syntax. Problems with syntax occur not only in speaking and writing but also in
attempts to comprehend the meaning of words heard or seen. For example, the word ear is responded to more reliably than is are, cat more than act, and eye
more than I. The language content of spontaneously uttered sentences is condensed, missing many of the filler words, causing telegraphic speech, or agrammatism.
Agrammatism is an important sign of a major lesion of the operculum and insula. When the causative lesion involves many gyri, as with large infarcts, hemorrhages,
and neoplasms or abscesses large enough to produce unilateral weakness, the reduction of both speech and comprehension is profound and is called total aphasia.
Within weeks or months in cases of infarction and hemorrhage, comprehension improves, especially for nongrammatic forms, and speaking and writing seem to be
affected more than listening and reading. This last syndrome, in which dysphasia is most evident in speaking and writing, is known as motor aphasia; the eponym
Broca aphasia is often used. This syndrome emerges from an initial total aphasia as a late residual. It is not the usual acute syndrome of a circumscribed infarction,
even when the lesion is confined to the pars opercularis of the inferior frontal gyrus (Broca area).
Sensory Aphasias
A different set of acute symptoms follows acute focal lesions of the posterior half of the temporal lobe and the posterior parietal and lateral occipital regions. Infarction
is also the usual cause of the discrete syndromes, while hemorrhage, epilepsy, and acute encephalitis may account for sudden major syndromes. Even large lesions
in these areas are usually far enough removed from the sensorimotor cortex so that hemiparesis and speech disturbances (e.g., dysprosody, dysarthria, or mutism)
are only occasionally part of the clinical picture.
In patients with large posterior lesions, the effects are almost the reverse of the insular-opercular syndromes: Syntax is better preserved than semantics; speech is
filled with small grammatic words, but the predicative words (i.e., words that contain the essence of the message) are omitted or distorted. Patients vocalize easily,
engage in simple conversational exchanges, and even appear to be making an effort to communicate; however, little meaning is conveyed in the partial phrases,
disjointed clauses, and incomplete sentences. In the most severe form, speech is incomprehensible gibberish. Errors take the form of words that fail to occur
(omissions), are mispronounced as similar-sounding words ( literal paraphasias), or are replaced by others that have a similar meaning ( verbal paraphasias). A similar
disturbance affects understanding words heard or seen. These language disturbances may require prolonged conversation to be revealed in mild cases. Because this
disturbance in language contrasts with motor aphasia, it is often labeled as sensory aphasia, or Wernicke aphasia, but neither syndrome is purely motor or sensory.
The posterior portions of the brain are more compact than the anterior portions. As a result, large infarctions or mass lesions from hemorrhage, abscess, encephalitis,
or brain tumors in the posterior brain tend to cause similar clinical disorders with few variations in syndrome type. Contralateral hemianopia usually implies a deep
lesion. When hemianopia persists for longer than about 1 week, the aphasia is likely to persist.
Highly focal lesions are uncommon and, when present, usually mean focal infarction. Those limited to the posterior temporal lobe usually produce only a part of the
larger syndrome of sensory aphasia. Speech and language are only slightly disturbed, reading for comprehension may pass for normal, but auditory comprehension
of language is grossly defective. This syndrome was classically known as pure word deafness. Patients with this disorder also usually reveal verbal paraphasias in
spontaneous speech and disturbed silent reading comprehension. This syndrome might be better named the auditory form of sensory aphasia. It has a good
prognosis, and useful clinical improvement occurs within weeks; some patients are almost normal.
A similarly restricted dysphasia may affect reading and writing, more so than auditory comprehension, because of a more posteriorly placed focal lesion that damages
the posterior parietal and lateral occipital regions. Reading comprehension and writing morphology are strikingly abnormal. This syndrome has traditionally been
known as alexia with agraphia, but spoken language and auditory comprehension are also disturbed (although less than reading and writing). A better label might be
the visual form of sensory aphasia. It also has a good prognosis.
The more limited auditory and visual forms of Wernicke aphasia are rarely produced by mass lesions from any cause and tend to blend in larger lesions. Whether the
major syndrome of sensory aphasia is a unified disturbance or a synergistic result of several separate disorders has not been determined.
Amnestic Aphasia
Anomia or its more limited form dysnomia is the term applied to errors in tests of naming. Analysis requires special consideration because the mere occurrence of
naming errors is of less diagnostic importance than is the type of error made. In all major aphasic syndromes, errors in language production cause defective naming
(dysnomia), taking the form of paraphasias of the literal (e.g., flikt for flight) or verbal (e.g., jump for flight) type. For this reason, it is not usually of diagnostic
value to focus a clinical examination on dysnomias alone, as they have little value as signs of focal brain disease.
A pattern known as amnestic dysnomia has a greater localizing value. Patients act as though the name has been forgotten and may give functional descriptions
instead. Invoking lame excuses, testimonials of prowess, claims of irrelevance, or impatience, patients seem unaware that the amnestic dysnomia is a sign of disease.
The disturbance is common enough in normal individuals, but in those with disease it is prominent enough to interfere with conversation. Amnestic aphasia, when fully
developed, is usually the result of disease of the deep temporal lobe gray and white matter. A frequent cause is Alzheimer disease, in which atrophy of the deep
temporal lobe occurs early, and forgetfulness for names may be erroneously attributed to old age by the family. Identical symptoms may occur in the early stages of
evolution of mass lesions from neoplasms or abscess but are rarely a sign of infarction in the deep temporal lobe. Other disturbances in language, such as those
involving grammar, reading aloud, spelling, or writing, are usually absent, unless the responsible lesion encroaches on the adjacent temporal parietal or sylvian
regions. When due to a mass lesion, the disturbance often evolves into the full syndrome of Wernicke aphasia.
Thalamic Lesions and Aphasia
An acute deep lesion on the side of the dominant hemisphere may cause dysphasia if it involves the posterior thalamic nuclei that have reciprocal connections with
the language zones. Large mass lesions or slowly evolving thalamic tumors distort the whole hemisphere, making it difficult to recognize the components of the
clinical picture. Small lesions are most often hematomas and are the usual cause of the sudden syndrome. As in delirium, consciousness fluctuates widely in this
syndrome. As it fluctuates, language behavior varies from normal to spectacular usage. The syndrome may be mistaken for delirium due to metabolic causes (e.g.,
alcohol withdrawal). It is also important in the theory of language because the paraphasic errors are not due to a lesion that affects the cerebral surface, as was
claimed traditionally. Prompt computed tomography usually demonstrates the thalamic lesion.
APRAXIA
The term apraxia (properly known as dyspraxia because the disorder is rarely complete) refers to disturbances in the execution of learned movements other than
those disturbances caused by any coexisting weakness. These disorders are broadly considered to be the body-movement equivalents of the dysphasias and, like
them, have classically been categorized into motor, sensory, and conduction forms.
Limb-kinetic or Innervatory Dyspraxia
This motor form of dyspraxia occurs as part of the syndrome of paresis caused by a cerebral lesion. Attempts to use the involved limbs reveal a disturbance in
movement beyond that accounted for simply by weakness. Because attempted movements are disorganized, patients appear clumsy or unfamiliar with the movements
called for in tasks such as writing or using utensils. Although difficult to demonstrate and easily overlooked in the presence of the more obvious weakness, innervatory
dyspraxia is a useful sign to elicit because it indicates that the lesion causing the hemiparesis involves the cerebrum, presumably including the premotor region and
other association systems. Dyspraxias of this type are thought to be caused by a lesion involving the cerebral surface or the immediately adjacent white matter;
apraxia is not seen in lesions that involve the internal capsule or lower parts of the neuraxis.
Ideational Dyspraxia
Ideational dyspraxia is a different type of disorder altogether. Movements of affected body parts appear to suffer from the absence of a basic plan, although many
spontaneous actions are easily carried out. This disorder is believed to be analogous to sensory aphasia (which features a breakdown of language organization
despite continued utterance of individual words). The term is apparently derived from the simplistic notion that the lesion disrupts the brain region containing the motor
plans for the chain of individual movements involved in complex behaviors such as feeding, dressing, or bathing. To the observer, patients appear uncertain about
what to do next and may be misdiagnosed as confused. The lesion causing ideational dyspraxia is usually in the posterior half of the dominant hemisphere. The
coexisting sensory aphasia often directs diagnostic attention away from the dyspraxia, which, like innervatory dyspraxia, is only rarely prominent enough to result in
separate clinical recognition.
Ideomotor Dyspraxia
This form of dyspraxia is frequently encountered. The term derives from the notion that a lesion disrupts the connections between the region of the brain containing
ideas and the region involved in the execution of movements. The disturbance is analogous to conduction aphasia: Motor behavior is intact when executed
spontaneously, but faulty when attempted in response to verbal command. For movements to be executed by the nondominant hemisphere in response to dictated
commands processed by the dominant hemisphere, the lesion could involve the presumed white-matter pathways through the dominant hemisphere to its motor
cortex, the motor cortex itself, or the white matter connecting to the motor cortex of the nondominant hemisphere through the corpus callosum. Because so many
presumed pathways are involved, ideomotor dyspraxia is common. The syndrome is most frequently encountered in the limbs served by the nondominant hemisphere
when the lesion involves the convexity of the dominant hemisphere. Concomitant right hemiparesis and dysphasias, usually of the motor type, often occupy the
physician's attention so that the ideomotor dyspraxia of the nondominant limbs passes without notice. Dysphasia may make it impossible to determine whether
ideomotor dyspraxia is present, but, when mild, dyspraxia can be demonstrated by showing that patients cannot make movements on command, although they can
mimic the behavior demonstrated by the examiner and execute it spontaneously at other times. The disturbances are most apparent for movements that involve the
appendages (e.g., fingers, hands) or oropharynx. Axial and trunk movements are often spared.
AGNOSIA
When patients with a brain lesion respond to common environmental stimuli as if they had never encountered them previously, even though the primary neural
pathways of sensation function normally, this disorder is called an agnosia. Because the disturbance seen in response to a few stimuli is assumed to apply to others
with similar properties, agnosias embrace specific classes of stimuli (e.g., agnosia for colors) or more global disturbances for a form of sensation (e.g., visual or
auditory agnosia).
Such sweeping generalizations are usually unjustified in practice because careful examination often shows that the abnormality can be explained in some other way,
including genuine unfamiliarity with the stimuli, faulty discrimination due to poor lighting, poor instructions from the examiner, or an overlooked end-organ failure (e.g.,
peripheral neuropathy, otosclerosis, cataracts). Faulty performance may also result from a dysphasia or dyspraxia. Errors arising from a dysphasia are easily
understood; a dyspraxia may be more difficult to recognize. Sometimes, it is not clear whether dyspraxia produces agnosia, or vice versa. Posterior parietal lesions
arising from cardiac arrest, neoplasm, or infections may impair cerebral control of the precise eye movements involved in the practiced exploration of a picture or
other complex visual stimuli; the resulting chaotic but conjugate eye movements prevent the victim from naming or interacting properly with the stimuli. This
abnormality seems to be a form of cerebral blindness (which patients may deny) and is an essential element of Balint syndrome (biparietal lesions causing disordered
ocular tracking, bilateral hemineglect, and difficulties deciphering complex thematic pictures). Similar disturbances in skilled manual manipulation of objects may be
documented in anterior parietal lesions that interfere with the ability to name or use an object properly.
When all these variables have been taken into account, a small group of patients may remain for whom the term agnosia may apply. Some neurologists deny that
such a state exists, the errors presumably resulting from a combination of dementia and impaired primary sensory processing; others postulate anatomic
disconnections due to lesions that lie between intact language areas and intact cerebral regions responsible for processing sensory input.
Two claimed clinical subtypes of visual agnosia embrace these differing theories of agnosia: Apperceptive agnosia refers to abnormality in the discrimination process,
and associative agnosia implies an inability to link the fully discriminated stimulus to prior experience in naming or matching the stimulus to others. Clinically, patients
with apperceptive visual agnosia are said to fail tests of copying a stimulus or cross-matching a stimulus with others having the same properties (i.e., different views of
a car), whereas patients with the associative form can copy and cross-match; neither type can name the stimulus as such. Disturbances of the ability to respond to
stimuli have been described for colors ( color agnosia) and for faces (prosopagnosia). Although the definition of agnosia requires that a patient treat the stimuli as
unfamiliar, the errors often pass almost unnoticed (i.e., dark colors are misnamed for other dark colors; names of famous people are mismatched with their pictures).
In the auditory system, a similar disturbance may occur with a normal audiogram in discrimination of sounds (cortical deafness or auditory agnosia), including words
(pure word deafness or auditory agnosia for speech). A patient's inability to recognize familiar objects by touch while still being able to recognize them by sight is
referred to as tactile agnosia.
In practical clinical terms, the clinical diagnosis of agnosia warrants consideration when patients respond to familiar stimuli in an unusually unskillful manner, treat
them as unfamiliar, or misname them for other stimuli having similar hue, shape, or weight, but do not show other signs of dysphasia or dyspraxia in other tests. The
special testing is time-consuming but may yield a diagnosis of a disorder arising from lesions of the corpus callosum, the deep white matter, or the cerebrum adjacent
to the main sensory areas. The usual cause is atrophy or metastatic or primary tumor. When the disorder develops further, the more obvious defects occur in formal
confrontation visual field testing, and the agnosia is even more difficult to demonstrate.
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CHAPTER 3. SYNCOPE AND SEIZURE
MERRITTS NEUROLOGY
CHAPTER 3. SYNCOPE AND SEIZURE

TIMOTHY A. PEDLEY AND DEWEY K. ZIEGLER
Syncope
Seizures and Epilepsy
Suggested Readings
Unexplained loss of consciousness is a common clinical problem. Seizure and syncope usually figure high on the list of diagnostic possibilities. The distinction is
critical. This chapter considers clinical features that help discriminate among various causes of loss of consciousness and other episodic alterations in behavior and
responsiveness.
SYNCOPE
Syncope refers to the transient alteration of consciousness accompanied by loss of muscular tone that results from an acute, reversible global reduction in cerebral
blood flow. It is one of the most common causes of fading or complete loss of consciousness and accounts for about 3% of visits to emergency rooms. The prevalence
of syncope has been as high as 47% in surveys of college students or young military flying personnel, and is equally high or higher in the elderly. In all forms of
syncope, symptoms result from a sudden and critical decrease in cerebral perfusion. The causes of syncope are diverse ( Table 3.1), and there is no uniformly
satisfactory classification. Clinical features distinguish different types of syncope ( Table 3.2).
TABLE 3.1. CAUSES OF SYNCOPE
TABLE 3.2. DIFFERENTIAL DIAGNOSIS OF TYPES OF SYNCOPE
Although syncope is generally a benign condition, nearly one-third of persons who experience syncope sustain injuries, including fractures of the hip or limbs.
Additional morbidity may relate to the underlying cause of syncope.
Cardiovascular causes are most often encountered, although the exact mechanisms vary and include hypotension, arrhythmias, or direct cardiac inhibition ( Table
3.3). Direct cardiac inhibition is responsible for the common vasovagal forms of syncope; bradycardia and hypotension are abnormal responses arising from activation
of myocardial mechanoreceptors. Syncope can also occur when vasomotor tone is altered.
TABLE 3.3. CAUSES OF SYNCOPE
In reporting syncope, many patients say that they passed out or had a spell. Careful history taking, with attention to the meaning patients attach to words, is the
cornerstone of differentiating syncope from other conditions. Important differential points for syncope include precipitating stimuli or situations, the nature of the fall,
the character and evolution of prodromal symptoms, and the absence of any true postictal phase.
The following description is typical of most syncopal events. In the premonitory phase, the person feels light-headed and often apprehensive with a strong but
ill-defined sensation of malaise. Peripheral vasoconstriction imparts a pale or ashen appearance, and the pulse is rapid. Profuse sweating is often accompanied by
nausea and an urge to urinate or defecate. At this point, some individuals hyperventilate, which results in hypocapnia and further reduction in cerebral blood flow.
Vision blurs and characteristically fades or grays out before consciousness is lost, but no alterations or distortions suggest an epileptic aura; there are no visual or
olfactory hallucinations, or metamorphopsia. Response times slow, and the patient may feel detached or floating just before losing consciousness. Attacks usually
occur when the person is standing or sitting and may be aborted if one can lie down or at least lower the head below the level of the heart.
If the attack proceeds, the patient loses tone in the muscles of the legs and trunk as consciousness is lost, but the fall is more of a swoon or limp collapse. While
unconscious, the patient continues to be pale and sweaty; the limbs are flaccid. The period of unconsciousness is brief, lasting only seconds or a few minutes. If the
hypoxia associated with syncope is severe, brief tonic posturing of the trunk or a few clonic jerks of the arms and legs ( convulsive syncope) may be seen as the
episode ends. Although these involuntary movements may superficially suggest a seizure, the absence of a typical tonic-clonic sequence, the prompt recovery, and
other features of the attack lead to the correct diagnosis.
Pulse and blood pressure rapidly return to normal, and symptoms resolve promptly and completely if the patient is allowed to remain recumbent. Some patients feel
weak and are briefly confused on recovery; incontinence is rare.
Neurocardiogenic (Vasovagal) Syncope
This type of syncope most often occurs in adolescents and young adults and is especially common in individuals with some emotional lability. There is usually some
provoking stimulus, such as severe pain, apprehension of pain, or sudden emotional shock. A variety of background states, such as fasting, hot overcrowded rooms,
prolonged standing, and fatigue, may add to the likelihood of vasovagal syncope.
Carotid sinus syncope arises when the carotid sinus displays unusual sensitivity to normal pressure stimuli. In elderly patients, this sensitivity is probably related to
atherosclerosis of the carotid sinus region. Because the carotid sinus is abnormally sensitive even to slight pressure, syncope can be caused by a tight collar or
inadvertent pressure on the side of the neck. The result is direct cardiac inhibition with bradycardia and occasionally even cardiac arrest. If carotid sinus syndrome is
suspected, light massage of the neck area can be performed one side at a time as a diagnostic maneuver. This procedure should be done only by an experienced
clinician with electrocardiograph (ECG) monitoring and, preferably, electroencephalograph (EEG) recording, as well.
Syncope can occur after emptying a distended urinary bladder ( micturition syncope). This syndrome is confined to men and may be the result of both vagal stimuli and
orthostatic hypotension. It occurs especially after ingestion of excess fluid and alcohol.
Syncope after prolonged coughing ( tussive syncope) is usually seen in stocky individuals with chronic lung disease. In children with asthma, tussive syncope may
mimic epilepsy. Increased intrathoracic pressure may decrease cardiac output, and vagal stimuli presumably play a role. Syncope with weight lifting probably results
from similar mechanisms.
Vasomotor Syncope
A mild orthostatic fall in blood pressure often occurs in normal individuals without causing symptoms. However, syncope results when vascular reflexes that maintain
cerebral blood flow with upright posture are impaired. In the United States, prescribed drugs may be the most common cause, but susceptibility varies markedly from
one individual to the another. The frail and elderly are particularly vulnerable to this effect. Use of phenothiazines to control agitation in elderly patients often results in
hypotension, syncope, a fall, and hip fracture. Other agents frequently implicated in orthostatic hypotension include antihypertensive drugs, diuretics, arterial
vasodilators, levodopa, calcium channel blockers, tricyclic antidepressants, beta-blockers, and lithium. Orthostatic hypotension may also follow prolonged standing or
an illness that leads to prolonged bed rest. Conditions that cause debilitation or lower blood pressure, such as malnutrition, anemia, blood loss, or adrenal
insufficiency, also predispose to orthostatic hypotension.
Finally, several diseases of the central nervous system (CNS) or peripheral nervous system lead to failure of the vasomotor reflexes that are normally activated by
standing, and may cause orthostatic hypotension. These conditions include peripheral neuropathy, especially diabetic peripheral neuropathy; diseases that affect the
lateral columns of the spinal cord, such as syringomyelia; and multiple system atrophy, including the Shy-Drager syndrome.
Cardiac Syncope
Cardiac arrhythmias occur at all ages, but they are particularly frequent in the elderly. Attacks can be produced by many types of cardiac disease, and both
tachyarrhythmias and bradyarrhythmias can produce syncope. The most commonly diagnosed arrhythmias are atrioventricular and sinoatrial block, and paroxysmal
supraand infraventricular tachyarrhythmias. When cardiac arrhythmia is suspected, a chest x-ray and routine ECG should first be obtained. Frequently, however, the
resting ECG is normal, and thus longer periods of recording are then necessary. Minor and clinically insignificant disturbances in heart rhythm are common under
such circumstances, and firm diagnosis requires concurrence of typical syncopal symptoms with a recorded arrhythmia. For a select group of patients, exercise testing
and intracardiac electrophysiologic recordings may be necessary for diagnosis. Invasive electrophysiologic testing is also usually necessary when the conduction
disturbance must be localized precisely. Other cardiac conditions that can cause syncope include a failing myocardium from cardiomyopathy or multiple infarctions,
aortic and mitral stenosis, myxoma, congenital heart diseases, and pulmonary stenosis or emboli. Clues to a cardiac origin for syncope include attacks with little
relation to posture, position, or specific triggers, as well as frequent presyncopal symptoms. Patients are often aware of a chest sensation that is difficult to describe.
Syncope after exertion is typical of outflow obstruction. Finally, although cardiac syncope is usually of rapid onset, some tachyarrhythmias produce prolonged
premonitory symptoms. Diagnosis of a cardiac cause of syncope is especially important because the 5-year mortality rate can exceed 50% in this group of patients.
Treatment
Treatment must be based on accurate diagnosis of the underlying cause of syncope. Isolated syncopal episodes require no treatment other than reassurance.
Refractory vasovagal syncope, confirmed by tilt-table testing, responds best to beta-blockers, which suppress overactive cardiac mechanoreceptors. Disopyramide
phosphate (Norpace), an antiarrhythmic drug, may be an alternative for some patients. Anticholinergic drugs may be effective but are poorly tolerated, especially by
the elderly. In patients with orthostatic hypotension and autonomic insufficiency, initial measures should expand the intravascular volume by increasing fluid and salt
intake. Fludrocortisone acetate (Florinef Acetate) is a mineralocorticoid that can be a useful adjunct in volume expansion. It must be used with caution in patients at
risk for congestive heart failure. Compression stockings or other support garments may be required in more severe cases.
Episodic vertigo is a sudden violent sensation of movement, either of the self or the environment. The patient may interpret this as loss of consciousness. The
diagnostic problem is complicated by prominent autonomic symptoms, such as sweating, nausea, and, occasionally, light-headedness, that frequently accompany
vertiginous episodes. The critical element is the intensity of the vertigo.
Occasionally, transient loss of tone in the legs (e.g., in atonic seizures or with drop attacks) may be mistaken for syncope.
Transient ischemic attacks (TIAs) due to severe atherosclerotic disease of the vertebrobasilar system are a rare cause of loss of consciousness. Episodic ischemia of
the reticular formation of the brainstem is the presumptive cause. Vertebrobasilar TIAs causing loss of consciousness usually occur in patients who at other times
have additional manifestations of brainstem, cerebellar, or occipital lobe dysfunction (i.e., cranial nerve palsies, Babinski sign, ataxia, hemianopia, or cortical
blindness).
Hypoglycemia may cause feelings of faintness or dizziness, but only rarely with rapid loss of consciousness and rapid recovery. Characteristic of hypoglycemia are
states of impaired consciousness of varying degrees and altered behavior of insidious onset. Symptoms last from minutes to hours, and if the hypoglycemia is
prolonged or severe, generalized tonic-clonic seizures usually occur. Diagnosis depends on documenting profound hypoglycemia with the symptoms and reversing
them by intravenous injection of glucose. Borderline or mild degrees of hypoglycemia do not cause CNS dysfunction.
SEIZURES AND EPILEPSY
Many nonepileptic events may be mistaken for seizures, depending on patient age, the nature of the symptoms, and the circumstances of the attacks ( Table 3.4).
Syncope has been reviewed in the foregoing section, but additional points may be pertinent. Epileptic seizures, unlike syncope, are never consistently related to head
or body posture. In complex partial seizures, impaired or lost consciousness is usually accompanied by automatisms or other involuntary movements. Falls are
unusual, unless the seizure becomes generalized. Urinary incontinence and postictal confusion or lethargy are common with seizures; both are rare with syncope.
Likewise, warning feelings described as faintness or light-headedness are uncommon in seizures, and preictal diaphoresis is rare in contrast to the sequence of
events in syncope. Atonic seizures, which may be confused with syncope, most often occur in children and young adults and tend to be much more energetic, even
propulsive, than the fall experienced with syncope.
TABLE 3.4. DIFFERENTIAL DIAGNOSIS OF SEIZURES
A few generalizations about other disorders that can be confused with epilepsy are warranted.
Panic Attacks
Panic attacks and anxiety attacks with hyperventilation are often unrecognized by neurologists. In both conditions, symptoms may superficially mimic partial seizures
with affective or special sensory symptoms. In panic attacks, patients typically describe a suffocating sensation or lack of oxygen, racing heart beat or palpitations,
trembling or shaking, feelings of depersonalization or detachment, gastrointestinal discomfort, and fear, especially of dying or going crazy. Hyperventilation episodes
can be similar, and the overbreathing may not be obvious unless specifically considered. The most common complaints are dizziness, a sense of floating or levitation,
feelings of anxiety, epigastric or substernal discomfort, muscle twitching or spasms (tetany), flushing or chills, and sometimes feeling like my mind goes blank. If
sufficiently prolonged and intense, hyperventilation may result in syncope.
Psychogenic Seizures
In epilepsy-monitoring units, psychogenic seizures account for about 30% of admissions. Definite diagnosis of psychogenic seizures on the basis of historical data
alone is usually not possible. However, the diagnosis may be suggested by atypical attacks with consistent precipitating factors that include a strong emotional or
psychologic overlay, a history of child abuse or incest, and a personal or family history of psychiatric disease. Repeatedly normal interictal EEGs in the presence of
frequent and medically refractory seizures also raise the possibility of psychogenic seizures.
Violent flailing or thrashing of arms and legs, especially when movements are asynchronous or arrhythmic, and pelvic thrusting are widely considered to be signs of
hysteric seizures, but similar phenomena may be observed in complex partial seizures of frontal lobe origin. Preserved consciousness with sustained motor activity of
the arms and legs is rare in epilepsy. Even experienced observers cannot distinguish epileptic from psychogenic seizures more than 50% to 80% of the time. Thus, for
many patients, a secure diagnosis of psychogenic seizure can be made only by inpatient monitoring with simultaneous video-EEG recording. Careful analysis of the
patient's behavior during a typical attack and correlation of the behavior with time-locked EEG activity permit classification of most episodes ( Table 3.5).
TABLE 3.5. DISTINGUISHING FEATURES OF EPILEPTIC AND PSYCHOGENIC SEIZURES
The situation, however, may be more complicated because psychogenic seizures and epileptic seizures frequently coexist in the same patient. Therefore, recording
nonepileptic attacks in a patient with uncontrolled seizures does not, by itself, prove that all the patient's seizures are psychogenic. Before reaching a final conclusion
in these circumstances, one must verify with the patient and family that the recorded events are typical of the habitual and disabling seizures experienced at home.
Serum prolactin measurements may help classify a seizure as psychogenic or epileptic if the clinical behavior includes bilateral convulsive movements that last more
than 30 seconds, if the prolactin measurements are obtained within 15 minutes of the event and compared with interictal baseline levels drawn on a different day at
the same time, and if values are established for what constitutes a significant elevation.
Sleep Disorders
Some sleep disorders mimic seizures. In children, diagnostic difficulty is most often encountered with the parasomnias: sleep talking (somniloquy), somnambulism,
night terrors, and enuresis. Confusion with complex partial seizures arises because all these conditions are paroxysmal, may include automatic behavioral
mannerisms, and tend to be recurrent. In addition, the patient is usually unresponsive during the attacks and amnesic for them afterward. Parasomnias occur during
the period of deepest slow-wave sleep, especially just before or during the transition into the first rapid eye movement period. They tend to occur in the early part of
the night. Seizures are less predictable, although they tend to occur shortly after going to sleep or in the early morning hours. Finally, the pace of observed
movements in parasomnias is usually slow and trancelike; motor activity lacks the complex automatisms, stereotyped postures, and clonic movements typical of
epileptic seizures.
In adults, the automatic behavior syndrome may result in periods of altered mental function, awareness of lost time having elapsed, detached behavior that seems
out of touch with the environment, and amnesia. This syndrome is usually associated with excessive daytime sleepiness and is caused by repeated episodes of
microsleep that impair performance and vigilance. Attacks due to the automatic behavior syndrome lack an aura, a change in affect, oroalimentary automatisms, and a
postictal period. In addition, stimulation usually stops the episode, unlike an epileptic seizure.
Migraine
Some migraine events may be mistaken for seizures, especially when the headache is mild or inconspicuous. Basilar artery migraine may include episodic confusion
and disorientation, lethargy, mood changes, vertigo, ataxia, bilateral visual disturbances, and alterations in, or even loss of, consciousness. In children, migraine can
occur as a confusional state that resembles absence status or as paroxysms of cyclic vomiting with signs of vasomotor instability (flushing, pallor, mydriasis) and
photophobia.
Transient Ischemic Attack
TIAs are not usually confused with seizures. Diagnosis is occasionally difficult when a TIA is apparent only by dysphasia or disturbed sensation over part or all of one
side of the body, or when muscle weakness results in a fall. In general, focal sensory symptoms associated with epilepsy show sequential spread from one body area
to another, whereas ischemic paresthesias lack this segmental spread, instead developing simultaneously over affected areas. Absence of clonic motor activity and
confusion favor focal ischemia more than epilepsy. Furthermore, the negative nature of the predominant symptoms generally argue against epilepsy.
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Pritchard PB, Wannamaker BB, Sagel J, Daniel CM. Serum prolactin and cortisol levels in evaluation of pseudoepileptic seizures. Ann Neurol 1985;18:8789.
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1993;328:10851090.
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Sturzenegger MH, Meienberg O. Basilar artery migraine: a follow-up study in 82 cases. Headache 1985;25:408415.
CHAPTER 4. COMA
MERRITTS NEUROLOGY
CHAPTER 4. COMA
JOHN C.M. BRUST
Examination and Major Diagnostic Procedures

Coma from Supratentorial Structural Lesions
Coma from Infratentorial Structural Lesions
Coma from Metabolic or Diffuse Brain Disease
Hysteria and Catatonia
Locked-In Syndrome
Vegetative State
Brain Death
Suggested Readings
Consciousness, the awareness of self and environment, requires both arousal and mental content; the anatomic substrate includes both reticular activating system
and cerebral cortex. Coma is a state of unconsciousness that differs from syncope in being sustained and from sleep in being less easily reversed. Cerebral oxygen
uptake (cerebral metabolic rate of oxygen [CMRO 2]) is normal in sleep or actually increases during the rapid eye movement stage, but CMRO 2 is abnormally reduced
in coma.
Coma is clinically defined by the neurologic examination, especially responses to external stimuli. Terms such as lethargy, obtundation, stupor, and coma usually
depend on the patient's response to normal verbal stimuli, shouting, shaking, or pain. These terms are not rigidly defined, and it is useful to record both the response
and the stimulus that elicited it. Occasionally, the true level of consciousness may be difficult or impossible to determine (e.g., when there is catatonia, severe
depression, curarization, or akinesia plus aphasia).
Confusional state and delirium are terms that refer to a state of inattentiveness, altered mental content, and, sometimes, hyperactivity rather than to a decreased level
of arousal; these conditions may presage or alternate with obtundation, stupor, or coma.
EXAMINATION AND MAJOR DIAGNOSTIC PROCEDURES
In the assessment of a comatose patient, it is first necessary to detect and treat any immediately life-threatening condition: Hemorrhage is stopped; the airway is
protected, with intubation when necessary (including the prevention of aspiration in a patient who is vomiting); circulation is supported; and an electrocardiogram is
obtained to detect dangerous arrhythmia. If the diagnosis is unknown, blood is drawn for glucose determination, after which 50% dextrose is given intravenously with
parenteral thiamine. (Administering glucose alone to a thiamine-deficient patient may precipitate Wernicke-Korsakoff syndrome.) When opiate overdose is a
possibility, naloxone hydrochloride (Narcan) is given. If trauma is suspected, damage to internal organs and fracture of the neck should be taken into consideration
until radiographs determine otherwise.
The next step is to ascertain the site and cause of the lesion. The history is obtained from whoever accompanies the patient, including ambulance drivers and police.
Examination should include the following: skin, nails, and mucous membranes (for pallor, cherry redness, cyanosis, jaundice, sweating, uremic frost, myxedema,
hypo- or hyperpigmentation, petechiae, dehydration, decubiti, or signs of trauma); the breath (for acetone, alcohol, or fetor hepaticus); and the fundi (for papilledema,
hypertensive or diabetic retinopathy, retinal ischemia, Roth spots, granulomas, or subhyaloid hemorrhages). Fever may imply infection or heat stroke; hypothermia
may occur with cold exposure (especially in alcoholics), hypothyroidism, hypoglycemia, sepsis, or, infrequently, a primary brain lesion. Asymmetry of pulses may
suggest dissecting aneurysm. Urinary or fecal incontinence may signify an unwitnessed seizure, especially in patients who awaken spontaneously. The scalp should
be inspected and palpated for signs of trauma (e.g., Battle sign), and the ears and nose are examined for blood or cerebrospinal fluid (CSF). Resistance to passive
neck flexion but not to turning or tilting suggests meningitis, subarachnoid hemorrhage, or foramen magnum herniation, but may be absent early in the course of the
disorder and in patients who are deeply comatose. Resistance in all directions suggests bone or joint disease, including fracture.
In their classic monograph, Plum and Posner (1980) divided the causes of coma into supra- and infratentorial structural lesions and diffuse or metabolic diseases. By
concentrating on motor responses to stimuli, respiratory patterns, pupils, and eye movements, the clinician can usually identify the category of coma.
The patient is observed to assess respiration, limb position, and spontaneous movements. Myoclonus or seizures may be subtle (e.g., twitching of one or two fingers
or the corner of the mouth). More florid movements, such as facial grimacing, jaw gyrations, tongue protrusion, or complex repetitive limb movements, may defy ready
interpretation. Asymmetric movements or postures may signify either focal seizures or hemiparesis.
Asymmetry of muscle tone suggests a structural lesion, but it is not always clear which side is abnormal. Gegenhalten, or paratonia, is resistance to passive
movement that, in contrast to parkinsonian rigidity, increases with the velocity of the movement and, unlike clasp-knife spasticity, continues through the full range of
the movement; it is attributed to diffuse forebrain dysfunction and is often accompanied by a grasp reflex.
Motor responses to stimuli may be appropriate, inappropriate, or absent. Even when patients are not fully awake, they may be roused to follow simple commands.
Some patients who respond only to noxious stimuli (e.g., pressure on the sternum or supraorbital bone, pinching the neck or limbs, or squeezing muscle, tendon, or
nailbeds) may make voluntary avoidance responses. The terms decorticate and decerebrate posturing are physiologic misnomers but refer to hypertonic flexion or
extension in response to noxious stimuli. In decorticate rigidity, the arms are flexed, adducted, and internally rotated, and the legs are extended; in decerebrate rigidity,
the arms and legs are all extended. These postures are most often associated with cerebral hemisphere disease, including metabolic encephalopathy, but may follow
upper brainstem lesions or transtentorial herniation.
Flexor postures generally imply a more rostral lesion and have a better prognosis than extensor posturing, but the pattern of response may vary with different stimuli,
or there may be flexion of one arm and extension of the other. When these postures seem to occur spontaneously, there may be an unrecognized stimulus (e.g.,
airway obstruction or bladder distention). With continuing rostrocaudal deterioration, there may be extension of the arms and flexion of the legs until, with lower
brainstem destruction, there is flaccid unresponsiveness. However, lack of motor response to any stimulus should always raise the possibility of limb paralysis caused
by cervical trauma, Guillain-Barr& neuropathy, or the locked-in state.
Respiration
In Cheyne-Stokes respiration (CSR), periods of hyperventilation and apnea alternate in a crescendo-decrescendo fashion. The hyperpneic phase is usually longer
than the apneic, so that arterial gases tend to show respiratory alkalosis; during periods of apnea, there may be decreased responsiveness, miosis, and reduced
muscle tone. CSR occurs with bilateral cerebral disease, including impending transtentorial herniation, upper brainstem lesions, and metabolic encephalopathy. It
usually signifies that the patient is not in imminent danger. Conversely, short-cycle CSR ( cluster breathing) with less smooth waxing and waning is often an ominous
sign of a posterior fossa lesion or dangerously elevated intracranial pressure.
Sustained hyperventilation is usually due to metabolic acidosis, pulmonary congestion, hepatic encephalopathy, or stimulation by analgesic drugs ( Fig. 4.1). Rarely, it
is the result of a lesion in the rostral brainstem. Apneustic breathing, consisting of inspiratory pauses, is seen with pontine lesions, especially infarction; it occurs
infrequently with metabolic coma or transtentorial herniation.
FIG. 4.1. Cerebral herniation secondary to hemispheral infarction. Noncontrast axial CT demonstrates an extensive area of decreased density within the left frontal,
temporal, and parietal lobes with relative sparing of the left thalamus and left occipital lobe. A dense left middle cerebral artery is seen, consistent with thrombosis. A:
Obliteration of the suprasellar cistern by the medial left temporal lobe indicates uncal herniation. B: Left-to-right shift of the left frontal lobe, left caudate nucleus, and
left internal capsule denote severe subfalcine herniation. (Courtesy of Dr. S. Chan, Columbia University College of Physicians and Surgeons, New York, N.Y.)
Respiration having an variably irregular rate and amplitude ( ataxic or Biot breathing) indicates medullary damage and can progress to apnea, which also occurs
abruptly in acute posterior fossa lesions. Loss of automatic respiration with preserved voluntary breathing ( Ondine curse) occurs with medullary lesions; as the patient
becomes less alert, apnea can be fatal. Other ominous respiratory signs are end-expiratory pushing (e.g., coughing) and fish-mouthing (i.e., lower-jaw depression
with inspiration). Stertorous breathing (i.e., inspiratory noise) is a sign of airway obstruction.
Pupils
Pupillary abnormalities in coma may reflect an imbalance between input from the parasympathetic and sympathetic nervous systems or lesions of both. Although
many people have slight pupillary inequality, anisocoria should be considered pathologic in a comatose patient. Retinal or optic nerve damage does not cause
anisocoria, even though there is an afferent pupillary defect. Parasympathetic lesions (e.g., oculomotor nerve compression in uncal herniation or after rupture of an
internal carotid artery aneurysm) cause pupillary enlargement and ultimately full dilatation with loss of reactivity to light. Sympathetic lesions, either intraparenchymal
(e.g., hypothalamic injury or lateral medullary infarction) or extraparenchymal (e.g., invasion of the superior cervical ganglion by lung cancer), cause Horner syndrome
with miosis. With involvement of both systems (e.g., midbrain destruction), one or both pupils are in midposition and are unreactive. Pinpoint but reactive pupils
following pontine hemorrhage are probably the result of damage to descending intraaxial sympathetic pathways, as well as to a region of the reticular formation that
normally inhibits the Edinger-Westphal nucleus.
With few exceptions, metabolic disease does not cause unequal or unreactive pupils. Fixed, dilated pupils after diffuse anoxia-ischemia carry a bad prognosis.
Anticholinergic drugs, including glutethimide, amitriptyline, and antiparkinsonian agents, abolish pupillary reactivity. Hypothermia and severe barbiturate intoxication
can cause not only fixed pupils but a reversible picture that mimics brain death. Bilateral or unilateral pupillary dilatation and unreactivity can accompany (or briefly
follow) a seizure. In opiate overdose, miosis may be so severe that a very bright light and a magnifying glass are necessary to detect reactivity. Some pupillary
abnormalities are local in origin (e.g., trauma or synechiae).
Eyelids and Eye Movements
Closed eyelids in a comatose patient mean that the lower pons is intact, and blinking means that reticular activity is taking place; however, blinking can occur with or
without purposeful limb movements. Eyes that are conjugately deviated away from hemiparetic limbs indicate a destructive cerebral lesion on the side toward which
the eyes are directed. Eyes turned toward paretic limbs may mean a pontine lesion, an adversive seizure, or the wrong-way gaze paresis of thalamic hemorrhage.
Eyes that are dysconjugate while at rest may mean paresis of individual muscles, internuclear ophthalmoplegia, or preexisting tropia or phoria.
When the brainstem is intact, the eyes may rove irregularly from side to side with a slow, smooth velocity; jerky movements suggest saccades and relative
wakefulness. Repetitive smooth excursions of the eyes first to one side and then to the other, with 2- to 3-second pauses in each direction ( periodic alternating or
ping-pong gaze), may follow bilateral cerebral infarction or cerebellar hemorrhage with an intact brainstem.
If cervical injury has been ruled out, oculocephalic testing (the doll's-eye maneuver) is performed by passively turning the head from side to side; with an intact reflex
arc (vestibularbrainstemeye muscles), the eyes move conjugately in the opposite direction. A more vigorous stimulus is produced by irrigating each ear with 30 to
100 mL of ice water. A normal awake person with head elevated 30 degrees has nystagmus with the fast component in the direction opposite the ear stimulated, but a
comatose patient with an intact reflex arc has deviation of the eyes toward the stimulus, usually for several minutes. Simultaneous bilateral irrigation causes vertical
deviation, upward after warm water and downward after cold water.
Oculocephalic or caloric testing may reveal intact eye movements, gaze palsy, individual muscle paresis, internuclear ophthalmoplegia, or no response. Cerebral
gaze paresis can often be overcome by these maneuvers, but brainstem gaze palsies are usually fixed. Complete ophthalmoplegia may follow either extensive
brainstem damage or metabolic coma, but except for barbiturate or phenytoin sodium (Dilantin) poisoning, eye movements are preserved early in metabolic
encephalopathy. Unexplained dysconjugate eyes indicate a brainstem or cranial nerve lesion (including abducens palsy due to increased intracranial pressure).
Downward deviation of the eyes occurs with lesions in the thalamus or midbrain pretectum and may be accompanied by pupils that do not react to light ( Parinaud
syndrome). Downward eye deviation also occurs in metabolic coma, especially in barbiturate poisoning, and after a seizure. Skew deviation, or vertical divergence,
follows lesions of the cerebellum or brainstem, especially the pontine tegmentum.
Retraction and convergence nystagmus may be seen with midbrain lesions, but spontaneous nystagmus is rare in coma. Ocular bobbing (conjugate brisk downward
movements from the primary position) usually follows destructive lesions of the pontine tegmentum (when lateral eye movements are lost) but may occur with
cerebellar hemorrhage, metabolic encephalopathy, or transtentorial herniation. Unilateral bobbing (nystagmoid jerking) signifies pontine disease.
Tests
Computed tomography (CT) or magnetic resonance imaging (MRI) is promptly performed whenever coma is unexplained. Unless meningitis is suspected and the
patient is clinically deteriorating, imaging should precede lumbar puncture. If imaging is not readily available, a spinal tap is cautiously performed with a no.20 or
no.22 needle. If imaging reveals frank transtentorial or foramen magnum herniation, the comparative risks of performing a lumbar puncture or of treating for meningitis
without CSF confirmation must be weighed individually for each patient.
Other emergency laboratory studies include blood levels of glucose, sodium, calcium, and blood urea nitrogen (or creatinine); determination of arterial pH and partial
pressures of oxygen and carbon dioxide; and blood or urine toxicology testing (including blood levels of sedative drugs and ethanol). Blood and CSF should be
cultured, and liver function studies and other blood electrolyte levels determined. Coagulation studies and other metabolic tests are based on index of suspicion.
The electroencephalogram (EEG) can distinguish coma from psychic unresponsiveness or locked-in state, although alphalike activity in coma after brainstem
infarction or cardiopulmonary arrest may make the distinction difficult. In metabolic coma, the EEG is always abnormal, and early in the course, it may be a more
sensitive indicator of abnormality than the clinical state of the patient. The EEG may also reveal asymmetries or evidence of clinically unsuspected seizure activity.
Infrequently, patients without clinical seizures demonstrate repetitive electrographic seizures or continuous spike-and-wave activity; conversely, patients with subtle
motor manifestations of seizures sometimes display only diffuse electrographic slowing. Distinguishing true status epilepticus from myoclonus (common after
anoxic-ischemic brain damage) is often difficult, both clinically and electrographically; and if any doubt exists, anticonvulsant therapy should be instituted.
COMA FROM SUPRATENTORIAL STRUCTURAL LESIONS

Coma can result from bilateral cerebral damage or from sudden large unilateral lesions that functionally disrupt the contralateral hemisphere ( diaschisis). CT studies
indicate that with acute hemisphere masses, early depression of consciousness correlates more with lateral brain displacement than with transtentorial herniation.
Eventually, however, downward brain displacement and rostrocaudal brainstem dysfunction ensue. Transtentorial herniation is divided into lateral (uncal) or central
types. In uncal herniation (as in subdural hematoma), there is early compression of the oculomotor nerve by the inferomedial temporal lobe with ipsilateral pupillary
enlargement. Alertness may not be altered until the pupil is dilated, at which point there may be an acceleration of signs with unilaterally and then bilaterally fixed
pupils and oculomotor palsy, CSR followed by hyperventilation or ataxic breathing, flexor and then extensor posturing, and progressive unresponsiveness. Aqueductal
obstruction and posterior cerebral artery compression may further raise supratentorial pressure. If the process is not halted, there is progression to deep coma,
apnea, bilaterally unreactive pupils, ophthalmoplegia, and eventually circulatory collapse and death.
In central transtentorial herniation (as in thalamic hemorrhage), consciousness is rapidly impaired, pupils are of normal or small diameter and react to light, and eye
movements are normal. CSR, gegenhalten, and flexor or extensor postures are also seen. As the disorder progresses, the pupils become fixed in midposition, and this
is followed by the same sequence of unresponsiveness, ophthalmoplegia, and respiratory and postural abnormalities as seen in uncal herniation. During the
downward course of transtentorial herniation, there may be hemiparesis ipsilateral to the cerebral lesion, attributed to compression of the contralateral midbrain
peduncle against the tentorial edge ( Kernohan notch). The contralateral oculomotor nerve is occasionally compressed before the ipsilateral oculomotor nerve.
The major lesions causing transtentorial herniation are traumatic (epidural, subdural, or intraparenchymal hemorrhage), vascular (ischemic or hemorrhagic), infectious
(abscess or granuloma, including lesions associated with acquired immunodeficiency syndrome), and neoplastic (primary or metastatic). CT or MRI locates and often
defines the lesion.
COMA FROM INFRATENTORIAL STRUCTURAL LESIONS
Infratentorial structural lesions may compress or directly destroy the brainstem. Such lesions may also cause brain herniation, either transtentorially upward (with
midbrain compression) or downward through the foramen magnum, with distortion of the medulla by the cerebellar tonsils. Abrupt tonsillar herniation causes apnea
and circulatory collapse; coma is then secondary, for the medullary reticular formation has little direct role in arousal. In coma, primary infratentorial structural lesions
are suggested by bilateral weakness or sensory loss, crossed cranial nerve and long tract signs, miosis, loss of lateral gaze with preserved vertical eye movements,
dysconjugate gaze, ophthalmoplegia, short-cycle CSR, and apneustic or ataxic breathing. The clinical picture of pontine hemorrhage (i.e., sudden coma, pinpoint but
reactive pupils, and no eye movement) is characteristic, but if the sequence of signs in a comatose patient is unknown, it may not be possible without imaging to tell
whether the process began supratentorially or infratentorially. Infrequent brainstem causes of coma include multiple sclerosis and central pontine myelinolysis.
COMA FROM METABOLIC OR DIFFUSE BRAIN DISEASE
In metabolic, diffuse, or multifocal encephalopathy, mental and respiratory abnormalities occur early; there is often tremor, asterixis, or multifocal myoclonus.
Gegenhalten, frontal release signs (snout, suck, or grasp), and flexor or extensor posturing may occur. Except in anticholinergic intoxication, the pupils remain
reactive. The eyes may be deviated downward, but sustained lateral deviation or dysconjugate eyes argue against a metabolic disturbance. Metabolic disease,
however, can cause both focal seizures and lateralizing neurologic signs, often shifting but sometimes persisting (as in hypoglycemia and hyperglycemia).
Arterial gas determinations are especially useful in metabolic coma. Of the diseases listed in Table 4.1, psychogenic hyperventilation is more likely to cause delirium
than stupor, but may coexist with hysterical coma. Mental change associated with metabolic alkalosis is usually mild.
TABLE 4.1. CAUSES OF ABNORMAL VENTILATION IN UNRESPONSIVE PATIENTS
Metabolic and diffuse brain diseases causing coma are numerous but not unmanageably so. Most entities listed in Table 4.2 are described in other chapters.
TABLE 4.2. DIFFUSE BRAIN DISEASES OR METABOLIC DISORDERS THAT CAUSE COMA
HYSTERIA AND CATATONIA
Hysterical (conversion) unresponsiveness is rare and probably overdiagnosed. Indistinguishable clinically from malingering, it is usually associated with closed eyes,
eupnea or tachypnea, and normal pupils. The eyelids may resist passive opening and, when released, close abruptly or jerkily rather than with smooth descent; lightly
stroking the eyelashes causes lid fluttering. The eyes do not slowly rove but move with saccadic jerks, and ice-water caloric testing causes nystagmus rather than
sustained deviation. The limbs usually offer no resistance to passive movement yet demonstrate normal tone. Unless organic disease or drug effect is also present,
the EEG pattern is one of normal wakefulness.
In catatonia (which may occur with schizophrenia, depression, toxic psychosis, or other brain diseases), there may be akinetic mutism, grimacing, rigidity, posturing,
catalepsy, or excitement. Respirations are normal or rapid, pupils are large but reactive, and eye movements are normal. The EEG is usually normal.
LOCKED-IN SYNDROME
Infarction or central pontine myelinolysis may destroy the basis pontis, producing total paralysis of the lower cranial nerve and limb muscles with preserved alertness
and respiration. At first glance, the patient appears unresponsive, but examination reveals voluntary vertical and sometimes horizontal eye movements, including
blinking. (Even with facial paralysis, inhibition of the levator palpebrae can produce partial eye closure.) Communication is possible with blinking or eye movements to
indicate yes, no, or letters.
VEGETATIVE STATE
The terms akinetic mutism and coma vigil have been used to describe a variety of states, including coma with preserved eye movements following midbrain lesions,
psychomotor bradykinesia with frontal lobe disease, and isolated diencephalic and brainstem function after massive cerebral damage. For this last condition, the term
vegetative state is preferred to refer to patients with sleepwake cycles, intact cardiorespiratory function, and primitive responses to stimuli, but without evidence of
inner or outer awareness (Table 4.3). Patients who survive coma usually show varying degrees of recovery within 2 to 4 weeks; those who enter the vegetative state
may recover further, even fully. Persistent vegetative state is defined as a vegetative state present for at least 1 month. Although further improvement is then unlikely,
anecdotal reports exist of recovery after many months. The technologic feasibility of indefinitely prolonging life without consciousness has generated considerable
ethical debate.
TABLE 4.3. CRITERIA FOR DETERMINATION OF VEGETATIVE STATE
BRAIN DEATH
Unlike vegetative state, in which the brainstem is intact, the term brain death means that neither the cerebrum nor the brainstem is functioning. The only spontaneous
activity is cardiovascular, apnea persists in the presence of hypercarbia sufficient for respiratory drive, and the only reflexes present are those mediated by the spinal
cord (Table 4.4). In adults, brain death rarely lasts more than a few days and is always followed by circulatory collapse. In the United States, brain death is equated
with legal death. When criteria are met, artificial ventilation and blood pressure support are appropriately discontinued, whether or not organ harvesting is intended.
TABLE 4.4. CRITERIA FOR DETERMINATION OF BRAIN DEATH
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Multi-society Task Force on PVS. Medical aspects of the persistent vegetative state. N Engl J Med 1994;330:14991508, 15721579.
Payne K, Taylor RM, Stocking C, et al. Physicians' attitudes about the care of patients in the persistent vegetative state: a national survey. Ann Intern Med 1996;125:104110.
Plum F, Posner JB. The diagnosis of stupor and coma, 3rd ed. Philadelphia: FA Davis Co, 1980.
Ropper AH. Lateral displacement of the brain and level of consciousness in patients with an acute hemispheral mass. N Engl J Med 1986;314: 953958.
CHAPTER 5. DIAGNOSIS OF PAIN AND PARESTHESIAS
MERRITTS NEUROLOGY
CHAPTER 5. DIAGNOSIS OF PAIN AND PARESTHESIAS

LEWIS P. ROWLAND
Neck Pain
Low Back Pain
Arm Pain
Leg Pain and Paresthesias
Suggested Readings
All pain sensations are carried by nerves and therefore concern neurology; however, not all pain is relevant to neurologic diagnosis. The pain of any traumatic lesion
is a separate concern. Except for attacks of herpes zoster or diabetic radiculopathy, pain in the thorax or abdomen almost always implies a visceral disorder rather
than one of the spinal cord or nerve roots. Headache and other head pains, in contrast, are a major neurologic concern (see Chapter 8) and Chapter 139). This
chapter considers pain in the neck, low back, and limbs.
Pain syndromes often include another sensory aberration, paresthesia, a spontaneous and abnormal sensation. The problem may arise from an abnormality
anywhere along the sensory pathway from the peripheral nerves to the sensory cortex. A paresthesia is often described as a pins-and-needles sensation and is
recognizable by anyone who has ever had an injection of local anesthetic for dental repairs. Central nervous system disorders may cause particular kinds of
paresthesias: focal sensory seizures with cortical lesions, spontaneous pain in the thalamic syndrome, or bursts of paresthesias down the back or into the arms on
flexing the neck (Lhermitte symptoms) in patients with multiple sclerosis or other disorders of the cervical spinal cord. Level lesions of the spinal cord may cause
either a band sensation or a girdle sensation, a vague sense of awareness of altered sensation encircling the abdomen, or there may be a sensory level (i.e., altered
sensation below the level of the spinal cord lesion). Nerve root lesions or isolated peripheral nerve lesions may also cause paresthesias, but the most intense and
annoying paresthesia encountered is due to multiple symmetric peripheral neuropathy (polyneuropathy). Dysesthesia is the term for the disagreeably abnormal
sensations evoked when an area of abnormal sensation is touched; sometimes even the pressure of bedclothes cannot be tolerated by a patient with dysesthesia.
Beginning students are often confused by reports of paresthesias when the review of systems is recorded, or when they find abnormalities in the sensory examination
that do not conform to normal anatomic patterns. Two general rules may help:
1. If paresthesias do not persist, they are likely to imply a neurologic lesion. (Pressure on a nerve commonly causes transient paresthesias in normal people who
cross their legs, sit too long on a toilet seat, drape an arm over the back of a chair, or lean on one elbow while holding a newspaper in that hand. Many people
have fleeting paresthesias of unknown cause and no significance.)
2. If paresthesias persist and the examiner fails to find a corresponding abnormality to explain it, the patient should be reexamined. Persistent paresthesias reliably
imply an abnormality of sensory pathways.
NECK PAIN
Most chronic neck pain is caused by bony abnormalities (cervical osteoarthritis or other forms of arthritis) or by local trauma. If pain remains local (i.e., not radiating
into the arms), it is rarely of neurologic significance unless there are abnormal neurologic signs. It may be possible to demonstrate overactive tendon reflexes, clonus,
or Babinski signs in a patient who has no symptoms other than neck pain. These signs could be evidence of compression of the cervical spinal cord and might be an
indication for cervical magnetic resonance imaging (MRI) or myelography to determine whether the offending lesion is some form of arthritis, tumor, or a congenital
malformation of the cervical spine; however, neck pain is rarely encountered as the only symptom of a compressive lesion.
Neck pain of neurologic significance is more commonly accompanied by other symptoms and signs, depending on the location of the lesion: Radicular distribution of
pain is denoted by radiation down the medial (ulnar) or lateral (radial) aspect of the arm, sometimes down to the corresponding fingers. Cutaneous sensation is
altered within the area innervated by the compromised root, or below the level of spinal end compression. The motor disorder may be evident by weakness and
wasting of hand muscles innervated by the affected root, and the gait may be abnormal if there are corticospinal signs of cervical spinal cord compression. When
autonomic fibers in the spinal cord are compromised, abnormal urinary frequency, urgency, or incontinence may occur, there may be bowel symptoms, and men may
note sexual dysfunction. Reflex changes may be noted by the loss of tendon reflexes in the arms and overactive reflexes in the legs. Cervical pain of neurologic
significance may be affected by movement of the head and neck, and it may be exaggerated by natural Valsalva maneuvers in coughing, sneezing, or straining during
bowel movements.
Cervical spondylosis is a more common cause of neck pain than is spinal cord tumor, but it is probably not possible to make the diagnostic distinction without MRI or
myelography because the pain may be similar in the two conditions. In young patients (i.e., younger than 40 years), tumors, spinal arteriovenous malformations, and
congenital anomalies of the cervicooccipital region are more common causes of neck pain than cervical spondylosis.
LOW BACK PAIN
The most common cause of low back pain is herniated nucleus pulposus, but it is difficult to determine the exact frequency because acute attacks usually clear
spontaneously and chronic low back pain is colored by psychologic factors. The pain of an acute herniation of a lumbar disc is characteristically abrupt in onset and
brought on by heavy lifting, twisting, or Valsalva maneuvers (sneezing, coughing, or straining during bowel movements). The patient may not be able to stand erect
because paraspinal muscles contract so vigorously, yet the pain may be relieved as soon as the patient lies down, only to return again on any attempt to stand. The
pain may be restricted to the low back or may radiate into one or both buttocks or down the posterior aspect of the leg to the thigh, knee, or foot. The distribution of
pain sometimes gives a precise delineation of the nerve root involved, but this is probably true in only a minority of cases. The pain of an acute lumbar disc herniation
is so stereotyped that the diagnosis can be made even if there are no reflex, motor, or sensory changes.
Chronic low back pain is a different matter. If neurologic abnormalities are present on examination, MRI or myelography is often indicated to determine whether the
problem is caused by tumor, lumbar spondylosis with or without spinal stenosis, or arachnoiditis. If there are no neurologic abnormalities or if the patient has already
had a laminectomy, chronic low back pain may pose a diagnostic and therapeutic dilemma. This major public health problem accounts for many of the patients who
enroll in pain clinics.
ARM PAIN
Pain in the arms takes on a different significance when there is no neck pain. Local pain arises from musculoskeletal diseases (e.g., bursitis or arthritis), which are
now common because of widespread participation in sports by people who are not properly prepared.
Chronic pain may arise from invasion of the brachial plexus by tumors that extend directly from lung or breast tissue or that metastasize from more remote areas. The
brachial plexus may also be affected by a transient illness (e.g., brachial plexus neuritis) that includes pain in the arm that is often poorly localized. The combination of
pain, weakness, and wasting has given rise to the name neuralgic amyotrophy. (Amyotrophy is taken from Greek words meaning loss of nourishment to muscles; in
practice, it implies the wasting of muscle that follows denervation.)
Thoracic outlet syndromes are another cause of arm pain that originates in the brachial plexus. The pain of a true thoracic outlet syndrome is usually brought on by
particular positions of the arm and is a cause of diagnostic vexation because there may be no abnormality on examination (see Chapter 69). In a true thoracic outlet
syndrome, the neurologic problems are often caused by compressed and distended blood vessels that in turn secondarily compress nerves or lead to ischemia of
nerves.
Single nerves may be involved in entrapment neuropathies that cause pain in the hands. Carpal tunnel syndrome of the median nerve is the best known entrapment
neuropathy. The ulnar nerve is most commonly affected at the elbow but may be subject to compression at the wrist. The paresthesias of entrapment neuropathies are
restricted to the distribution of the affected nerve and differ from the paresthesias of areas innervated by nerve roots, although the distinction may be difficult to make
if only a portion of the area supplied by a particular nerve root is affected.
Causalgia (see Chapter 70) is the name given to a constant burning pain accompanied by trophic changes that include red glossy skin, sweating in the affected area,
and abnormalities of hair and nails. The trophic changes are attributed to an autonomic disorder. Causalgia was described in the 19th century in a monograph by
Mitchell, Morehouse, and Keen when they reviewed gunshot wounds and other nerve injuries of American Civil War veterans. The basic mechanisms of causalgia are
still poorly understood. The traumatic lesions of peripheral nerves are usually incomplete, and several nerves are often involved simultaneously. Causalgia usually
follows high-velocity missile wound (bullets or shrapnel). It is less commonly caused by traction injury and is only rarely seen in inflammatory neuropathy or other
types of peripheral nerve disease. The arms are more often involved than the legs, and the lesions are usually above the elbow or below the knee. Symptoms usually
begin within the first few days following injury. Causalgic pain most often involves the hand. The shiny red skin, accompanied by fixed joints, is followed by
osteoporosis. Both physical and emotional factors seem to play a role. Causalgia may be relieved by sympathectomy early in the course of treatment and may be due
to ephaptic transmission through connections between efferent autonomic fibers at the site of partial nerve injury. This concept of artificial synapses after nerve injury
has been widely accepted; however, there has been no convincing anatomic or physiologic corroboration.
Reflex sympathetic dystrophy refers to local tissue swelling and bony changes that accompany causalgia. Similar changes may be encountered after minor trauma or
arthritis of the wrist. In the shoulderhand syndrome, inflammatory arthritis of the shoulder joint may be followed by painful swelling of the hand, with local vascular
changes, disuse, and atrophy of muscle and bone. Sympathectomy has been recommended.
A major problem in the management of causalgic syndromes is the lack of properly controlled comparison of placebo with sympathetic blockade, as well as the
difficulty in evaluating psychogenic factors and the confusion caused by incomplete syndromes (with or without preceding trauma, with or without attendant vascular
abnormalities, and with or without response to sympathetic block).
LEG PAIN AND PARESTHESIAS
Leg pain due to occlusive vascular disease, especially with diabetes, varies markedly in different series but seems to be related to the duration of the diabetes and
shows increasing incidence with age. Pain may be a major symptom of diabetic peripheral neuropathy of the multiple symmetric type. Diabetic mononeuritis multiplex,
attributed to infarcts of the lumbosacral plexus or a peripheral nerve, is a cause of more restricted pain, usually of abrupt onset. Diabetic mononeuropathy may be
disabling and alarming at the onset, but both pain and motor findings improve in a few months to 1 or 2 years. Nutritional neuropathy is an important cause of limb
pain, especially in the legs, in some parts of the world. This condition was striking in prisoner-of-war camps in World War II and has also been noted in patients on
hemodialysis. Sudden fluid shifts may cause peripheral nerve disease symptoms for a time after dialysis.
Barring intraspinal disease, the most common neurologic cause of leg pain and paresthesias is probably multiple symmetric peripheral neuropathy. The paresthesias
usually take on a glove-and-stocking distribution, presumably because the nerve fibers most remote from the perikaryon are most vulnerable. The feet are usually
affected, sometimes alone or sometimes with the hands; the hands are rarely affected alone. Mixed sensorimotor neuropathies show motor abnormalities with
weakness and wasting, as well as loss of tendon reflexes. Some neuropathies are purely sensory. Pain is characteristic of severe diabetic neuropathy, alcoholic
neuropathy, amyloid neuropathy, and some carcinomatous neuropathies, but it is uncommon in inherited neuropathies or the Guillain-Barr syndrome. The pain of
peripheral neuropathy, for unknown reasons, is likely to be more severe at night.
Entrapment neuropathy rarely affects the legs; however, diabetic mononeuropathy, especially femoral neuropathy, may cause pain of restricted distribution and abrupt
onset, with later improvement of the condition that may take months.
Another major cause of leg pain is invasion of the lumbosacral plexus by tumor, but this is rarely an isolated event and other signs of the tumor are usually evident.
The problem of distinguishing between spinal and vascular claudication is discussed in Chapter 67.
Limb pain and paresthesias are important in neurologic diagnosis not only because they persist for prolonged periods. They also become the object of symptomatic
therapy by analgesics, tricyclic antidepressant drugs, and monoamine oxidase inhibitors (which may affect abnormal sensations by actions other than antidepressant
effects), transcutaneous nerve stimulation, dorsal column stimulation, cordotomy, acupuncture, and other procedures. The long list of remedies attests to the
limitations of each. Psychologic factors cannot be ignored in chronic pain problems.
SUGGESTED READINGS
Bowsher D. Neurogenic pain syndromes and their management. Br Med Bull 1991;19:644646.
Chapman CR, Foley KM. Current and emerging issues in cancer pain: research and practice. New York: Raven Press, 1993.
Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992;268:760765.
Dotson RM. Causalgiareflex sympathetic dystrophysympathetically maintained pain: myth and reality. Muscle Nerve 1993;16:10491055.
Fields HL, ed. Pain syndromes in neurology. London: Butterworth, 1990.
Fields HL. Pain mechanisms and management. New York: McGraw-Hill, 1999.
Frank A. Low back pain. BMJ 1993;306:901909.
Frymoyer JW. Back pain and sciatica. N Engl J Med 1988;318:291300.
Hanks GW, Justins DM. Cancer pain: management. Lancet 1992;339: 10311036.
Haerer AF. DeJong's the neurologic examination, 3rd ed. Philadelphia: JB Lippincott Co, 1992.
Illis LS. Central pain: much can be offered from a methodical approach. BMJ 1993;300:12841286.
Livingston WK; Fields HL, ed. Pain and suffering. Seattle, WA: IASP Press, 1998.
Mitchell SW, Morehouse GR, Keen WW. Gunshot wounds and other injuries of nerves. Philadelphia: JB Lippincott, 1864.
Payne R, Patt RB, Hill S, eds. Assessment and treatment of cancer pain. Seattle, WA: IASP Press, 1998.
Pither CE. Treatment of persistent pain. BMJ 1989;299:12391240.
Schwartzman RJ, Maleki J. Postinjury neuropathic pain syndromes. Med Clin North Am 1999;83:597626.
Wall PD, Melzack R, eds. Textbook of pain, 3rd ed. Edinburgh: Churchill Livingstone, 1994.
Woolf CJ, Mannion RJ. Neuropathic pain: aetiology, symptoms, mechanisms, and management. Lancet 1999;353:19591964.
CHAPTER 6. DIZZINESS AND HEARING LOSS
MERRITTS NEUROLOGY
CHAPTER 6. DIZZINESS AND HEARING LOSS

JACK J.WAZEN
Tinnitus
Hearing Loss
Dizziness
Common Causes of Dizziness and Hearing Loss
Taking the History
Conclusion
Suggested Readings
The peripheral auditory system is composed of the outer ear, the middle ear, the inner ear (cochlea and vestibular system), and the eighth cranial nerve. Lesions of
these structures cause three major symptoms: hearing loss, vertigo, and tinnitus. Vertigo usually implies a lesion of the inner ear or the vestibular portion of the eighth
nerve. Tinnitus and hearing loss may arise from lesions anywhere in the peripheral or central auditory pathways.
TINNITUS
Tinnitus is an auditory sensation that arises within the head and is perceived in one or both ears, or inside the head. The sound may be continuous, intermittent, or
pulsatile. Tinnitus should be divided into objective tinnitus, heard by the examiner as well as the patient, or subjective tinnitus, heard only by the patient. Objective
tinnitus is uncommon, but it is associated with several serious conditions that mandate early diagnosis.
Objective Tinnitus
This condition results from intravascular turbulence, increased blood flow, or movement in the eustachian tube, soft palate, or temporomandibular joint. Bruits due to
vascular turbulence may arise from aortic stenosis, carotid stenosis, arteriovenous malformations of the head and neck, vascular tumors (e.g., glomus jugulare), or
aneurysms of the abdomen, chest, head, or neck. A continuous hum may result from asymmetric enlargement of the sigmoid sinus and the jugular vein. Pulsatile
objective tinnitus may result from high blood pressure, hyperthyroidism, or increased intracranial pressure. As part of the diagnostic evaluation of objective tinnitus,
the stethoscope should be used for auscultation of the ear, head, and neck in all patients who note noises in the head or ear. Anyone with pulsatile tinnitus should
also have blood pressure and funduscopic evaluation.
Subjective Tinnitus
Unless of brief duration, subjective tinnitus results from damage or abnormality somewhere in the auditory system. The abnormality can be in the external ear, middle
ear, inner ear, eighth cranial nerve, or central auditory connections. Tinnitus may be an early warning signal, such as pain arising from a lesion in or near a sensory
peripheral nerve. For example, tinnitus after exposure to loud noise is due to cochlear injury, usually resulting in a temporary shift of the threshold in hearing
sensitivity. Repeated exposure to noise may result in permanent cochlear damage and permanent hearing loss. Unilateral tinnitus is an early symptom of acoustic
neuroma, often years before there is overt loss of hearing or unsteadiness of gait. Persistent tinnitus therefore requires otologic evaluation, including hearing tests.
The basic hearing tests for evaluation of patients with tinnitus comprise pure tone and speech audiometry, as well as middle ear impedance measures, including
tympanometry and measurement of the threshold and decay of the stapedial reflex. Auditory evoked potentials are often necessary, even in the absence of a
significant difference in the hearing thresholds. Auditory evoked potentials, however, do not replace conventional audiometry and must be interpreted in light of the
audiogram. These tests help localized the site of the lesion.
HEARING LOSS
Hearing loss can be divided into two anatomic types on the basis of the site of the lesion: conductive and sensorineural. Conductive hearing loss is due to middle ear
disease. Sensorineural hearing loss is most often due to a lesion in the cochlea or the cochlear nerve. It rarely results from central auditory dysfunctions.
Conductive Hearing Loss
This type of hearing loss results from conditions in the external or middle ear that interfere with movement of the oval or round window. Patients with conductive
hearing loss speak with a soft voice or with normal loudness because to them their own voices sound louder than background sounds in the environment. External ear
or middle ear abnormalities are usually evident on physical examination, except when there is ossicular fixation (e.g., with otosclerosis), ossicular discontinuity from
trauma, or erosion from chronic otitis media with or without cholesteatoma. In tuning-fork tests, best carried out with a 256- or 512-Hz tuning fork, sound conveyed by
bone conduction is as loud as or louder than air conduction (negative Rinne test). In contrast, sound conveyed by air conduction is perceived as louder than bone
conduction sound in patients with normal hearing or with sensorineural hearing loss. In conductive hearing loss, a tuning fork placed at midline of the forehead is
heard louder in the ear on the side of the hearing loss (Weber test lateralizes to the abnormal side).
The diagnosis of conductive hearing loss can be confirmed by testing middle ear impedance, which measures the resistance of the middle ear to the passage of
sound and can differentiate ossicular discontinuity from stiffness or mass effects that interfere with movement of the oval window. The severity of hearing loss and the
conductive component should be assessed by audiometry, which determines sound conduction by air and bone. Conductive hearing loss most commonly affects
children and is usually due to otitis media with effusion. Conductive hearing loss should be treated vigorously in children because persistent hearing loss, even if
slight, may interfere with speech and cognitive development. Chronic forms of conductive hearing loss can usually be restored to functional levels of hearing by
reconstructive microsurgery. Hearing aids are also effective in rehabilitating patients with conductive hearing loss.
Sensorineural Hearing Loss
This condition is due to defects in the cochlea, cochlear nerve, or the brainstem and cortical connections. Patients with sensorineural hearing loss tend to speak with
a loud voice. Findings on physical examination are normal. Tuning-fork tests show that air conduction exceeds bone conduction (positive Rinne test); in the Weber
test, the tuning fork seems louder in the better ear.
Patients with sensorineural hearing loss require a battery of audiometric tests to determine the site of the abnormality. Patients with cochlear damage may show
low-frequency hearing loss, a flat audiometric configuration, or, more commonly, high-frequency hearing loss. The main causes are excessive exposure to noise,
ototoxic drugs, age-related cochlear degeneration, congenital cochlear defects, and viral or bacterial infections. Speech discrimination remains relatively preserved,
compared to the extent of pure-tone hearing loss. The stapedial reflex threshold, as determined by impedance measurements, is present at reduced sensation levels;
that pattern implies recruitment, an abnormal increase in the subjective sensation of loudness as the amplitude of the test sounds increases above the threshold.
Brainstem auditory evoked responses show a delay in the first brainstem wave, but a normal or shortened interpeak latency.
Patients with damage to the cochlear nerve, such as the neural form of presbycusis or compression of the nerve by an acoustic neuroma, usually show high-frequency
hearing loss, as do patients with cochlear lesions. In nerve lesions, however, speech discrimination tends to be more severely affected than pure-tone hearing loss.
The stapedial reflex either is absent or shows abnormal adaptation or decay. The test is carried out as part of impedance audiometry and is useful in determining the
site of the lesion. Stapedial reflex threshold and decay, along with tympanometry, must be considered part of the diagnostic workup for all patients with asymmetric
sensorineural hearing loss. Brainstem auditory evoked response testing in neural forms of hearing loss shows no waves at all, poorly formed waves, or normal or
increased interpeak latency, either absolute or in comparison with the opposite ear.
Central lesions, such as recurrent small strokes or multiple sclerosis, often cause no detectable pure-tone hearing loss because the central auditory pathways are
bilateral. Some patients, however, do note hearing loss. For them, hearing should be evaluated by brainstem auditory evoked response testing, which may show
bilateral conduction delay despite normal pure-tone hearing. Central auditory testing may show abnormalities.
Most patients with sensorineural hearing loss can be helped by amplification; hearing aids are becoming smaller and more effective. The narrow range between
speech and noise is being ameliorated by improved microcircuitry. The latest in hearing aid technology, including digital and programmable devices, allows
individuals to change the hearing aid parameters under different acoustical conditions for better hearing, particularly in noisy backgrounds. Patients with profound
bilateral sensorineural hearing loss not responding to hearing aids may be candidates for a cochlear implant.
DIZZINESS
Complaints of dizziness must be separated into three different categories: vertigo, disequilibrium, and dizziness. Vertigo is a hallucination of movement involving the
patient or the environment. Vertigo often implies a spinning sensation but may also be experienced as a feeling of swaying back and forth or falling. All such
characteristics are most often related to a peripheral vestibular lesion. Vertigo of peripheral origin is usually episodic, with normal periods between spells. It is
accompanied by horizontal or rotatory-horizontal nystagmus with nausea and vomiting. Disequilibrium or ataxia is a feeling of unsteadiness on walking. Patients may
feel normal when they are stationary, but they notice difficulty in walking. Often, they have no symptoms of vertigo or dizziness. Disequilibrium suggests a central
lesion. Patients with severe bilateral peripheral vestibular dysfunction may also note unsteady gait and oscillopsia, the symptom of nystagmus in which objects seem
to be jumping from side to side or up and down while the patient is walking. Dizziness without spinning or disequilibrium is difficult for patients to describe. They
mention light-headedness, sensations of swimming and floating, or giddiness. These symptoms have no localizing value and may be due to circulatory, metabolic,
endocrine, degenerative, or psychologic factors. Peripheral vestibular and central lesions must be ruled out.
The sense of equilibrium and position in space is an integrated function of multiple peripheral sensory inputs into the brain, including the visual, vestibular, and
proprioceptive systems. The vestibular system plays a dual role, responding to gravity and linear acceleration through the utricle and saccule, and to angular
acceleration through the semicircular canals. If insufficient or conflicting information is presented to the central nervous system, different degrees of dizziness result.
Spinning vertigo, associated with nystagmus, nausea, and vomiting and aggravated by head and body movement, suggests a peripheral vestibular lesion, especially if
it is episodic and recurrent. Other symptoms suggesting a peripheral origin of these symptoms are accompanying hearing loss or tinnitus.
COMMON CAUSES OF DIZZINESS AND HEARING LOSS
Benign Positional Paroxysmal Vertigo
This condition is characterized by recurrent momentary episodes of vertigo that are brought on by changing head position, mainly with extension of the neck, by
rolling over in bed from side to side, by rising from bed, or by bending down. The vertigo starts after a latency of a few seconds after the stimulating position is
assumed. Vertigo builds to a peak before it subsides, usually lasting less than 1 minute. It is associated with rotatory nystagmus, beating toward the floor if the patient
is lying down with the head turned toward the offending ear. As the patient sits up or turns to a neutral position, a few beats of nystagmus are experienced, with the
rapid phase toward the opposite side. These symptoms can be re-produced in the office by positional testing. The patient is asked to lie down quickly from a sitting
position, with the head extended and turned all the way to one side. Benign paroxysmal vertigo is fatigable. Repeating the positional test abolishes the response.
Known causes of the syndrome include head trauma, labyrinthitis, and aging. Histologic sections of temporal bones from affected patients have shown otoconia in the
posterior semicircular canal ampulla. These calcium carbonate crystals are normally found in the utricle and the saccule; they are thought to have been dislodged into
the posterior canal and consequently to stimulate the vertigo, thus the term cupulolithiasis.
The natural history of benign positional vertigo is spontaneous resolution. Most patients are free of symptoms within a few weeks or months. Symptoms can be
abolished by a variety of positioning exercises, the most successful and frequently performed being the Epley maneuver. Labyrinthine suppressants, such as
meclizine hydrochloride (Antivert) and diazepam, may reduce the intensity of the vertigo. Avoiding the offending position is highly effective in avoiding the symptoms.
If disabling positional vertigo persists for more than 1 year despite multiple maneuvers and conservative medical management, section of the posterior ampullary
nerve (singular neurectomy) through a middle ear approach often abolishes the vertigo while preserving hearing. Another highly successful procedure is obliteration
of the posterior semicircular canal through a transmastoid approach. Hearing and the remainder of the vestibular function are preserved through either procedure.
The syndrome must be differentiated from other positional vertigo conditions ( Table 6.1). Otologic evaluation with audiologic and vestibular testing may be necessary
for final diagnosis.
TABLE 6.1. DIFFERENTIATION BETWEEN PERIPHERAL AND CENTRAL PAROXYSMAL POSITIONAL NYSTAGMUS
Vestibular Neuronitis
In this condition, vertigo occurs suddenly and severely with vomiting and nystagmus; it may last several days. There are no cochlear symptoms, and audiologic tests
are normal. Caloric tests show a reduced response on the affected side. The patient may feel unsteady for several weeks after an attack. Recurring attacks usually
seem less severe than the first and may continue for several months. The syndrome results from a sudden loss of function of one vestibular system; it is analogous to
sudden loss of hearing. Vestibular neuronitis may follow an overt viral illness. In most cases, however, the cause is unknown. A brief course of vestibular
suppressants followed by encouragement of physical activity may shorten the duration of disability by enhancing vestibular compensation.
Meniere Syndrome
This illness is characterized by recurrent attacks of tinnitus, hearing loss, and vertigo accompanied by a sense of pressure in the ear, distortion of sounds, and
sensitivity to noise. All the symptoms may not occur at the same time in the same spell. Hearing loss or vertigo may even be absent for several years. Symptoms
occur in clusters with variable periods of remission that may last for several years. Major attacks of vertigo with nausea and vomiting last from a few minutes to many
hours and may force cessation of all usual activities. Minor spells are characterized by unsteadiness, giddiness, or light-headedness. Hearing loss begins as a
low-frequency cochlear type of hearing loss that improves between attacks. In severe cases, hearing loss becomes slowly progressive and persistent, with a flat
configuration on the audiogram. Symptoms are usually unilateral but become bilateral in 20% to 30% of patients with long-term follow-up. The pathogenesis is
unknown.
A typical histopathologic feature of Meniere syndrome, endolymphatic hydrops, consists of an increase in the endolymphatic fluid pressure and volume with ballooning
of the cochlear duct, utricle, and saccule. As in other conditions characterized by increased extracellular fluid volume, symptoms are aggravated by salt-loading and
may be helped by reducing dietary intake of salt or by giving diuretics. In the few patients who are incapacitated by major spells of vertigo, ablative surgery is used
through either a labyrinthectomy, when there is no useful hearing, or a vestibular nerve section that spares the cochlear nerve in patients with serviceable hearing.
Endolymphatic sac decompression and shunt are another commonly performed procedure when hearing preservation is desired. However, the long-term success
rates in vertigo control are better with vestibular neurectomy.
Meniere syndrome must be separated from congenital or tertiary syphilis, which also causes endolymphatic hydrops, vertigo, and hearing loss. In syphilis, hearing
loss is progressive and usually bilateral. Cogan syndrome also resembles Meniere syndrome with endolymphatic hydrops, hearing loss, and vertigo. In Cogan
syndrome, in addition, ocular inflammation occurs without evidence of syphilis. Cogan syndrome is thought to be an autoimmune condition, which may also be true of
Meniere syndrome.
Perilymphatic Fistula
Hearing loss with or without vertigo may follow sudden changes of pressure in the middle ear or cerebrospinal fluid that may be due to weight lifting, barotrauma from
scuba diving or flying, or even forceful coughing or nose blowing. Perilymphatic fistula may arise spontaneously, especially in children with congenital defects of the
inner ear. Stapedectomy also increases the risk for perilymphatic fistula. Surgery to patch the fistula may be necessary in selected patients to stop progression of the
symptoms.
Cerebellopontine Angle Tumors
The most common tumor involving the cerebellopontine angle is the acoustic neuroma (schwannoma). By the time loss of corneal reflex, cerebellar signs, gross
nystagmus, and facial weakness are seen, the tumor is large. Because the earliest symptoms are tinnitus, hearing loss, and dizziness, this tumor must always be
considered in the evaluation of a patient with any of these symptoms. Early diagnosis is particularly important because improvement in microsurgical techniques has
made possible complete removal of the tumor without damaging the facial nerve, and even preservation of useful hearing if the tumor is small. Dizziness is rarely
true vertigo and does not occur in recurrent attacks; rather, there is a persistent sense of unsteadiness or light-headedness. All patients with tinnitus, hearing loss, or
dizziness must have audiometric testing, including impedance testing with stapedial reflex evaluation. If the initial evaluation suggests a neural site of hearing loss,
then electronystagmography with a caloric test and a brainstem auditory evoked response test should be carried out. Magnetic resonance imaging with gadolinium
enhancement is the definitive test in the diagnosis of acoustic neuroma.
Drug Toxicity
Salicylates, aminoglycoside antibiotics, furosemide (Lasix), anticonvulsants, and alcohol can cause dizziness in the form of vertigo, disequilibrium, and
light-headedness. Tinnitus and hearing loss may also occur. These symptoms are bilateral and are often accompanied by ataxic gait, as they variously affect the
vestibular and cochlear apparatuses. Sedatives (e.g., diazepam, phenobarbital), antihistamines, mood elevators, and antidepressants can also cause
light-headedness and disequilibrium. Recent intake of possibly toxic drugs should be reviewed with any patient complaining of dizziness. Cessation of use of a drug
usually causes clearing of the symptoms in a few days, although vestibular and cochlear damage due to aminoglycosides and other ototoxic drugs can result in
permanent ataxia or hearing loss.
Craniocerebral Injuries
Loss of hearing, tinnitus, and vertigo (often postural) can be sequelae of head injury. Hearing loss may be due to a fracture in the middle ear ossicles or the cochlea.
Vertigo may be due to concussion or hemorrhage into the labyrinth or a perilymphatic fistula. Postural vertigo may be a nonspecific reaction to concussion and part of
the postconcussion syndrome, or may be secondary to posttraumatic cupulolithiasis and benign paroxysmal vertigo.
Cardiac Arrhythmia
Cardiac arrhythmias sufficient to lower cardiac output can cause dizziness. The patient may not notice palpitations. If a cardiac arrhythmia is suspected, 24- to
48-hour continuous electrocardiograph monitoring (Holter monitor) may help establish the relationship of arrhythmias to episodes of dizziness.
End-organ Degeneration
With the increase in life expectancy, many patients now reach ages at which degenerative losses cause disequilibrium. Past a certain age (which is different for each
patient), there is an almost linear decline in the numbers of hair cells in the cochlea and of nerve fibers in the vestibular nerve; deterioration of other sensory systems
(i.e., visual, proprioceptive, exteroceptive, and auditory) and of the ability to integrate information from those sensory systems causes disequilibrium in older patients.
Older patients also lose cerebral adaptive functions and cannot compensate for the loss of sensory function.
Psychophysiologic Causes of Vertigo: Hyperventilation
Acute anxiety attacks or panic attacks can cause vertigo. It is not always easy to differentiate psychophysiologic cause and effect because vertigo can sometimes
trigger acute anxiety or panic attacks. The history usually includes a period of external stress, fear of blacking out, fear of dying, shortness of breath, palpitations,
tingling or weakness in the hands, mouth, or legs, and frequent or daily occurrence. Whirling vertigo is uncommon. These spells are often induced by hyperventilation.
Asking the patient to hyperventilate for 2 minutes will evoke the typical symptoms. Patients with anxiety, depression, and panic attacks may respond to specific
therapy and the appropriate psychopharmacologic agents.
Other Causes of Dizziness
Dizziness may be a secondary effect of a variety of disorders, including the following:

Migraine (vertebrobasilar type)
Multiple sclerosis
Neurosyphilis
Cervical spondylosis
Sensory deprivation (e.g., polyneuropathy, visual impairment)
Vertebrobasilar insufficiency (e.g., transient ischemic attack, infarction)
Cerebellar hemorrhage
Anemia
Orthostatic hypotension
Intralabyrinthine hemorrhage (e.g., leukemia, trauma)
Carotid sinus syncope
Diabetes mellitus
Hypoglycemia
TAKING THE HISTORY
The first step in taking the patient's history is to determine whether the patient is suffering from vertigo, disequilibrium, light-headedness, motor incoordination,
seizure, syncope, or a combination of these. It is necessary to determine the time of onset, temporal pattern, associated symptoms, and factors that seem to
precipitate, aggravate, or relieve symptoms. If there are episodes, the sequence of events needs to be known, including activities at onset, possible aura, quality,
severity, sequence of symptoms, and the patient's response during the attack. Does the patient have to sit or lie down? Is consciousness lost? Can someone
communicate with the patient during an attack? What other symptoms occur? After an attack, how does the patient feel? Can the patient remember the events that
occurred during an attack? Can the patient function normally following an attack? These considerations suggest specific questions that must be asked in taking the
history. The following list contains examples of the kinds of specific questions that should be put to the patient:
1. Is the dizziness precipitated by head movement? (Benign positional vertigo is characteristically precipitated by head movement, but orthostatic hypotension
causes dizziness on rising from sitting or lying. Neck movements may precipitate dizziness in cervical osteoarthritis or muscle spasm. Head turning may
precipitate dizziness with carotid sinus syncope if the patient is wearing a tight collar.)
2. If there is vertigo, is it rotational? Does the patient have a veering gait or an unsteady stance with nausea, perspiration, and tachycardia? In which direction does
the vertigo occur?
3. Are cochlear and vestibular symptoms associated? (This pattern would suggest a peripheral lesion affecting both portions of the inner ear or eighth cranial
nerve.)
4. Has there been recent head trauma?
5. Are there other neurologic symptoms, such as visual changes, paralysis, sensory alterations, altered consciousness, or headaches? (These symptoms might
suggest a more generalized neurologic disorder in which dizziness and hearing loss are only a part.)
6. Is there numbness in the hands and feet, visual impairment, or a history of diabetes or anemia? (Sensory loss in the elderly or chronically debilitated patient can
lead to environmental disorientation that is interpreted as dizziness.)
7. Are there cardiac symptoms (e.g., tachycardia, palpitation, or angina) that suggest a cardiac disorder?
8. Are there psychiatric symptoms (e.g., thought disorders, delusions, hallucinations, bizarre behavior, or depression) that suggest dizziness of a psychic nature?
Do symptoms of anxiety suggest possible hyperventilation?
9. Transient ischemic attacks may cause recurrent dizziness. Inquiry should include questions about other recurrent symptoms of vertebrobasilar ischemia, as well
as risk factors (e.g., hypertension and cardiovascular disease).
10. Is there a familial history of dizziness or hearing loss?
CONCLUSION
Diagnosing dizziness, disequilibrium, or vertigo can be a challenging task. The differential diagnosis is spread across medical specialties and may require multiple
consultations. If symptoms are persistent, neurologic and neurootologic evaluations are indicated. An accurate clinical history, appropriate examinations, and tests of
audiologic and vestibular systems are needed for accurate diagnosis and effective treatment.
SUGGESTED READINGS
Baloh RW, Honrubia V. Clinical neurophysiology of the vestibular system, 2nd ed. Contemporary Neurology Series. Philadelphia: FA Davis Co, 1990.
Barber HO. Current ideas on vestibular diagnosis. Otolaryngol Clin North Am 1978;11:283300.
Coles RRA, Hallan RS. Tinnitus and its management. Br Med Bull 1987;43:983998.
Dobie RA, Berlin CI. Influence of otitis media on hearing and development. Ann Otol Rhinol Laryngol 1979;88:4856.
Drachman DA, Hart CW. A new approach to the dizzy patient. Neurology 1972;22:323334.
Gacek RR. Transection of the posterior ampullary nerve for the relief of benign paroxysmal positional vertigo. Ann Otol Rhinol Laryngol 1974;83: 596605.
Grundfast KM, Bluestone CD. Sudden or fluctuating hearing loss and vertigo in children due to perilymph fistula. Ann Otol Rhinol Laryngol 1978;87:761779.
Lambert PR. Evaluation of the dizzy patient. Compr Ther 1997;23: 719723.
Schuknecht HF. Cupulolithiasis. Arch Otolaryngol 1969;90:113126.
Schuknecht HF. Pathology of the ear, 2nd ed. Philadelphia: Lea & Febiger, 1994.
Shulman A. Neuroprotective drug therapy: a medical and pharmacological treatment for tinnitus control. Int Tinnitus J 1997;3:7793.
CHAPTER 7. IMPAIRED VISION
MERRITTS NEUROLOGY
CHAPTER 7. IMPAIRED VISION

MYLES M. BEHRENS
Ocular Lesions
Optic Nerve Lesions
Lesions of the Optic Chiasm
Retrochiasmal Lesions
Impairment of Ocular Motility
Suggested Readings
Impaired vision may be due to a lesion within the eyes, in the retrobulbar visual pathway (including the optic nerve and optic chiasm), or in the retrochiasmal pathway.
The retrochiasmal pathway includes the optic tract, geniculate body (where synapse occurs), the visual radiation through the parietal and temporal lobes, and the
occipital cortex. The pattern of visual loss may identify the site of the lesion. The course and accompanying symptoms and signs may clarify its nature.
OCULAR LESIONS
Impaired vision of ocular origin may be caused by refractive error, opacity of the ocular media (which may be seen by external inspection or ophthalmoscopy), or a
retinal abnormality (e.g., retinal detachment, inflammation, hemorrhage, vascular occlusion). There may be associated local symptoms or signs, such as pain or soft
tissue swelling.
OPTIC NERVE LESIONS
A visual defect may originate in the optic nerve, particularly if the symptoms affect only one eye. The hallmarks of optic nerve dysfunction include blurred vision
(indicated by decreased visual acuity), dimming or darkening of vision (usually with decreased color perception), and decreased pupillary reaction to light. This
pupillary sign is not seen if the problem is media opacity, minor retinal edema, or nonorganic visual loss. It may be present to a mild degree in simple amblyopia.
The relative afferent pupillary defect results from an optic nerve lesion in one eye; the sign is best shown by the swinging-flashlight test. A bright flashlight is swung
from one eye to the other just below the visual axis while the subject stares at a distant object in a dark room. Constriction of the pupils should be the same when
either eye is illuminated. However, if an eye with optic nerve dysfunction is illuminated, the pupils constrict less quickly in response to the light, less completely, and
less persistently than when the normal fellow eye is illuminated. If the expected constriction does not occur or if the pupils actually dilate after an initial constriction on
stimulation of one eye, the test is positive. Both pupils are equal in size at all times in purely afferent defects because there is hemidecussation of all afferent light
input to the midbrain with equal efferent stimulation through both third cranial nerves. Therefore, if one pupil is fixed to light because of an efferent defect, the other
one can be observed throughout the performance of this test.
The patient may be aware of, or the examiner may find, a scotoma (blind spot) in the visual field. This is often central or centrocecal (because the lesion affects the
papillomacular bundle that contains the central fibers of the optic nerves), or altitudinal (because arcuate or nerve-fiber-bundle abnormalities respect the nasal
horizontal line, corresponding to the separation of upper and lower nerve-fiber bundles by the horizontal raphe in the temporal portion of the retina). These
abnormalities are often evident on confrontation tests of the visual fields.
In a central scotoma of retinal origin (e.g., due to macular edema affecting photoreceptors), the patient may report that lines seem to be distorted (metamorphopsia) or
objects may seem small (micropsia). Recovery of visual acuity may be delayed (e.g., in comparison to a normal fellow eye) after photostress, such as a flashlight
stimulus for 10 seconds.
Bilateral optic nerve abnormalities, in particular those with centrocecal scotomas ( Fig. 7.1A), suggest a hereditary, toxic, nutritional, or demyelinating disorder;
unilateral optic nerve disease is usually ischemic, inflammatory, or compressive. The course and associated symptoms and signs help differentiate these possibilities.
FIG. 7.1. A: Bilateral centrocecal scotoma. B: Inferior altitudinal defect with central scotoma O.S. (left eye) and upper temporal hemianopic (junctional) defect O.D.
(right eye). C: Bitemporal hemianopia. D: Total right homonymous hemianopia. E: Incongruous right homonymous hemianopia. F: Congruous left homonymous
hemianopic scotoma. G: Left homonymous hemianopia with macular sparing. H: Bilateral congruous homonymous hemianopia.
Optic nerve infarction (anterior ischemic optic neuropathy) usually affects patients older than 50 years. The visual defect is usually primarily altitudinal, occasionally
centrocecal, sudden in onset, and stable (occasionally progressive during the initial weeks). There is pallid swelling of the optic disc with adjacent superficial
hemorrhages. The swelling resolves in 4 to 6 weeks, leaving optic atrophy and arteriolar narrowing on the disc ( Fig. 7.2). The cause may be arteritis (giant cell or
temporal arteritis, often with associated symptoms and signs) but is usually idiopathic, painless, and only rarely associated with carotid occlusive disease. In the
idiopathic nonarteritic variety, the discs are characteristically crowded, with small, if any, physiologic cup, thus suggesting structural susceptibility. The fellow eye is
often similarly affected after months or years.
FIG. 7.2. A: Pallid swelling of the disc with superficial hemorrhages in a patient with acute anterior ischemic optic neuropathy. B: Optic atrophy with arteriolar
narrowing after anterior ischemic optic neuropathy.
Optic neuritis usually affects young adults. It typically begins with a central or centrocecal scotoma and subacute progression of the defect that is followed by a
gradual resolution; there may be residual optic atrophy. Initially, the disc may be normal (retrobulbar neuritis) or swollen (papillitis). Local tenderness or pain on
movement of the eye is usually present and suggests such an intraorbital inflammatory disorder. The Pulfrich phenomenon is a stereo illusion that may be caused by
delayed conduction in one optic nerve, making it difficult to localize moving objects. This is not specific and may occur with retinal abnormality or media defect. The
Uhthoff symptom is an exacerbation of a symptom after exercise or exposure to heat; it is not specific but occurs most often in demyelinating disorders. If in a case
suggesting optic neuritis there is evidence of preexisting optic atrophy in either eye or optic neuropathy in the fellow eye (e.g., if the degree of relative afferent
pupillary defect is less than anticipated, suggesting subclinical involvement of the other eye), demyelinating disease is also suggested.
In compressive optic neuropathy, there is usually steady progression of visual defect, although it may be stepwise or even remitting. The disc may remain relatively
normal in appearance for months before primary optic atrophy is indicated funduscopically by decrease in color of the disc, visible fine vessels on the disc, and
peripapillary nerve fibers (best seen with a bright ophthalmoscope with red-free light). This form of optic atrophy must be distinguished from other specific types (e.g.,
glaucoma, in which the nerve head has an excavated or cupped appearance; postpapilledema [secondary] atrophy with narrowing and sheathing of vessels and often
indistinct margins; retinal pigmentary degeneration with narrowed vessels, which may also be seen after central retinal artery occlusion or optic nerve infarction; and
congenital defects, such as coloboma or hypoplasia of the disc, with a small nerve head and a peripapillary halo that corresponds to the expected normal size of the
disc).
LESIONS OF THE OPTIC CHIASM
In a patient with optic neuropathy, recognition of an upper temporal hemianopic visual-field defect (which may be asymptomatic) in the other eye is evidence of a
chiasmal lesion that affects the anteriorly crossing lower fibers (see Fig. 7.1B). In contrast to optic nerve lesions, the majority of chiasmal lesions are compressive.
The typical visual-field defect is bitemporal hemianopia (see Fig. 7.1C). Because the macular fibers permeate the chiasm, any compressive lesion of the chiasm with a
visual-field defect is accompanied by temporal hemianopic dimming of red objects of any size in a pattern that respects the vertical line and permits secure
confrontation testing.
RETROCHIASMAL LESIONS
Homonymous hemianopia results from a retrochiasmal lesion. There may be varying awareness of the defect. It may be mistakenly attributed to the eye on the side of
the defect, or the patient may be aware only of bumping into things on that side or of trouble reading (slowness and difficulty seeing the next word with right
homonymous hemianopia, or difficulty finding the next line with left hemianopia). The patient may ignore that side of the visual acuity test chart that corresponds to the
hemianopia, but can see 20/20 unless there is another defect (see Fig. 7.1D).
With subtotal lesions, the congruity of the visual-field defect in the two eyes helps in localization. Optic tract and geniculate lesions tend to have grossly incongruous
visual-field defects (see Fig. 7.1E). The farther posterior that the lesion is, the more congruous is the defect because the fibers from corresponding retinal loci in the
two eyes converge on the same occipital locus.
With optic tract lesions anterior to the geniculate synapse, optic atrophy may develop. The eye with a temporal field defect develops a bow-tie pattern of atrophy,
which may also occur with chiasmal lesions. The nasal portion of the disc is pale due to loss of the nasal fibers; the usual mild temporal pallor is more evident due to
loss of the nasal half of the papillomacular bundle. An imaginary vertical line through the macula corresponds to the vertical line that separates the nasal and temporal
halves of the visual field. There is a relatively pink appearance above and below where fibers from the temporal retina reach the disc.
With optic tract lesions, afferent pupillary input is impaired. When the lesion is grossly incongruous, a relative afferent pupillary defect may occur on the side with the
greater deficit. It is found in the eye with temporal hemianopia when homonymous hemianopia is total, because the temporal half-field is more extensive than the
nasal half-field. The Wernicke hemianopic pupillary phenomenon may be difficult to elicit: Pupillary constriction is more vigorous when the unaffected portion of the
retina is stimulated. When an optic tract lesion is close to and encroaches on the chiasm, visual acuity in the ipsilateral eye diminishes. There may be a relative
afferent pupillary defect on that side, as well.
Retrogeniculate lesions are not accompanied by clinical impairment of pupillary reactivity or optic atrophy. The homonymous hemianopic visual-field defect tends to
be superior when the temporal lobe radiations are affected, and the defect is denser below if the lesion is parietal. Occipital lesions result in precisely congruous
defects, often scotomas with preserved peripheral vision (see Fig. 7.1F). If the scotoma is large enough, the area of preserved peripheral vision may be present only
in the eye with the loss of temporal field (a preserved temporal crescent). This corresponds to the most anterior portion of the occipital cortex. The central portion of
the visual field is represented in the posterior striate cortex, a marginal perfusion zone of both posterior and middle cerebral arteries. When the posterior cerebral
artery is occluded, collateral supply from the middle cerebral artery may allow gross macular sparing (see Fig. 7.1G), preserving central vision. Homonymous
hemianopia of occipital origin is often total. Isolated homonymous hemianopia is due to an infarct in 90% of patients. Cerebral blindness (bilateral homonymous
hemianopia [see Fig. 7.1H]) may require distinction from hysterical blindness; opticokinetic nystagmus (OKN) can be elicited in psychogenic disorders, but not after
bilateral occipital lesions when they are complete.
Irritative visual phenomena include formed visual hallucinations (usually of temporal lobe origin) and unformed hallucinations (usually of occipital origin), including the
scintillating homonymous scotoma of migraine. Amaurosis fugax of one eye is occasionally due to vasospasm in migraine but is usually due to ophthalmic-carotid
hypoperfusion or embolization, or cardiogenic emboli. Formed or unformed hallucinations may be release phenomena when there is visual loss due to a lesion
anywhere along the visual pathway. Phosphenes (light flashes) may occur in several kinds of optic nerve lesions, including demyelinating optic neuritis, or they may
occur with movement of the eye. Vitreoretinal traction is a frequent and nonsinister cause of light flashes, especially with advancing age, although a retinal tear
premonitory to retinal detachment may occur and must be ruled out.
IMPAIRMENT OF OCULAR MOTILITY
Impairment of ocular motility is often a clue to diagnosis in many neurologic disorders. It may reflect a supra-, inter-, or infranuclear (fascicular or peripheral nerve)
neurogenic lesion, neuromuscular transmission defect, myopathy, or mechanical restriction in the orbit. Diplopia (double vision) indicates malalignment of the visual
axes if it is relieved by occlusion of either eye. Diplopia of monocular origin is psychogenic or due to a disturbance of the refractive media in the eye (e.g., astigmatism
or opacity of the cornea or lens). Malalignment of the visual axes may occur in psychogenic convergence spasm (suggested by associated miosis due to the near
response), in decompensation of strabismus (including convergence insufficiency, usually of no pathologic import), and, less frequently, in divergence insufficiency
(possibly due to bilateral sixth cranial nerve paresis, occasionally caused by increased intracranial pressure). The diplopia and malalignment of the visual axes in
these cases are usually commitant, that is, equal in all directions of gaze. If strabismus begins in early childhood, there may be habitual suppression of the image of
one eye, with impaired development of vision in that eye ( amblyopia) rather than diplopia.
Incommitance, or inequality in the alignment of the visual axes in the direction of gaze, suggests limitation of action of one or more muscles. The deviation is generally
greater if the paretic eye is fixing. The patient may use one eye or adopt a head-turn or tilt to avoid diplopia (e.g., turning to the right when the right lateral rectus is
limited, or tilting to the left if the right superior oblique is affected, to avoid the need for the intortional effect of that muscle). The patient may not be aware of either the
diplopia or these adaptations.
To determine which muscle is impaired, the examiner obtains information from the history and examination (including use of a red glass). It is important to know
whether the diplopia is vertical or horizontal, whether it is crossed (if the visual axes are divergent) or uncrossed (if convergent), whether greater near (if adducting
muscles are involved) or at a distance (if abducting muscles are involved), and the direction of gaze in which the diplopia is maximal.
If the pattern of motility limitation conforms to muscles innervated by a single nerve, the lesion probably affects that nerve. With a third cranial nerve palsy, there is
ptosis, limitation of action of the medial, inferior, and superior rectus muscles and of the inferior oblique muscle; that is, all the extraocular muscles are affected except
the lateral rectus (sixth cranial nerve) and superior oblique (fourth cranial nerve). Internal ophthalmoplegia (i.e., pupillary enlargement with defective constriction and
defective accommodation) may be evident. When the ptotic lid is lifted, the eye is abducted (unless the sixth cranial nerve is also affected), and on attempted
downward gaze the globe can be seen to intort (by the observation of nasal episcleral vessels) if the fourth cranial nerve is intact. If more than one of these nerves is
affected, the lesion is probably in the cavernous sinus, superior orbital fissure, or orbital apex. There may also be fifth cranial nerve (ophthalmic division) and
oculosympathetic defect (Horner syndrome). The latter is indicated by relative miosis, mild ptosis, and incomplete and delayed dilation of the pupil. Such involvement
is usually due to tumor, aneurysm, or inflammation, whereas isolated involvement of one of the ocular motor nerves may be ischemic.
Mechanical limitation of ocular motility may occur with orbital lesions, such as thyroid ophthalmopathy, orbital fracture, or tumor. It is indicated by limitation on forced
duction, such as an attempt to rotate the globe with forceps (traction test), or by elevation of intraocular pressure on the attempted movement with relatively intact
velocity saccades (i.e., rapid eye movements). Other symptoms or signs of orbital lesions include proptosis (or enophthalmos in the case of fracture) beyond
acceptable normal asymmetry of 2 mm, resistance to retropulsion, vascular congestion, tenderness, and eyelid abnormality other than ptosis (e.g., retraction, lid-lag,
swelling).
Myasthenia gravis (see Chapter 120) is suggested when affected muscles do not conform to the distribution of a single nerve (although they may) and when
symptoms vary, including diurnal fluctuation and fatigability. A demonstrable increase in paresis or a slowing of saccades may occur after sustained gaze or repetitive
movement. Ptosis may similarly increase after sustained upward gaze (or lessen after rest in sustained eye closure) or a momentary lid twitch may be seen on return
of gaze from downward to straight ahead. There is no clinical abnormality of the pupils in myasthenia gravis.
Analysis of saccadic function is of particular value in the analysis of supra- and internuclear ocular motility defects. The supranuclear control mechanisms of ocular
movements include the saccadic system of rapid conjugate eye movement of contralateral frontal lobe origin to achieve foveal fixation on a target (a combination of
pulse, burst discharge in agonist with total inhibition of antagonist, and step, increased level of agonist and decreased level of antagonist discharge to maintain the
new eccentric position); the pursuit system of slow conjugate movement of ipsilateral occipital lobe origin to maintain foveal fixation on a slowly moving target; the
vestibular system of slow conjugate movement to maintain stability of the retinal image if the head moves in relation to the environment; and the vergence system of
dysconjugate slow movement to maintain alignment of the visual axes for binocular single vision. OKN is the normal response to a sequence of objects moving slowly
across the field of vision and can be considered a combination of pursuit and refixation saccades (to allow continuous pursuit, because vision is suppressed during
the saccadic phase).
The polysynaptic saccadic pathway crosses at the level of the fourth cranial nerve nucleus to enter the pontine paramedian reticular formation (PPRF), where
ipsilateral saccades and other horizontal movements are generated by stimulation of neurons in the sixth cranial nerve nucleus and also interneurons therein that
travel up the opposite medial longitudinal fasciculus (MLF) to stimulate the contralateral subnucleus for the medial rectus in the third cranial nerve nucleus to assure
normal conjugate gaze. Pathways for vertical movement seem to require bilateral stimuli. The immediate supranuclear apparatus for generating vertical gaze is in the
midbrain, the rostral interstitial nucleus of the MLF.
General dysfunction of saccades (with limitation, slowing, or hypometria) is seen in several disorders, including Huntington disease (see Chapter 108), hereditary
cerebellar degeneration (see Chapter 107), progressive supranuclear palsy (see Chapter 115), and Wilson disease (see Chapter 89). Congenital ocular motor apraxia
is a benign abnormality of horizontal saccades that resolves with maturity. Infants with this abnormality are unable to perform horizontal saccades and substitute
characteristic head thrusts past the object of regard, achieving fixation by the contraversive vestibular doll's-head movement and then maintaining it while slowly
rotating the head back. Focal dysfunction of saccades is manifested by lateral gaze paresis after contralateral frontal or ipsilateral pontine lesions; vestibular stimuli
may overcome frontal gaze palsies but do not affect pontine lesions.
Internuclear ophthalmoplegia is the result of a lesion in the MLF that interrupts adduction in conjugate gaze (but convergence may be intact). Abduction nystagmus is
seen in the contralateral eye. When the defect is partial, adducting saccades are slow, with resultant dissociation of nystagmus again more marked in the abducting
eye, as when OKN is elicited. When the lesion is unilateral, an ischemic lesion is likely; a bilateral syndrome suggests multiple sclerosis. Vertical gaze-evoked
nystagmus and skew deviation (one eye higher than the other) may be seen. The latter is a supranuclear vertical divergence of the eyes, seen with brainstem or
cerebellar lesions.
A unilateral pontine lesion that involves both the MLF and PPRF causes the combination of ipsilateral gaze palsy and internuclear ophthalmoplegia on contralateral
gaze, a pattern called the 1 1/2 syndrome. The only remaining horizontal movement is abduction of the contralateral eye. The eyes are straight or exodeviated (if
there is gaze preference away from the side of the gaze palsy). Superimposed esodeviation with related diplopia may occur if there is sixth cranial nerve (fascicular)
involvement, as well.
Vertical gaze disorders are seen with midbrain lesions (the sylvian aqueduct syndrome). Characteristic dyssynergia on attempted upward saccades is best
demonstrated by downward moving OKN stimuli: Failure of inhibition leads to cofiring of oculomotor neurons with convergence-retraction nystagmus and related
fleetingly blurred vision or diplopia. This may also occur, to a lesser extent, with horizontal saccades, causing excessive adductor discharge and pseudo sixth cranial
nerve paresis. There is usually pupillary sluggishness in response to light (often with light-near dissociation) due to interruption of the periaqueductal afferent light
input to the third cranial nerve nuclei. Concomitant abnormalities may include lid retraction ( Collier sign), defective or excess accommodation or convergence, and
skew deviation or monocular elevator palsy.
Oscillopsia is a sensation of illusory movement of the environment that is unidirectional or oscillatory; it is seen with acquired nystagmus of various types. Nystagmus
is an involuntary rhythmic oscillation of the eyes, generally conjugate and of equal amplitude but occasionally dysconjugate (as in the sylvian aqueduct syndrome) or
dissociated in amplitude (as in internuclear ophthalmoplegia). The oscillations may be pendular or jerk in type; the latter is more common in acquired pathologic
nystagmus. In jerk nystagmus, the slow phase is operative and the fast phase is a recovery movement. The amplitude usually increases on gaze in the direction of the
fast phase.
Horizontal and upward gaze-evoked nystagmus may be due to sedative or anticonvulsant drugs. Otherwise, vertical nystagmus indicates posterior fossa disease.
Extreme end-gaze physiologic nystagmus, which may be of greater amplitude in the abducting eye, must be distinguished. It occurs only horizontally. Jerk nystagmus
in the primary position, or rotatory nystagmus, usually indicates a vestibular disorder that may be either central or peripheral. In a destructive peripheral lesion, the
fast phase is away from the lesion; the same pattern is seen with a cold stimulus when the horizontal canals are oriented vertically (i.e., with the head elevated 30
degrees in the supine position). Downbeating nystagmus in the primary position, often more marked on lateral gaze to either side, frequently indicates a lesion at the
cervicomedullary junction. Ocular bobbing is usually associated with total horizontal pontine gaze palsy; it is not rhythmic, is coarser than nystagmus, may vary in
amplitude, and is occasionally asymmetric; the initial movement is downward with a slower return. Upbeating nystagmus in the primary position may indicate a lesion
of the cerebellar vermis or medulla but most commonly the pons. Seesaw nystagmus is vertically dysconjugate with a rotatory element, so that there is intortion of the
elevating eye and simultaneous extortion of the falling eye. This pattern is often seen with parachiasmal lesions and is probably a form of alternating skew deviation
due to involvement of vertical and tortional oculomotor control regions around the third ventricle. Periodic alternating nystagmus implies a nonsinister lesion of the
lower brainstem; in effect, it is a gaze-evoked nystagmus to either side of a null point that cycles back and forth horizontally. In the primary position, there is
nystagmus of periodically alternating direction. Rebound nystagmus, which may be confused with periodic alternating nystagmus, is a horizontal jerk nystagmus that
is transiently present in the primary position after sustained gaze to the opposite side; it implies dysfunction of the cerebellar system.
Other ocular oscillations that follow cerebellar system lesions include ocular dysmetria (overshoot or terminal oscillation of saccades), ocular flutter (bursts of similar
horizontal oscillation, actually back-to-back saccades without usual latency), opsoclonus (chaotic multidirectional conjugate saccades), and fixation instability
(square-wave jerks), in which small saccades interrupt fixation, with movement of the eye away from the primary position and then its return after appropriate latency
for a saccade. Ocular myoclonus is a rhythmic ocular oscillation that often is vertical and associated with synchronous palatal myoclonus.
When oscillopsia is monocular, there may be dissociated pathologic nystagmus of posterior fossa origin, including the jellylike, primarily vertical, pendular nystagmus
akin to myoclonus that is occasionally seen in multiple sclerosis. There may be benign myokymia of the superior oblique muscle, in which the patient is often aware of
both a sensation of ocular movement and oscillopsia. Monocular nystagmus may also result from monocular visual loss in early childhood or from the insignificant and
transient acquired entity of spasmus nutans, which is of uncertain etiology. It begins after 4 months of age and disappears within a few years. The nystagmus of
spasmus nutans is asymmetric and rapid and may be accompanied by head nodding. It may be similar to congenital nystagmus. The latter begins at birth, persists,
and is usually horizontal, either gaze-evoked or pendular, often with jerks to the sides, and there may be a null with head turn adopted for maximal visual acuity. It
originates in a motor disorder, although it may be mimicked by the nystagmus of early binocular visual deprivation.
SUGGESTED READINGS
Behrens MM. Neuro-ophthalmic motility disorders. American Academy of Ophthalmology and Otolaryngology CETV videotape, 1975;1(5).
Burde RM, Savino PJ, Trobe JD. Clinical decisions in neuro-ophthalmology, 2nd ed. St. Louis, MO: CV Mosby, 1992.
Glaser JS. Neuro-ophthalmology, 2nd ed. Philadelphia: JB Lippincott Co, 1990.
Leigh RJ, Zee DS. The neurology of eye movements, 2nd ed. Philadelphia: FA Davis Co, 1991.
Miller NR, Newman NJ. The essentials. Walsh and Hoyt's clinical neuro-ophthalmology, 5th ed. Baltimore: Lippincott Williams % Wilkins, 1998.
Miller NR, Newman NJ, eds. Walsh and Hoyt's clinical neuro-ophthalmology, 5th ed, vols 15. Baltimore: Lippincott Williams % Wilkins, 1998.
CHAPTER 8. HEADACHE
MERRITTS NEUROLOGY
CHAPTER 8. HEADACHE
NEIL H. RASKIN
General Principles
Pain-Sensitive Structures of the Head
Approach to the Patient with Headache
Suggested Readings
Nearly everyone is subject to headache from time to time; moreover, 40% of persons experience severe headaches annually. The mechanism generating headaches
may be activated by worry and anxiety, but emotional stress is not necessary for the symptom to appear. Genetic factors may augment this system, so that some
people are susceptible to more frequent or more severe head pain. The term migraine is increasingly being used to refer to a mechanism of this kind, in
contradistinction to prior usage of the term as an aggregation of certain symptoms. Thus, stress-related or tension headaches, perhaps the most common syndrome
reported by patients, is an example of the expression of this mechanism when it is provoked by an adequate stimulus; it may also be activated in some people by the
drinking of red wine, by exposure to glare or pungent odors, or premenstrually.
Headache is usually a benign symptom and only occasionally is a manifestation of a serious illness, such as brain tumor or giant cell arteritis. The first issue to
resolve in the care of a patient with headache is to make the distinction between benign and more ominous causes. If the data supporting a benign process are strong
enough, as reviewed in this chapter, neuroimaging can be deferred. If a benign diagnosis cannot be made, magnetic resonance imaging is a better choice than
computed tomography (CT) for visualizing the posterior fossa; posterior fossa tumors are far more likely than forebrain tumors to cause headache as the only
symptom. Moreover, the Arnold-Chiari malformation, an important structural cause of headache, cannot be visualized with CT.
GENERAL PRINCIPLES
The quality, location, duration, and time course of the headache and the conditions that produce, exacerbate, or relieve it should be elicited.
Most headaches are dull, deeply located, and aching in quality. Superimposed on such nondescript pain may be other elements that have greater diagnostic value; for
example, jabbing, brief, sharp pain, often occurring multifocally ( ice-picklike pain), is the signature of a benign disorder. A throbbing quality and tight muscles about
the head, neck, and shoulder girdle are common nonspecific accompaniments of headache that suggest that intra- and extracranial arteries and skeletal muscles of
the head and neck are activated by a generic mechanism that generates head pain. Tight, pressing hat-band headaches were once believed to indicate anxiety or
depression, but studies have not supported this view.
Pain intensity seldom has diagnostic value, nor does response to placebo medication provide any useful information. Administration of placebo simply identifies
placebo responders, a group that includes about 30% of the population. No evidence reveals that placebo responders have lower pain levels than nonresponders or
that they do not really have pain. Patients entering emergency departments with the most severe headache of their lives usually have migraine. Meningitis,
subarachnoid hemorrhage, and cluster headache also produce intense cranial pain. Contrary to common belief, the headache produced by a brain tumor is not
usually severe.
Data regarding headache location is occasionally informative. If the source is an extracranial structure, as in giant cell arteritis, correspondence with the site of pain is
fairly precise. Inflammation of an extracranial artery causes scalp pain and extensive tenderness localized to the site of the vessel. Posterior fossa lesions cause pain
that is usually occipitonuchal, and supratentorial lesions most often induce frontotemporal pain. Multifocality alone is a strong indicator of benignity.
Time-intensity considerations are particularly useful. A ruptured aneurysm results in head pain that peaks in an instant, thunderclap-like manner; much less often,
unruptured aneurysms may similarly signal their presence. Cluster headache attacks peak over 3 to 5 minutes, remain at maximal intensity for about 45 minutes, and
then taper off. Migraine attacks build up over hours, are maintained for several hours to days, and are characteristically relieved by sleep. Sleep disruption is
characteristic of headaches produced by brain tumors.
The relationship of a headache to certain biologic events or to physical environmental changes is essential information for triage of patients. The following
exacerbating phenomena have high probability value in asserting that a headache syndrome is benign: provocation by red wine, sustained exertion, pungent odors,
hunger, lack of sleep, weather change, or menses. The association of diarrhea with attacks is pathognomonic of a benign disorder (migraine). Cessation or
amelioration of headache during pregnancy, especially in the second and third trimesters, is similarly pathognomonic. Patients with continuous benign headache often
observe a pain-free interlude of several minutes on waking before the head pain begins once again. This phenomenon, wherein the cessation of sleep seems to
unleash the headache mechanism, also occurs with other centrally mediated pain syndromes, such as thalamic pain, but does not occur among patients with somatic
disease as the cause of pain.
A history of amenorrhea or galactorrhea leads to the possibility that the polycystic ovary syndrome or a prolactin-secreting pituitary adenoma is the source of
headache (Table 8.1). Headache arising de novo in a patient with a known malignancy suggests either cerebral metastasis or carcinomatous meningitis. When the
accentuation of pain is striking with eye movement, a systemic infection, particularly meningitis, should be considered. Head pain appearing abruptly after bending,
lifting, or coughing can be a clue to a posterior fossa mass or the Arnold-Chiari malformation. Orthostatic headache arises after lumbar puncture and also occurs with
subdural hematoma and benign intracranial hypertension. The eye itself is seldom the cause of acute orbital pain if the sclerae are white and noninjected; red eyes
are a sign of ophthalmic disease. Similarly, acute sinusitis nearly always declares itself through a dark green, purulent nasal exudate.
TABLE 8.1. STUDIES PERFORMED TO INVESTIGATE CHRONIC HEADACHE
The analysis of facial pain requires a different approach. Trigeminal and glossopharyngeal neuralgias are common causes of facial pain, especially the trigeminal
syndrome. Neuralgias are painful disorders characterized by paroxysmal, fleeting, often electric shocklike episodes; these conditions are caused by demyelinative
lesions of nerves (the trigeminal or glossopharyngeal nerves in cranial neuralgia) that activate a pain-generating mechanism in the brainstem. Trigger maneuvers
characteristically provoke paroxysms of pain. However, the most common cause of facial pain by far is dental; provocation by hot, cold, or sweet foods is typical.
Application of a cold stimulus repeatedly induces dental pain, whereas in neuralgic disorders a refractory period usually occurs after the initial response so that pain
cannot be induced repeatedly. The presence of refractory periods nearly always can be elicited in the history, thereby saving the patient from a painful experience.
Mealtimes offer the physician an opportunity to gain needed insight into the mechanism of a patient's facial pain. Does chewing, swallowing, or the taste of a food
elicit pain? Chewing points to trigeminal neuralgia, temporomandibular joint dysfunction, or giant cell arteritis ( jaw claudication), whereas the combination of
swallowing and taste provocation points to glossopharyngeal neuralgia. Pain on swallowing is common among patients with carotidynia (facial migraine), because the
inflamed, tender carotid artery abuts the esophagus during deglutition.
As in other painful conditions, many patients with facial pain do not describe stereotypic syndromes. These patients have sometimes had their syndromes categorized
as atypical facial pain, as though this were a well-defined clinical entity. Only scant evidence shows that nondescript facial pain is caused by emotional distress, as
is sometimes alleged. Vague, poorly localized, continuous facial pain is characteristic of the condition that may result from nasopharyngeal carcinoma and other
somatic diseases; a burning painful element often supervenes as deafferentation occurs and evidence of cranial neuropathy appears. Occasionally, the cause of a
pain problem cannot be promptly resolved, thus necessitating periodic follow-up examinations until further clues appear (and they usually do). Facial pain of unknown
cause is a more reasonable tentative diagnosis than atypical facial pain.
PAIN-SENSITIVE STRUCTURES OF THE HEAD
The most common type of pain results from activation of peripheral nociceptors in the presence of a normally functioning nervous system, as in the pain resulting from
scalded skin or appendicitis. Another type of pain results from injury to or activation of the peripheral or central nervous system. Headache, formerly believed to
originate peripherally, may originate from either mechanism. Headache may arise from dysfunction or displacement of, or encroachment on, pain-sensitive cranial
structures. The following are sensitive to mechanical stimulation: the scalp and aponeurosis, middle meningeal artery, dural sinuses, falx cerebri, and the proximal
segments of the large pial arteries. The ventricular ependyma, choroid plexus, pial veins, and much of the brain parenchyma are insensitive to pain. On the other
hand, electrical stimulation near midbrain dorsal raphe cells may result in migrainelike headaches. Thus, most of the brain is insensitive to electrode probing, but a
particular midbrain site is nevertheless a putative locus for headache generation.
Sensory stimuli from the head are conveyed to the brain by the trigeminal nerves from structures above the tentorium in the anterior and middle fossae of the skull.
The first three cervical nerves carry stimuli from the posterior fossa and infradural structures. The ninth and tenth cranial nerves supply part of the posterior fossa and
refer pain to the ear and throat.
Headache can occur as the result of the following:
1. Distention, traction, or dilation of intracranial or extracranial arteries,

2. Traction or displacement of large intracranial veins or their dural envelope,
3. Compression, traction, or inflammation of cranial and spinal nerves,
4. Spasm, inflammation, and trauma to cranial and cervical muscles,
5. Meningeal irritation and raised intracranial pressure,
6. Perturbation of intracerebral serotonergic projections.
By and large, intracranial masses cause headache when they deform, displace, or exert traction on vessels, dural structures, or cranial nerves at the base of the
brain; these changes often happen long before intracranial pressure rises. Such mechanical displacement mechanisms do not explain headaches resulting from
cerebral ischemia, benign intracranial hypertension after reduction of the pressure, or febrile illnesses and systemic lupus erythematosus. Impaired central inhibition
as a result of perturbation of intracerebral serotonergic projections has been posited as a possible mechanism for these phenomena.
APPROACH TO THE PATIENT WITH HEADACHE
Entirely different diagnostic possibilities are raised by the patient who has the first severe headache ever and the one who has had recurrent headaches for many
years. The probability of finding a potentially serious cause is considerably greater in patients with their first severe headache than in those with chronic recurrent
headaches. Acute causes include meningitis, subarachnoid hemorrhage, epidural or subdural hematoma, glaucoma, and purulent sinusitis. In general, acute, severe
headache with stiff neck and fever means meningitis, and without fever means subarachnoid hemorrhage; when the physician is confronted with such a patient,
lumbar puncture is mandatory. Acute, persistent headache and fever are often manifestations of an acute systemic viral infection; if the neck is supple, lumbar
puncture may be deferred. A first attack of migraine is always a possibility, but fever is a rare associated feature. Nearly all illnesses have been an occasional cause
of headache; however, some illnesses are characteristically associated with headache. These include infectious mononucleosis, systemic lupus erythematosus,
chronic pulmonary failure with hypercapnia (early morning headaches), Hashimoto thyroiditis, corticosteroid withdrawal, oral contraceptives, ovulation-promoting
agents, inflammatory bowel disease, many illnesses associated with human immunodeficiency virus infection, and acute blood pressure elevation that occurs in
pheochromocytoma and malignant hypertension. Pheochromocytoma and malignant hypertension are the exceptions to the generalization that hypertension per se is
an uncommon cause of headache; a diastolic pressure of at least 120 mm Hg is requisite for hypertension to cause headache.
Adolescents with chronic daily frontal or holocephalic headache pose a special problem. Extensive diagnostic tests, including psychiatric assessment, are most often
unrevealing. Fortunately, the headaches tend to stop after a few years, so that structured analgesic support can enable these teenagers to move through secondary
school and enter college. By the time they reach their late teens, the cycle has usually ended.
The relationship of head pain to depression is not straightforward. Many patients in chronic daily pain cycles become depressed (a reasonable sequence of events);
moreover, there is a greater-than-chance coincidence of migraine with both bipolar (manic-depressive) and unipolar depressive disorders. Studies of large
populations of depressed patients do not reveal headache prevalence rates that are different from those in the general population. The physician should be cautious
about assigning depression as the cause of recurring headache; drugs with antidepressant action are also effective in migraine.
Finally, note must be made of recurring headaches that may be pain-driven. As an example, temporomandibular joint (TMJ) dysfunction generally produces
preauricular pain that is associated with chewing food. The pain may radiate to the head but is not easily confused with headache per se. Conversely,
headache-prone patients may observe that headaches are more frequent and severe in the presence of a painful TMJ problem. Similarly, headache disorders may be
activated by the pain attending otologic or endodontic surgical procedures. Treatment of such headaches is largely ineffectual until the cause of the primary pain is
treated. Thus, pain about the head as a result of somatic disease or trauma may reawaken an otherwise quiescent migrainous mechanism.
SUGGESTED READINGS
Day JW, Raskin NH. Thunderclap headache: symptom of unruptured cerebral aneurysm. Lancet 1986;2:12471248.
Lance JW, Goadsby PJ. Mechanism and management of headache, 6th ed. London: Butterworth, 1998.
Raskin NH. On the origin of head pain. Headache 1988;28:254257.
Raskin NH. Headache, 2nd ed. New York: Churchill Livingstone, 1988.
Rasmussen BK, Olesen J. Symptomatic and nonsymptomatic headaches in a general population. Neurology 1992;42:12251231.
CHAPTER 9. INVOLUNTARY MOVEMENTS
MERRITTS NEUROLOGY
CHAPTER 9. INVOLUNTARY MOVEMENTS

STANLEY FAHN
Suggested Readings
Although convulsions, fasciculations, and myokymia are involuntary movements, these disorders have special characteristics and are not classified with the types of
abnormal involuntary movements described in this chapter. The disorders commonly called abnormal involuntary movements, or dyskinesias, are usually evident
when a patient is at rest, are frequently increased by action, and disappear during sleep. There are exceptions to these generalizations. For example, palatal
myoclonus may persist during sleep, and mild torsion dystonia may be present only during active voluntary movements (action dystonia), but not when the patient is at
rest. The known dyskinesias are distinguished mainly by visual inspection of the patient. Electromyography can occasionally be helpful by determining the rate,
rhythmicity, and synchrony of involuntary movements. Sometimes, patients have a dyskinesia that bridges the definitions of more than one disorder; this leads to
compound terms such as choreoathetosis, which describes features of both chorea and athetosis.
Most abnormal involuntary movements are continual or easily evoked, but some are intermittent or paroxysmal, such as tics, the paroxysmal dyskinesias, and episodic
ataxias. Gross movements of joints are highly visible, unlike the restricted muscle twitching of fasciculation or myokymia.
Tremors are rhythmic oscillatory movements. They result from alternating contractions of opposing muscle groups (e.g., parkinsonian tremor at rest) or from
simultaneous contractions of agonist and antagonist muscles (e.g., essential tremor). A useful way to clinically differentiate tremor to aid in diagnosis is to determine
whether the tremor is present under the following conditions: when the affected body part is at rest, as in parkinsonian disorders of the extrapyramidal system; when
posture is maintained (e.g., with arms outstretched in front of the body), as in essential tremor (see Chapter 113); when action is undertaken (e.g., writing or pouring
water from a cup), as in essential tremor, which increases with action; or when intention is present (e.g., finger-to-nose maneuver), as in cerebellar disease (see
Chapter 107).
The term myoclonus (see Chapter 110) refers to shocklike movements due to contractions or inhibitions (negative myoclonus). Chorea delineates brief, irregular
contractions that, although rapid, are not as lightninglike as myoclonic jerks. In classic choreic disorders, such as Huntington disease (see Chapter 108) and
Sydenham chorea (see Chapter 109), the jerks affect individual muscles as random events that seem to flow from one muscle to another. They are not repetitive or
rhythmic. Ballism is a form of chorea in which the choreic jerks are of large amplitude, producing flinging movements of the affected limbs. Chorea is presumably
related to disorders of the caudate nucleus but sometimes involves other structures. Ballism is related to lesions of the subthalamic nucleus.
Dystonia (see Chapter 112) is a syndrome of sustained muscle contraction that frequently causes twisting and repetitive movements or abnormal postures. Dystonia is
represented by (1) sustained contractions of both agonist and antagonist muscles, (2) an increase of these involuntary contractions when voluntary movement in other
body parts is attempted (overflow), (3) rhythmic interruptions ( dystonic tremor) of these involuntary, sustained contractions when the patient attempts to oppose
them, (4) inappropriate or opposing contractions during specific voluntary motor actions ( action dystonia), and (5) torsion spasms that may be as rapid as chorea but
differ because the movements are continual and of a twisting nature in contrast to the random and seemingly flowing movements of chorea. Torsion spasms may be
misdiagnosed as chorea; the other characteristics frequently lead to the misdiagnosis of a conversion reaction.
Tics are patterned sequences of coordinated movements that appear suddenly and intermittently. The movements are occasionally simple and resemble a myoclonic
jerk, but they are usually complex, ranging from head shaking, eye blinking, sniffing, and shoulder shrugging to complex facial distortions, arm waving, touching parts
of the body, jumping movements, or making obscene gestures (copropraxia). Most often, tics are rapid and brief, but occasionally they can be sustained motor
contractions (i.e., dystonic). In addition to motor tics, vocalizations may be a manifestation of tics. These range from sounds, such as barking, throat-clearing, or
squealing, to verbalization, including the utterance of obscenities ( coprolalia) and the repetitions of one's own sounds ( palilalia) or the sounds of others (echolalia).
Motor and vocal tics are the essential features of Tourette syndrome (see Chapter 111).
One feature of tics is the compelling need felt by the patient to make the motor or phonic tic, with the result that the tic movement brings relief from unpleasant
sensations that develop in the involved body part. Tics can be voluntarily controlled for brief intervals, but such a conscious effort is usually followed by more intense
and frequent contractions. The milder the disorder is, the more control the patient can exert. Tics can sometimes be suppressed in public. The spectrum of severity
and persistence of tics is wide. Sometimes, tics are temporary, and sometimes they are permanent.
Many persons develop personalized mannerisms. These physiologic tics may persist after repeated performances of motor habits and have therefore been called
habit spasms. As a result, unfortunately, all tics have been considered by some physicians as habit spasms of psychic origin. Today, however, the trend is to consider
pathologic tics a neurologic disorder.
Stereotypic movements (stereotypies) can resemble tics, but these are usually encountered in persons with mental retardation, autism, or schizophrenia. However,
bursts of stereotypic shaking movements, especially of the arms, can be encountered in otherwise normal children. Stereotypic movements are also encountered in
the syndrome of drug-induced tardive dyskinesia (see Chapter 116) and refer to repetitive movements that most often affect the mouth; in orobuccolingual dyskinesia,
there are constant chewing movements of the jaw, writhing and protrusion movements of the tongue, and puckering movements of the mouth. Other parts of the body
may also be involved.
Athetosis is a continuous, slow, writhing movement of the limbs (distal and proximal), trunk, head, face, or tongue. When these movements are brief, they merge with
chorea (choreoathetosis). When the movements are sustained at the peak of the contractions, they merge with dystonia, and the term athetotic dystonia can be
applied.
Akathitic movements are those of restlessness. They commonly accompany the subjective symptom of akathisia, an inner feeling of motor restlessness or the need to
move. Today, akathisia is most commonly seen as a side effect of anti-psychotic drug therapy, either as acute akathisia or tardive akathisia, which often accompanies
tardive dyskinesia. Akathitic movements (e.g., crossing and uncrossing the legs, caressing the scalp or face, pacing the floor, and squirming in a chair) can also be a
reaction to stress, anxiety, boredom, or impatience; it can then be termed physiologic akathisia. Pathologic akathisia, in addition to that induced by antipsychotic
drugs, can be seen in the encephalopathies of confusional states, in some dementias and in Parkinson disease. Picking at the bedclothes is a common manifestation
of akathitic movements in bedridden patients.
Two other neurologic conditions in which there are subjective feelings of the need to move are tics and the restless legs syndrome. The latter is characterized by
formication in the legs, particularly in the evening when the patient is relaxing and sitting or lying down and attempting to fall asleep. These sensations of ants
crawling under the skin disappear when the patient walks around. This disorder is not understood but may respond to opioids, levodopa, and dopamine agonists.
Continued muscle stiffness due to continuous muscle firing can be the result of neuromyotonia, encephalomyelitis with rigidity and myoclonus (spinal interneuronitis),
the stiff limb syndrome, and the stiff person syndrome (see Chapter 129). The last tends to involve axial and proximal limb muscles.
Paroxysmal movement disorders are syndromes in which the abnormal involuntary movements appear for brief periods out of a background of normal movement
patterns. They can be divided into four distinct groups: (1) the paroxysmal dyskinesias, (2) paroxysmal hypnogenic dyskinesias, (3) episodic ataxias, and (4)
hyperekplexias. The molecular genetics of the episodic ataxias implicate abnormalities of membrane ionic channels as underlying mechanisms for the paroxysmal
movement disorders.
Three types of paroxysmal dyskinesias are recognized ( Table 9.1). All three consist of bouts of any combination of dystonic postures, chorea, athetosis, and ballism.
They can be unilateral, always on one side or on either side, or bilateral. Unilateral episodes can be followed by a bilateral one. The attacks can be severe enough to
cause a patient to fall down. Speech is often affected, with inability to speak due to dystonia, but there is never any alteration of consciousness. Very often, patients
report variable sensations at the beginning of the paroxysms. Paroxysmal kinesigenic dyskinesia is the easiest to recognize. Attacks are very brief, usually lasting
seconds, and always less than 5 minutes. They are induced by sudden movements, startle, or hyperventilation, and can occur many times a day; they respond to
anticonvulsants. The primary forms of paroxysmal dyskinesias are inherited in an autosomal-dominant pattern, but secondary causes are common, particularly
multiple sclerosis. Attacks of paroxysmal nonkinesigenic dyskinesia last minutes to hours, sometimes longer than a day. Usually, they range from 5 minutes to 4 hours.
They are primed by consuming alcohol, coffee, or tea, as well as by psychologic stress, excitement, and fatigue. There are usually no more than three attacks per day,
and often attacks may be months apart. No consistent response to therapeutic interventions is yet available. This form can sometimes be the major presentation of a
psychogenic movement disorder. Paroxysmal exertional dyskinesia is triggered by prolonged exercise; attacks last from 5 to 30 minutes.
TABLE 9.1. CLINICAL FEATURES OF PAROXYSMAL KINESIGENIC (PKD), NONKINESIGENIC (PNKD), AND EXERTIONAL DYSKINESIA (PED)
Paroxysmal hypnogenic dyskinesias are divided into short- and long-duration attacks. Short-duration attacks are often the result of supplementary sensorimotor
seizures that occur during sleep. Three types of episodic ataxias have been distinguished ( Table 9.2). Hyperekplexia (excessive startle syndrome) consists of
dramatic complex motor responses to a sudden tactile or verbal stimulus. Echolalia and echopraxia are sometimes seen. The syndrome was originally described with
local names, such as jumping Frenchmen of Maine, Myriachit, and Latah. Hyperekplexia can be hereditary (glycine receptor on chromosome 5q) or sporadic. When it
is severe, the patient's movements must be curtailed because a sudden attack can lead to injury from falling.
TABLE 9.2. CLINICAL AND GENETIC FEATURES OF EPISODIC ATAXIAS
Although most of the involuntary movements described are the result of central nervous system disorders, particularly in the basal ganglia, some dyskinesias arise
from the brainstem, spinal cord, or peripheral nervous system. Dyskinesias attributed to peripheral disorders are hemifacial spasm (see Chapter 68), painful
legsmoving toes, jumpy stumps, belly-dancer's dyskinesia, and the sustained muscle contractions seen in reflex sympathetic dystrophy (see Chapter 70).
Psychogenic movement disorders seem to be increasingly more common. Usually, they appear with a mixture of different types of movements, particularly shaking,
paroxysmal disorders, fixed postures, or bizarre gaits. Careful evaluation for inconsistency, incongruity, false weakness or sensory changes, sudden onset, deliberate
slowness, and the appearance of marked fatigue and exhaustion from the involuntary movements helps suggest the diagnosis, which is best established by relief of
the signs and symptoms using psychotherapy, suggestion, and physiotherapy.
SUGGESTED READINGS
Baloh RW, Yue Q, Furman JM, Nelson SF. Familial episodic ataxia: clinical heterogeneity in four families linked to chromosome 19p. Ann Neurol 1997;41:816.
Bhatia KP, Bhatt MH, Marsden CD. The causalgia-dystonia syndrome. Brain 1993;116:843851.
Brown P. Physiology of startle phenomena. In: Fahn S, Hallett M, Luders HO, Marsden CD, eds. Negative motor phenomena. Advances in Neurology, vol 67. Philadelphia: LippincottRaven
Publishers, 1995:273287.
Dressler D, Thompson PD, Gledhill RF, Marsden CD. The syndrome of painful legs and moving toes: a review. Mov Disord 1994;9:1321.
Fahn S. Motor and vocal tics. In: Kurlan R, ed. Handbook of Tourette's syndrome and related tic and behavioral disorders. New York: Marcel Dekker, 1993:316.
Fahn S. Paroxysmal dyskinesias. In: Marsden CD, Fahn S, eds: Movement disorders, 3rd ed. Oxford: Butterworth-Heinemann, 1994;310345.
Fahn S. Psychogenic movement disorders. In: Marsden CD, Fahn S, eds. Movement disorders, 3rd ed. London: Butterworth, 1994:358372.
Iliceto G, Thompson PD, Day BL, et al. Diaphragmatic flutter, the moving umbilicus syndrome, and belly dancers' dyskinesia. Mov Disord 1990;5:1522.
Kulisevsky J, Marti-Fabregas J, Grau JM. Spasms of amputation stumps. J Neurol Neurosurg Psychiatry 1992;55:626627.
Marsden CD, Fahn S, eds. Movement disorders. London: Butterworth, 1982.
Marsden CD, Fahn S, eds. Movement disorders, 2nd ed. London: Butterworth, 1987.
Marsden CD, Fahn S, eds. Movement disorders, 3rd ed. London: Butterworth, 1994.
Tan A, Salgado M, Fahn S. The characterization and outcome of stereotypic movements in nonautistic children. Mov Disord 1997;12:4752.
Walters AS, Wagner ML, Hening WA, et al. Successful treatment of the idiopathic restless legs syndrome in a randomized double-blind trial of oxycodone versus placebo. Sleep 1993;16:327332.
CHAPTER 10. SYNDROMES CAUSED BY WEAK MUSCLES
MERRITTS NEUROLOGY
CHAPTER 10. SYNDROMES CAUSED BY WEAK MUSCLES

LEWIS P. ROWLAND
Recognition of Weakness or Pseudoweakness

Patterns of Weakness
Suggested Readings
Weakness implies that a muscle cannot exert normal force. Neurologists use the words paralysis or plegia to imply total loss of contractility; anything less than total
loss is paresis. In practice, however, someone may mention a partial hemiplegia, which conveys the idea even if it is internally inconsistent. Hemiplegia implies
weakness of an arm and leg on the same side. Crossed hemiplegia is a confusing term, generally implying unilateral cranial nerve signs and hemiplegia on the other
side, a pattern seen with brainstem lesions above the decussation of the corticospinal tracts. Monoplegia is weakness of one limb; paraplegia means weakness of
both legs.
This chapter describes syndromes that result from pathologically weak muscles, so that a student new to neurology can find the sections of the book that describe
specific diseases. There is more than one approach to this problem, because no single approach is completely satisfactory. Elaborate algorithms have been devised,
but the flowchart may be too complicated to be useful unless it is run by a computer.
It may be simpler to determine first whether there is pathologic weakness, then to find evidence of specific syndromes that depend on recognition of the following
characteristics: distribution of weakness, associated neurologic abnormalities, tempo of disease, genetics, and patient age.
RECOGNITION OF WEAKNESS OR PSEUDOWEAKNESS
Patients with weak muscles do not often use the word weakness to describe their symptoms. Rather, they complain that they cannot climb stairs, rise from chairs, or
run or that they note footdrop (and may actually use that term). They may have difficulty turning keys or doorknobs. If proximal arm muscles are affected, lifting
packages, combing hair, or working overhead may be difficult. Weakness of cranial muscles causes ptosis of the eyelids, diplopia, dysarthria, dysphagia, or the
cosmetic distortion of facial paralysis. These specific symptoms will be analyzed later.
Some people use the word weakness when there is no neurologic abnormality. For instance, aging athletes may find that they can no longer match the
achievements of youth, but that is not pathologic weakness. Weakness in a professional athlete causes the same symptoms that are recognized by other people when
the disorder interferes with the conventional activities of daily life. Losing a championship race, running a mile in more than 4 minutes, or jogging only 5 miles instead
of a customary 10 miles are not symptoms of diseased muscles.
Others who lack the specific symptoms of weakness may describe chronic fatigue. They cannot do housework; they have to lie down to rest after the briefest
exertion. If they plan an activity in the evening, they may spend the entire day resting in advance. Employment may be in jeopardy. Myalgia is a common component
of this syndrome, and there is usually evidence of depression.
The chronic fatigue syndrome affects millions of people and is a major public health problem. Vast research investments have been made to evaluate possible viral,
immune, endocrine, autonomic, metabolic, and other factors, None, however, seems as consistent as depression and psychosocial causes. It is not, as some put it, a
diagnosis of exclusion. Instead, the characteristic history is recognizable, and on examination there is no limb weakness or reflex alteration.
Fading athletes and depressed, tired people with aching limbs have different emotional problems, but both groups lack the specific symptoms of muscle weakness,
and they share two other characteristics: No abnormality appears on neurologic examination, and no true weakness is evident on manual muscle examination. That is,
there is no weakness unless the examiner uses brute force. A vigorous young adult examiner may outwrestle a frail octogenarian, but that does not imply pathologic
weakness in the loser. Students and residents must use reasonable force in tests of strength against resistance.
Fatigue and similar symptoms may sometimes be manifestations of systemic illness due to anemia, hypoventilation, congestive heart failure with hypoxemia and
hypercapnia, cancer, or systemic infection. There is usually other evidence of the underlying disease, however, and that syndrome is almost never mistaken for a
neurologic disorder.
Other patients have pseudoweakness. For instance, some patients attribute a gait disorder to weak legs, but it is immediately apparent on examination or even before
formal examination that they have parkinsonism. Or a patient with peripheral neuropathy may have difficulty with fine movements of the fingers, not because of
weakness but because of severe sensory loss. Or a patient may have difficulty raising one or both arms because of bursitis, not limb weakness. Or a patient with
arthritis may be reluctant to move a painful joint. These circumstances are explained by findings on examination.
Examination may also resolve another problem in the evaluation of symptoms that might be due to weakness. Sometimes, when limb weakness is mild, it is difficult for
the examiner to know how much resistance to apply to determine whether the apparent weakness is real. Then, the presence or absence of wasting, fasciculation, or
altered tendon reflexes may give the crucial clues. Symptomatic weakness is usually accompanied by some abnormality on examination. Even in myasthenia gravis,
symptoms may fluctuate in intensity, but there are always objective signs of abnormality on examination if the patient is currently having symptoms. There is a maxim:
A normal neurologic examination is incompatible with the diagnosis of symptomatic myasthenia gravis.
Finally, examination may uncover patients with pseudoweakness that may be due to deceit, deliberate or otherwise. Hysteric patients and Munchausen deceivers or
other malingerers who feign weakness all lack specific symptoms. Or they may betray inconsistencies in the history because they can participate in some activities but
not in others that involve the same muscles. On examination, their dress, cosmetic facial makeup, and behavior may be histrionic. In walking, they may stagger
dramatically, but they do not fall or injure themselves by bumping into furniture. In manual muscle tests, they abruptly give way, or they shudder in tremor rather than
apply constant pressure. Misdirection of effort is one way to describe that behavior. Some simply refuse to participate in the test. The extent of disorder may be
surprising, however. I and others have seen psychogenic impairment of breathing that led to use of a mechanical ventilator.
PATTERNS OF WEAKNESS
In analyzing syndromes of weakness, the examiner uses several sources of information for the differential diagnosis. The pattern of weakness and associated
neurologic signs delimit some of the anatomic possibilities to answer the question of where the lesion is located. Patient age and the tempo of evolution aid in
deciding what the lesion is.
The differential diagnosis of weakness encompasses much of clinical neurology, so the reader will be referred to other sections for some of the review. For instance,
the first task in the analysis of a weak limb is to determine whether the condition is due to a lesion of the upper or lower motor neuron, a distinction that is made on the
basis of clinical findings. Overactive tendon reflexes with clonus, Hoffmann signs, and Babinski signs denote an upper motor neuron disorder. Lower motor neuron
signs include muscle weakness, wasting, and fasciculation, with loss of tendon reflexes. These distinctions may seem crude, but they have been passed as reliable
from generation to generation of neurologists.
If the clinical signs imply a lower motor neuron disorder, the condition could be due to problems anywhere in the motor unit (motor neuron or axon, neuromuscular
junction, or muscle). This determination is guided by principles stated in Chapter 124. Diseases of the motor unit are also covered in that chapter, so the following
information will be concerned primarily (but not entirely) with central lesions.
Hemiparesis
If there is weakness of the arm and leg on the same side and upper motor neuron signs imply a central lesion, the lesion could be in the cervical spinal cord or in the
brain. Pain in the neck or in the distribution of a cervical dermatome might be clues to the site of the lesion. Unilateral facial weakness may be ipsilateral to the
hemiparesis, placing the lesion in the brain and above the nucleus of the seventh cranial nerve; or a change in mentation or speech may indicate that the lesion is
cerebral, not cervical. Sometimes, however, there are no definite clinical clues to the site of the lesion, and the examiner must rely on magnetic resonance imaging
(MRI), computed tomography (CT), electroencephalography, cerebrospinal fluid (CSF) findings, or myelography to determine the site and nature of the lesion
together.
The course of hemiparesis gives clues to the nature of the disorder. The most common cause in adults is cerebral infarction or hemorrhage. Abrupt onset, prior
transient attacks, and progression to maximal severity within 24 hours in a person with hypertension or advanced age are indications that a stroke has occurred. If no
cerebral symptoms are present, there could conceivably be transverse myelitis of the cervical spinal cord, but that condition would be somewhat slower in evolution
(days rather than hours) and more likely to involve all four limbs. Similarly, multiple sclerosis is more likely to be manifest by bilateral corticospinal signs than by a
pure hemiplegia.
If hemiparesis of cerebral origin progresses for days or weeks, it is reasonable to suspect a cerebral mass lesion, whether the patient is an adult or a child. If the
patient has had focal seizures, that possibility is the more likely. In addition to brain tumors, other possibilities include arteriovenous malformation, brain abscess, or
other infections. Infectious or neoplastic complications of acquired immunodeficiency syndrome are constant considerations these days. Metabolic brain disease
usually causes bilateral signs with mental obtundation and would be an unusual cause of hemiparesis, even in a child.
Hemiparesis of subacute evolution could arise in the cervical spinal cord if there were, for instance, a neurofibroma of a cervical root. That condition would be
signified by local pain in most cases, and because there is so little room in the cervical spinal canal, bilateral corticospinal signs would probably be present.
In general, hemiparesis usually signifies a cerebral lesion rather than one in the neck, and the cause is likely to be denoted by the clinical course and by CT or MRI.
Paraparesis
Paresis means weakness, and paraparesis is used to describe weakness of both legs. The term has also been extended, however, to include gait disorders caused by
lesions of the upper motor neuron, even when there is no weakness on manual muscle examination. The disorder is then attributed to spasticity or the clumsiness
induced by malfunction of the corticospinal tracts. In adults, the most common cause of that syndrome, spastic paraparesis of middle life, is multiple sclerosis. The
differential diagnosis includes tumors in the region of the foramen magnum, Chiari malformation, cervical spondylosis, arteriovenous malformation, and primary lateral
sclerosis (all described in other sections of this book). The diagnosis cannot be made on clinical grounds alone and requires information from CSF examination
(protein, cells, gamma globulin, oligoclonal bands), evoked potentials, CT, MRI, and myelography.
When there are cerebellar or other signs in addition to bilateral corticospinal signs, the disorder may be multiple sclerosis or an inherited disease, such as
olivopontocerebellar degeneration. The combination of lower motor neuron signs in the arms and upper motor neuron signs in the legs is characteristic of amyotrophic
lateral sclerosis; the same syndrome has been attributed without proof to cervical spondylosis. That pattern may also be seen in syringomyelia, but it is exceptional to
find syringomyelia without typical patterns of sensory loss.
Other clues to the nature of spastic paraparesis include cervical or radicular pain in neurofibromas or other extraaxial mass lesions in the cervical spinal canal. Or
there may be concomitant cerebellar signs or other indication of multiple sclerosis.
It is said that brain tumors in the parasagittal area may cause isolated spastic paraparesis by compressing the leg areas of the motor cortex in both hemispheres. This
possibility seems more theoretical than real, however, because no well documented cases have been reported.
Chronic paraparesis may also be due to lower motor neuron disorders. Instead of upper motor neuron signs, there is flaccid paraparesis, with loss of tendon reflexes
in the legs. This differential diagnosis includes motor neuron diseases, peripheral neuropathy, and myopathy as described in Chapter 124.
Paraparesis of acute onset (days rather than hours or weeks) presents a different problem in diagnosis. If there is back pain and tendon reflexes are preserved or if
there are frank upper motor neuron signs, a compressive lesion may be present. As the population ages, metastatic tumors become an increasingly more common
cause. In children or young adults, the syndrome may be less ominous, even with pain, because the disorder is often due to acute transverse myelitis. This may be
seen in children or adults, and in addition to the motor signs, a sensory level usually designates the site of the lesion. Spinal MRI or myelography is needed to make
this differentiation. In the elderly population, a rare cause of acute paraplegia is infarction of the spinal cord. That syndrome is also sometimes seen after surgical
procedures that require clamping of the aorta.
If the tendon reflexes are lost and there is no transverse sensory level in a patient with an acute paraparesis, the most common cause is Guillain-Barr syndrome, at
any age from infancy to the senium. Sensory loss may facilitate that diagnosis, but sometimes little or no sensory impairment occurs. Then, the diagnosis depends on
examination of the CSF and electromyography (EMG). The Guillain-Barr syndrome, however, may also originate from diverse causes. In developing countries, acute
paralytic poliomyelitis is still an important cause of acute paraplegia. Rarely, an acute motor myelitis may be due to some other virus. In China, for instance, there
have been summertime outbreaks of an acute motor axonopathy that differs from both Guillain-Barr syndrome and poliomyelitis, in particular, but, like the other
syndromes, causes paraparesis.
The reverse of paraplegia would be weakness of the arms with good function in the legs, or bibrachial paresis. Lower motor neuron syndromes of this nature are
seen in some cases of amyotrophic lateral sclerosis (with or without upper motor neuron signs in the legs). The arms hang limply at the side while the patient walks
with normal movements of the legs. Similar patterns may be seen in some patients with myopathy of unusual distribution. It is difficult to understand how a cerebral
lesion could cause weakness of the arms without equally severe weakness of the legs, but this man-in-the-barrel syndrome is seen in comatose patients who survive
a bout of severe hypotension. The site of the lesion is not known, but it could be bilateral and prerolandic.
Monomelic Paresis
If one leg or one arm is weak, the presence of pain in the low back or the neck may point to a compressive lesion. Whether acute or chronic, herniated nucleus
pulposus is high on the list of possibilities if radicular pain is present. Acute brachial plexus neuritis (neuralgic amyotrophy) is another cause of weakness in one limb
with pain; a corresponding syndrome of the lumbosacral plexus is much less common. Peripheral nerve entrapment syndromes may also cause monomelic weakness
and pain, but the pain is local, not radicular. Mononeuritis multiplex may also cause local pain, paresthesia, and paresis.
In painless syndromes of isolated limb weakness in adults, motor neuron disease is an important consideration if there is no sensory loss. Sometimes, in evaluating a
limb with weak, wasted, and fasciculating muscle, the examiner is surprised because tendon reflexes are preserved or even overactive, instead of being lost. This
apparent paradox implies lesions of both upper and lower motor neurons, almost pathognomonic of amyotrophic lateral sclerosis. The signs may be asymmetric in
early stages of the disease.
Although rare, it is theoretically possible for strokes or other cerebral lesions to cause monomelic weakness with upper motor neuron signs. Weakness due to a
cerebral lesion may be more profound in the arm, but abnormal signs are almost always present in the leg, too; that is, the syndrome is really a hemiparesis.
Neck Weakness
Difficulty holding up the head is seen in some patients with diseases of the motor unit, probably never in patients with upper motor neuron disorders. Usually, patients
with neck weakness also have symptoms of disorder of the lower cranial nerves (dysarthria and dysphagia) and often also of adjacent cervical segments, as manifest
by difficulty raising the arms. Amyotrophic lateral sclerosis and myasthenia gravis are probably the two most common causes.
Rarely, there is isolated weakness of neck muscles, with difficulty holding the head up, but no oropharyngeal or arm symptoms. This floppy head syndrome or
dropped head syndrome is a disabling disorder that is usually due to one of three conditions: motor neuron disease, myasthenia gravis, or polymyositis. I have seen
one such patient with a Chiari malformation. Some cases, however, are idiopathic.
New terms have been introduced to explain this syndrome: the bent spine syndrome and isolated myopathy of the cervical extensor muscles, which may be variations
of the same condition. EMG shows a myopathic pattern in affected paraspinal muscles, and MRI may show replacement of muscle by fat in cervical, thoracic, or both
areas.
Weakness of Cranial Muscles
The syndromes due to weakness of cranial muscles are reviewed in Chapter 7 and Chapter 68. The major problems in differential diagnosis involve the site of local
lesions that affect individual nerves of ocular movement, facial paralysis, or the vocal cords. Pseudobulbar palsy due to upper motor neuron lesions must be
distinguished from bulbar palsy due to lower motor neuron disease and then almost always a form of amyotrophic lateral sclerosis. This distinction depends on
associated signs of upper or lower motor neuron lesions. Myasthenia gravis can affect the eyes, face, or oropharynx (but only exceptionally the vocal cords); in fact,
the diagnosis of myasthenia gravis is doubtful if there are no cranial symptoms. Brainstem syndromes in the aging population may be due to stroke, meningeal
carcinomatosis, or brainstem encephalitis.
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1998;65:258259.
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CHAPTER 11. GAIT DISORDERS
MERRITTS NEUROLOGY
CHAPTER 11. GAIT DISORDERS

SID GILMAN
Examining Stance and Gait

Gait in Hemiparesis
Gait in Paraparesis
Gait in Parkinsonism
Gait in Cerebellar Disease
Gait in Sensory Ataxia
Psychogenic Gait Disorders
Gait in Cerebral Palsy
Gait in Chorea
Gait in Dystonia Musculorum Deformans
Gait in Muscular Dystrophy
Senile Gait Disorders
Gait in Lower Motor Neuron Disorders
Suggested Readings
Observation of the stance and gait of patients with neurologic symptoms can provide important diagnostic information and may immediately suggest particular
disorders of motor or sensory function, or even specific diseases. Some types of gait are so characteristic of certain diseases that the diagnosis may be obvious at the
initial encounter with a patient. An example of this is the typical posture and gait of patients with Parkinson disease.
In normal bipedal locomotion, one leg and then the other alternately supports the erect moving body. Each leg undergoes brief periods of acceleration and
deceleration as body weight shifts from one foot to the other. When the moving body passes over the supporting leg, the other leg swings forward in preparation for its
next support phase. One foot or the other constantly contacts the ground, and when support of the body is transferred from the trailing leg to the leading leg, both feet
are on the ground momentarily.
Normal bipedal locomotion requires two processes: continuous ground reaction forces that support the body's center of gravity, and periodic movement of each foot
from one position of support to the next in the direction of progression. As a consequence of these basic requirements, certain displacements of the body segments
regularly occur in walking. To start walking, a person raises one foot and accelerates the leg forward; this is the swing phase of walking. Muscle action in the
supporting leg causes the center of gravity of the body to move forward, creating a horizontal reaction force at the foot. The greater this reaction force is, the greater is
the acceleration of the body, because the amount of force equals the body mass multiplied by the amount of acceleration. The swing phase ends when the leg that
has swung forward makes contact with the ground, which is when the stance phase of walking begins. During the stance phase, the body weight shifts to the opposite
leg and another swing phase can begin. The major groups of muscles of the leg are active at the beginning and the end of the stance and swing phases. As the body
passes over the weight-bearing leg, it tends to be displaced toward the weight-bearing side, causing a slight side-to-side movement. In addition, the body rises and
falls with each step. The body rises to a maximum level during the swing phase and descends to a minimum level during the stance phase. As the body accelerates
upward during the swing phase, the vertical floor reaction increases to a value that exceeds the body weight. The vertical floor reaction falls to a minimum during
downward acceleration, reducing the total vertical reaction to a value less than the body weight.
EXAMINING STANCE AND GAIT
When examining patients' stance and gait, the physician should observe them from the front, back, and sides. Patients should rise quickly from a chair, walk normally
at a slow pace and then at a fast pace, and then turn around. They should walk successively on their toes, on their heels, and then in tandem (i.e., placing the heel of
one foot immediately in front of the toes of the opposite foot and attempting to progress forward in a straight line). They should stand with their feet together and the
head erect, first with open eyes and then with closed eyes, to determine whether they can maintain their balance.
When a person walks normally, the body should be held erect with the head straight and the arms hanging loosely at the sides, each moving rhythmically forward with
the opposite leg. The shoulders and hips should be approximately level. The arms should swing equally. The steps should be straight and about equal in length. The
head should not be tilted, and there should be no appreciable scoliosis or lordosis. With each step, the hip and knee should flex smoothly, and the ankle should
dorsiflex with a barely perceptible elevation of the hips as the foot clears the ground. The heel should strike the ground first, and the weight of the body should be
transferred successively onto the sole of the foot and then onto the toes. The head and then the body should rotate slightly with each step, without lurching or falling.
Although there are gross similarities in the way that normal people walk, each person walks in a distinctive fashion. The distinctions between people reflect both their
individual physical characteristics and their personality traits. Among the variables that compose the physical characteristics are speed, stride length, positions of the
feet (e.g., with the toes pointing outward or pointing inward), characteristics of the walking surface, and the type of footwear worn. Perhaps, more important are the
goals to be accomplished in walking, as well as the person's aspirations, motivations, and attitudes. For some situations, speed is the most important factor. In other
situations, safe arrival or the minimal expenditure of energy may be more important. Some people learn to walk gracefully or in the least obtrusive manner possible
and consequently may expend extra energy. Others learn to walk ungracefully but as effectively as possible for the amount of energy expended. The manner of
walking may provide clues to personality traits (e.g., aggressiveness, timidity, self-confidence, aloofness).
GAIT IN HEMIPARESIS
Hemiparesis from an upper motor neuron lesion results in a characteristic posture and gait owing to the combined effects of spasticity and weakness of the affected
limbs. Patients with hemiparesis usually stand and walk with the affected arm flexed and the leg extended. In walking, they have difficulty flexing the hip and knee and
dorsiflexing the ankle; the paretic leg swings outward at the hip to avoid scraping the foot on the floor. The leg maintains a stiff posture in extension and rotates in a
semicircle, first away from and then toward the trunk, with a circumduction movement. Despite the circumduction, the foot may scrape the floor so that the toe and
outer side of the sole of the shoe become worn first. The upper body often rocks slightly to the opposite side during the circumduction movement. The arm on the
hemiparetic side usually moves little during walking, remaining adducted at the shoulder, flexed at the elbow, and partially flexed at the wrist and fingers. In a person
without a previous motor disorder, loss of the swinging motion of an arm may be the first sign of a progressive upper motor neuron lesion that will result in a
hemiparesis.
GAIT IN PARAPARESIS
Paraparesis usually results from lesions of the thoracic portion of the spinal cord. The gait of these patients results from the combined effects of spasticity and
weakness of the legs and consists of slow, stiff movements at the knees and hips with evidence of considerable effort. The legs are usually maintained extended or
slightly flexed at the hips and knees and are often adducted at the hips. In some patients, particularly those with severe spasticity, each leg may cross in front of the
other during the swing phase of walking, causing a scissors gait. The steps are short, and patients may move the trunk from side to side in attempts to compensate for
the slow, stiff movements of the legs. The legs circumduct at the hips, and the feet scrape the floor, so that the soles of the shoes become worn at the toes.
GAIT IN PARKINSONISM
The gait in Parkinson disease reflects a combination of akinesia (difficulty in initiating movement), dystonia (relatively fixed abnormal postures), rigidity, and tremor.
These patients stand in a posture of general flexion, with the spine bent forward, the head bent downward, the arms moderately flexed at the elbows, and the legs
slightly flexed. They stand immobile and rigid, with a paucity of automatic movements of the limbs and a masklike fixed facial expression with infrequent blinking.
Although the arms are held immobile, often a rest tremor involves the fingers and wrists at 4 to 5 cycles per second. When these patients walk, the trunk bends even
farther forward; the arms remain immobile at the sides of the body or become further flexed and carried somewhat ahead of the body. The arms do not swing. As
patients walk forward, the legs remain bent at the knees, hips, and ankles. The steps are short so that the feet barely clear the ground and the soles of the feet shuffle
and scrape the floor. The gait, with characteristically small steps, is termed marche petits pas. Forward locomotion may lead to successively more rapid steps, and
the patient may fall unless assisted; this increasingly rapid walking is called festination. If patients are pushed forward or backward, they cannot compensate with
flexion or extension movements of the trunk. The result is a series of propulsive or retropulsive steps. Parkinsonian patients can sometimes walk with surprising
rapidity for brief intervals. These patients often have difficulty when they start to walk after standing still or sitting in a chair. They may take several very small steps
that cover little distance before taking longer strides. The walking movements may stop involuntarily, and the patient may freeze on attempts to pass through a
doorway or into an elevator.
GAIT IN CEREBELLAR DISEASE
Patients with disease of the cerebellum stand with their legs farther apart than normal and may develop titubation, a coarse fore-and-aft tremor of the trunk. Often,
they cannot stand with their legs so close that the feet are touching; they sway or fall in attempts to do so, whether their eyes are open or closed. They walk
cautiously, taking steps of varying length, some shorter and others longer than usual. They may lurch from one side to another. Because of this unsteady or ataxic
gait, which they usually attribute to poor balance, they fear walking without support and tend to hold onto objects in the room, such as a bed or a chair, moving
cautiously between these objects. When gait ataxia is mild, it can be enhanced by asking the patient to attempt tandem walking in a straight line, successively placing
the heel of one foot directly in front of the toes of the opposite foot. Patients commonly lose their balance during this task and must quickly place one foot to the side
to avoid falling.
When disease is restricted to the vermal portions of the cerebellum, disorders of stance and gait may appear without other signs of cerebellar dysfunction, such as
limb ataxia or nystagmus. This pattern is seen in alcoholic cerebellar degeneration. Diseases of the cerebellar hemispheres, unilateral or bilateral, may also affect
gait. With a unilateral cerebellar-hemisphere lesion, ipsilateral disorders of posture and movement accompany the gait disorder. Patients usually stand with the
shoulder on the side of the lesion lower than the other; there is accompanying scoliosis. The limbs on the side of the cerebellar lesion show decreased resistance to
passive manipulation (hypotonia). When these patients attempt to touch their nose and then the examiner's finger (the finger-nose-finger test), they miss their target
and experience a side-to-side tremor generated from the shoulder. When they attempt to touch the knee of one leg with the heel of the other leg and then move the
heel smoothly down along the shin (the heel-knee-shin test), a side-to-side tremor of the moving leg develops, generated from the hip. On walking, patients with
cerebellar disease show ataxia of the leg ipsilateral to the cerebellar lesion; consequently they stagger and progressively deviate to the affected side. This can be
demonstrated by asking them to walk around a chair. As they rotate toward the affected side, they tend to fall into the chair; rotating toward the normal side, they
move away from the chair in a spiral. Patients with bilateral cerebellar-hemisphere disease show a disturbance of gait similar to that seen in disease of the vermis, but
signs of cerebellar dysfunction also appear in coordinated limb movements. Thus, these patients show abnormal finger-nose-finger and heel-knee-shin tests
bilaterally.
GAIT IN SENSORY ATAXIA
Another characteristic gait disorder results from loss of proprioceptive sensation in the legs due to lesions of the afferent fibers in peripheral nerves, dorsal roots,
dorsal columns of the spinal cord, or medial lemnisci. Patients with such lesions are unaware of the position of the limbs and consequently have difficulty standing or
walking. They usually stand with their legs spread widely apart. If asked to stand with their feet together and eyes open, they remain stable, but when they close their
eyes, they sway and often fall ( Romberg sign). They walk with their legs spread widely apart, watching the ground carefully. In stepping, they lift the legs higher than
normal at the hips and fling them abruptly forward and outward. The steps vary in length and may cause a characteristic slapping sound as the foot contacts the floor.
They usually hold the body somewhat flexed, often using a cane for support. If vision is impaired and these patients attempt to walk in the dark, the gait disturbance
worsens.
PSYCHOGENIC GAIT DISORDERS
Psychogenic disorders of gait often appear in association with many other neurologic complaints, including dizziness, loss of balance, and weakness of both legs or
the arm and leg on one side of the body. The gait is usually bizarre, easily recognized, and unlike any disorder of gait evoked by organic disease. In some patients,
however, hysteric gait disorders may be difficult to identify. The key to the diagnosis is the demonstration that objective organic signs of disease are missing. In
hysteric hemiplegia, patients drag the affected leg along the ground behind the body and do not circumduct the leg, scraping the sole of the foot on the floor, as in
hemiplegia due to an organic lesion. At times, the hemiplegic leg may be pushed ahead of the patient and used mainly for support. The arm on the affected side does
not develop the flexed posture commonly seen with hemiplegia from organic causes, and the hyperactive tendon reflexes and Babinski sign on the hemiplegic side
are missing.
Hysteric paraplegic patients usually walk with one or two crutches or lie helplessly in bed with the legs maintained in rigid postures or at times completely limp. The
term astasia-abasia refers to patients who cannot stand or walk but who can carry out natural movements of the limbs while lying in bed. At times, patients with
hysteric gait disorders walk only with seemingly great difficulty, but they show normal power and coordination when lying in bed. On walking, patients cling to the bed
or objects in the room. If asked to walk without support, they may lurch dramatically while managing feats of extraordinary balance to avoid falling. They may fall, but
only when a nearby physician or family member can catch them or when soft objects are available to cushion the fall. The gait disturbance is often dramatic, with the
patient lurching wildly in many directions and finally falling, but only when other people are watching the performance. They often demonstrate remarkable agility in
their rapid postural adjustments when they attempt to walk.
GAIT IN CEREBRAL PALSY
The term cerebral palsy includes several different motor abnormalities that usually result from perinatal injury. The severity of the gait disturbance varies, depending
on the nature of the lesion. Mild limited lesions may result in exaggerated tendon reflexes and extensor plantar responses with a slight degree of talipes equinovarus
but no clear gait disorder. More severe and extensive lesions often result in bilateral hemiparesis; patients stand with the legs adducted and internally rotated at the
hips, extended or slightly flexed at the knees, with plantar flexion at the ankles. The arms are held adducted at the shoulders and flexed at the elbows and wrists.
Patients walk slowly and stiffly with plantar flexion of the feet, causing them to walk on the toes. Bilateral adduction of the hips causes the knees to rub together or to
cross, causing a scissors gait.
The gait in patients with cerebral palsy can be altered by movement disorders. Athetosis is common and consists of slow, serpentine movements of the arms and legs
between the extreme postures of flexion with supination and extension with pronation. On walking, patients with athetotic cerebral palsy show involuntary limb
movements that are accompanied by rotatory movements of the neck and constant grimacing. The limbs usually show the bilateral hemiparetic posture described
previously; however, superimposed on this posture may be partially fixed asymmetric limb postures with, for example, flexion with supination of one arm and extension
with pronation of the other. Asymmetric limb postures commonly occur in association with rotated postures of the head, generally with extension of the arm on the side
to which the chin rotates and flexion of the opposite arm.
GAIT IN CHOREA
Chorea literally means the dance and refers to the gait disorder seen most often in children with Sydenham chorea or adults with Huntington disease. Both conditions
are characterized by continuous and rapid movements of the face, trunk, and limbs. Flexion, extension, and rotatory movements of the neck occur with grimacing
movements of the face, twisting movements of the trunk and limbs, and rapid piano-playing movements of the digits. Walking generally accentuates these movements.
In addition, sudden forward or sideward thrusting movements of the pelvis and rapid twisting movements of the trunk and limbs result in a gait resembling a series of
dancing steps. With walking, patients speed up and slow down at unpredictable times, evoking a lurching gait.
GAIT IN DYSTONIA MUSCULORUM DEFORMANS
The first symptom of this disorder often consists of an abnormal gait resulting from inversion of one foot at the ankle. Patients walk initially on the lateral side of the
foot; as the disease progresses, this problem worsens, and other postural abnormalities develop, including elevation of one shoulder and hip and twisted postures of
the trunk. Intermittent spasms of the trunk and limbs then interfere with walking. Eventually, there is torticollis, tortipelvis, lordosis, or scoliosis. Finally, patients may
become unable to walk.
GAIT IN MUSCULAR DYSTROPHY
In muscular dystrophy, weakness of the muscles of the trunk and the proximal parts of the legs produces a characteristic stance and gait. In attempting to rise from the
seated position, patients flex the trunk at the hips, put their hands on their knees, and push the trunk upward by working their hands up the thighs. This sequence of
movements is termed Gowers sign. Patients stand with exaggerated lumbar lordosis and a protuberant abdomen because of weakness of the abdominal and
paravertebral muscles. They walk with the legs spread widely apart, showing a characteristic waddling motion of the pelvis that results from weakness of the gluteal
muscles. The shoulders often slope forward, and winging of the scapulae may be seen as the patients walk.
SENILE GAIT DISORDERS
Many disorders of gait have been observed in elderly persons, including some people who have overt neurologic disease.
Cautious Gait
This gait is often seen in normal elderly people. It is characterized by a slightly widened base, shortened stride, slowness of walking, and turning in a block. There is
no hesitancy in the initiation of gait and no shuffling or freezing. The rhythm of walking and foot clearance are normal. There is mild disequilibrium in response to a
push and difficulty in balancing on one foot.
Subcortical Disequilibrium
This gait disorder is seen with progressive supranuclear palsy and multiinfarct dementia. Patients have marked difficulty maintaining the upright posture and show
absent or poor postural adjustments in response to perturbations. Some patients hyperextend the trunk and neck and fall backward or forward, thus impairing
locomotion. These patients commonly show ocular palsies, dysarthria, and the parkinsonian signs of rigidity, akinesia, and tremor.
Frontal Disequilibrium
Many patients with frontal disequilibrium cannot rise, stand, or walk; some cannot even sit without support. Standing and walking are difficult or impossible. When they
try to rise from a chair, they lean backward rather than forward, and they cannot bring their legs under their center of gravity. When they attempt to step, their feet
frequently cross and move in a direction that is inappropriate to their center of gravity. Clinical examination usually reveals dementia, signs of frontal release (suck,
snout, and grasp reflexes), motor perseveration, urinary incontinence, pseudobulbar palsy, exaggerated muscle stretch reflexes, and extensor plantar responses.
Isolated Gait Ignition Failure
Patients with this disorder have difficulty starting to walk and continuing walking, even though they have no impairment of equilibrium, cognition, limb praxis, or
extrapyramidal function. Once they start to walk, the steps are short and their feet barely clear the ground, thereby creating a shuffling appearance. With continued
stepping, however, the stride lengthens, foot clearance is normal, and the arms swing normally. If their attention is diverted, their feet may freeze momentarily and
shuffling may recur. Postural responses and stance base are normal, and falls are rare. The terms magnetic gait or apraxia of gait pertain to both isolated gait ignition
failure and frontal gait disorder.
Frontal Gait Disorder
This disturbance is often seen with multiinfarct dementia or normal pressure hydrocephalus. Characteristically, these patients stand on a wide base (though
sometimes a narrow base) and take short steps with shuffling, hesitate in starting to walk and in turning, and show moderate disequilibrium. Associated findings
include cognitive impairment, pseudobulbar palsy with dysarthria, signs of frontal release (e.g., suck, snout, and grasping reflexes), paratonia, signs of corticospinal
tract disease, and urinary dysfunction. In patients who have this gait disorder in association with normal pressure hydrocephalus, ventricular shunting may restore a
normal gait.
GAIT IN LOWER MOTOR NEURON DISORDERS
Diseases of the motor neurons or peripheral nerves characteristically cause distal weakness, and footdrop is a common manifestation. In motor neuron disease and in
the hereditary neuropathies (e.g., Charcot-Marie-Tooth disease), the disorder is likely to be bilateral. If the patient has a compressive lesion of one peroneal nerve,
the process may be unilateral. In either case, patients cannot dorsiflex the foot in walking, as is normal each time the swinging leg begins to move. As a result, the
toes are scuffed along the ground. To avoid this awkwardness, patients raise the knee higher than usual, resulting in a steppage gait. If the proximal muscles of the
legs are affected (in addition to or instead of distal muscles), the gait also has a waddling appearance.
SUGGESTED READINGS
Alexander NB. Differential diagnosis of gait disorders in older adults. Clin Geriatr Med 1996;12:689703.
Alexander NB. Gait disorders in older adults. J Am Geriatr Soc 1996;44:434451.
Dietz V. Neurophysiology of gait disorders: present and future applications. Electroencephalogr Clin Neurophysiol 1997;103:333355.
Gilman S. Cerebellar disorders. In: Rosenberg R, Pleasure DE, eds. Comprehensive neurology, 2nd ed. New York: John Wiley & Sons, 1998:415433.
Keane JR. Hysterical gait disorders: 60 cases. Neurology 1989;39:586589.
Morris M, Iansek R, Matyas T, Summers J. Abnormalities in the stride length-cadence relation in parkinsonian gait. Mov Disord 1998;13:6169.
Nutt JG, Marsden CD, Thompson PD. Human walking and higher-level gait disorders, particularly in the elderly. Neurology 1993;43:268279.
Rubino FA. Gait disorders in the elderly: distinguishing between normal and dysfunctional gaits. Postgrad Med 1993;93:185190.
Tyrrell PJ. Apraxia of gait or higher level gait disorders: review and description of two cases of progressive gait disturbance due to frontal lobe degeneration. J R Soc Med 1994;87:454456.
CHAPTER 12. SIGNS AND SYMPTOMS IN NEUROLOGIC DIAGNOSIS
MERRITTS NEUROLOGY
CHAPTER 12. SIGNS AND SYMPTOMS IN NEUROLOGIC DIAGNOSIS

LEWIS P. ROWLAND
Patient Age
Sex
Ethnicity
Socioeconomic Considerations
Tempo of Disease
Duration of Symptoms
Medical History
Identifying the Site of Disorder
Suggested Readings
An anonymous sage once said that 90% of the neurologic diagnosis depends on the patient's medical history and that the remainder comes from the neurologic
examination and laboratory tests. Sometimes, of course, findings in blood tests, magnetic resonance imaging (MRI), or computed tomography (CT) are
pathognomonic, but students have to learn which tests are appropriate and when to order them. It is therefore necessary to know which diagnostic possibilities are
reasonable considerations for a particular patient. In the consideration of these different diagnostic possibilities, specific symptoms are not the only ingredient in the
analysis of a patient's history, as this chapter briefly reviews.
It is commonly taught that neurologic diagnosis depends on answers to two questions that are considered separately and in sequence:
1. Where is the lesion? Is it in the cerebrum, basal ganglia, brainstem, cerebellum, spinal cord, peripheral nerves, neuromuscular junction, or muscle?
2. What is the nature of the disease?
If the site of the lesion can be determined, the number of diagnostic possibilities is reduced to a manageable number. An experienced clinician, however, is likely to
deal with both questions simultaneously; site and disease are identified at the same time. Sometimes, the process is reversed. To take an obvious example, if a
patient suddenly becomes speechless or awakens with a hemiplegia, the diagnosis of stroke is presumed. The location is then deduced from findings on examination,
and both site and process are ascertained by CT or MRI. If there are no surprises in the imaging study (e.g., demonstration of a tumor or vascular malformation),
further laboratory tests might be considered to determine the cause of an ischemic infarct.
The specific nature of different symptoms and findings on examination are reviewed in preceding chapters and in teaching manuals on the neurologic examination.
Other considerations that influence diagnosis are briefly described here.
PATIENT AGE
The symptoms and signs of a stroke may be virtually identical in a 10-year-old, a 25-year-old, and a 70-year-old; however, the diagnostic implications are vastly
different for each patient. Some brain tumors are more common in children, and others are more common in adults. Progressive paraparesis is more likely to be due
to spinal cord tumor in a child, whereas in an adult it is more likely to be due to multiple sclerosis. Focal seizures are less likely to be fixed in pattern and are less
likely to indicate a specific structural brain lesion in a child than in an adult. Myopathic weakness of the legs in childhood is more likely to be caused by muscular
dystrophy than polymyositis; the reverse is true in patients older than 25 years. Muscular dystrophy rarely begins after age 35. Multiple sclerosis rarely starts after age
55. Hysteria is not a likely diagnosis when neurologic symptoms start after age 50. (These ages are arbitrary, but the point is that age is a consideration in some
diagnoses.)
SEX
Only a few diseases are sex-specific. X-linked diseases (e.g., Duchenne muscular dystrophy) occur only in boys or, rarely, in girls with chromosome disorders. Among
young adults, autoimmune diseases are more likely to affect women, especially systemic lupus erythematosus and myasthenia gravis, although young men are also
affected in some cases. Women are exposed to the neurologic complications of pregnancy and may be at increased risk of stroke because of oral contraceptives.
Men are more often exposed to head injury.
ETHNICITY
Stating the race of the patient in every case history is an anachronism of modern medical education. In neurology, race is important only when sickle cell disease is
considered. Malignant hypertension and sarcoidosis may be more prevalent in blacks, but whites are also susceptible. Other ethnic groups, however, are more
susceptible to particular diseases: Tay-Sachs disease, familial dysautonomia, and Gaucher disease in Ashkenazi Jews; thyrotoxic periodic paralysis in Japanese and
perhaps in other Asians; nasopharyngeal carcinoma in Chinese; Marchiafava-Bignami disease in Italian wine drinkers (a myth?); and hemophilia in descendants of
the Romanovs. Ethnicity is rarely important in diagnosis.
SOCIOECONOMIC CONSIDERATIONS
In general, social deprivation leads to increased mortality, and the reasons are not always clear. Ghetto dwellers, whatever their race, are prone to the ravages of
alcoholism, drug addiction, and trauma. Impoverishment is also accompanied by malnutrition, infections, and the consequences of medical neglect. Within the ghetto
and in other social strata, the acquired immunodeficiency syndrome epidemic has generated concern about the risk factors of male homosexuals, intravenous drug
users, prostitutes, and recipients of blood transfusions. For most other neurologic disorders, however, race, ethnicity, sex, sexual orientation, and socioeconomic
status do not affect the incidence.
TEMPO OF DISEASE
Seizures, strokes, and syncope are all abrupt in onset but differ in manifestations and duration. Syncope is the briefest. There are usually sensations that warn of the
impending loss of consciousness. After fainting, the patient begins to recover consciousness in a minute or so. A seizure may or may not be preceded by warning
symptoms. It can be brief or protracted and is manifested by alteration of consciousness or by repetitive movements, stereotyped behavior, or abnormal sensations. A
stroke due to cerebral ischemia or hemorrhage strikes out of the blue and is manifest by hemiparesis or other focal brain signs. The neurologic disorder that follows
brain infarction may be permanent, or the patient may recover partially or completely in days or weeks. If the signs last less than 24 hours, the episode is called a
transient ischemic attack (TIA). Sometimes, it is difficult to differentiate a TIA from the postictal hemiparesis of a focal motor seizure, especially if the seizure was not
witnessed. Another syndrome of abrupt onset is subarachnoid hemorrhage, in which the patient often complains of the worst headache of my life; this is sometimes
followed by loss of consciousness.
Symptoms of less than apoplectic onset may progress for hours (intoxication, infection, or subdural hematoma), days (Guillain-Barr syndrome), or longer (most
tumors of the brain or spinal cord). The acute symptoms of increased intracranial pressure or brain herniation are sometimes superimposed on the slower progression
of a brain tumor. Progressive symptoms of brain tumor may be punctuated by seizures. Heritable or degenerative diseases tend to progress slowly, becoming most
severe only after years of increasing disability (e.g., Parkinson disease or Alzheimer disease).
Remissions and exacerbations are characteristic of myasthenia gravis, multiple sclerosis, and some forms of peripheral neuropathy. Bouts of myasthenia tend to last
for weeks at a time; episodes in multiple sclerosis may last only days in the first attacks and then tend to increase in duration and to leave more permanent neurologic
disability. These diseases sometimes become progressively worse without remissions.
The symptoms of myasthenia gravis vary in a way that differs from any other disease. The severity of myasthenic symptoms may vary from minute to minute. More
often, however, there are differences in the course of a day (usually worse in the evening than in the morning, but sometimes vice versa) or from day to day.
Some disorders characteristically occur in bouts that usually last minutes or hours, rarely longer. Periodic paralysis, migraine headache, cluster headaches, and
narcolepsy are examples of such disorders.
To recognize the significance of these differences in tempo, it is necessary to have some notion of the different disorders.
DURATION OF SYMPTOMS
It may be of diagnostic importance to know how long the patient has had symptoms before consulting a physician. Long-standing headache is more apt to be a
tension or vascular headache, but headache of recent onset is likely to imply intracranial structural disease and should never be underestimated. Similarly, seizures
or drastic personality change of recent onset implies the need for CT, MRI, and other studies to evaluate possible brain tumor or encephalopathy. If no such lesion is
found or if seizures are uncontrolled for a long time, perhaps video-electroencephalographic monitoring should be carried out to determine the best drug therapy or
surgical approach.
MEDICAL HISTORY
It is always important to know whether any systemic disease is in the patient's background. Common disorders, such as hypertensive vascular disease or diabetes
mellitus, may be discovered for the first time when the patient is examined because of neurologic symptoms. Because they are common, these two disorders may be
merely coincidental, but depending on the neurologic syndrome, either diabetes or hypertension may actually be involved in the pathogenesis of the neural signs. If
the patient is known to have a carcinoma, metastatic disease is assumed to be the basis of neurologic symptoms until proved otherwise. If the patient is taking
medication for any reason, the possibility of intoxication must be considered. Cutaneous signs may point to neurologic complications of von Recklinghausen disease
or other phakomatoses or may suggest lupus erythematosus or some other systemic disease.
IDENTIFYING THE SITE OF DISORDER
Aspects of the history may suggest the nature of the disorder; specific symptoms and signs suggest the site of the disorder. Cerebral disease is implied by seizures or
by focal signs that can be attributed to a particular area of the brain; hemiplegia, aphasia, or hemianopia are examples. Generalized manifestations of cerebral
disease are seizures, delirium, and dementia. Brainstem disease is suggested by cranial nerve palsies, cerebellar signs of ataxia of gait or limbs, tremor, or
dysarthria. Dysarthria may be due to incoordination in disorders of the cerebellum itself or its brainstem connections. Cranial nerve palsies or the neuromuscular
disorder of myasthenia gravis may also impair speech. Ocular signs have special localizing value. Involuntary movements suggest basal ganglia disease.
Spinal cord disease is suggested by spastic gait disorder and bilateral corticospinal signs with or without bladder symptoms. If there is neck or back pain, a
compressive lesion should be suspected; if there is no pain, multiple sclerosis is likely. The level of a spinal compressive lesion is more likely to be indicated by
cutaneous sensory loss than by motor signs. The lesion that causes spastic paraparesis may be anywhere above the lumbar segments.
Peripheral nerve disease usually causes both motor and sensory symptoms (e.g., weakness and loss of sensation). The weakness is likely to be more severe distally,
and the sensory loss may affect only position or vibration sense. A more specific indication of peripheral neuropathy is loss of cutaneous sensation in a
glove-and-stocking distribution.
Neuromuscular disorders and diseases of muscle cause limb or cranial muscle weakness without sensory symptoms. If limb weakness and loss of tendon jerks are
the only signs (with no sensory loss), electromyography and muscle biopsy are needed to determine whether the disorder is one of motor neurons, peripheral nerve,
or muscle.
The diseases that cause these symptoms and signs are described later in this volume.
SUGGESTED READINGS
Angel M. Privilege and healthwhat is the connection? N Engl J Med 1993;329:126127.
Fried R. The hyperventilation syndrome: research and clinical treatment. Baltimore: Johns Hopkins University Press, 1987.
Haerer AF. Dejong's the neurologic examination, 5th ed. Philadelphia: JB Lippincott Co, 1992.
Mayo Clinic and Foundation. Clinical examinations in neurology, 5th ed. Philadelphia: WB Saunders, 1981.
Navarro N. Race or class versus race and class: mortality differences in the United States. Lancet 1990;336:12381240.
Wiebers DO, ed. Mayo Clinic examinations in neurology, 7th ed. St. Louis, MO: Mosby-Year Book, 1998.
CHAPTER 13. COMPUTED TOMOGRAPHY AND MAGNETIC RESONANCE IMAGING
MERRITTS NEUROLOGY
SECTION II. HOW TO SELECT DIAGNOSTIC TESTS

CHAPTER 13. COMPUTED TOMOGRAPHY AND MAGNETIC RESONANCE IMAGING
ROBERT DELAPAZ AND STEPHEN CHAN
Computed Tomography
Magnetic Resonance Imaging
Uses of Computed Tomography
Uses of Magnetic Resonance Imaging
Paradigm: Diagnostic Workup for Stroke
Suggested Readings
Computed tomography (CT) and magnetic resonance imaging (MRI) are the core imaging methods in neurodiagnosis. CT is quicker and less expensive, but MRI is
now the gold standard for detecting and delineating intracranial and spinal lesions. Given the advances in MR technology, including magnetic resonance
angiography (MRA), MR spectroscopy (MRS), and functional MRI, the usefulness of MRI will continue to grow. CT technology has also advanced. For instance, spiral
or helical CT now permits scanning an entire body part, such as the neck, in less than 1 minute; it also makes CT suitable for angiographic and dynamic studies. In
the past, the major advantage of CT was the speed of imaging, which reduced patient discomfort and motion artifact. New ultrafast MR methods such as echo-planar
imaging (EPI) are now bringing MRI into the same arena.
COMPUTED TOMOGRAPHY
CT is based on image reconstruction from sets of quantitative x-ray measurements through the head from multiple angles. A fan beam of x-rays emitted from a single
source passes through the head to an array of detectors. The x-ray source rotates around the patient's head, and the x-ray attenuation through the section plane is
measured in compartments called pixels. The computer reconstructs the image from about 800,000 measurements and assigns a number to each pixel according to
its x-ray attenuation (which is proportional to tissue electron density). These values are displayed along a gray scale from black for low density (low attenuation) to
white for high density. Iodinated water-soluble contrast agents, which have high x-ray density, can be given intravenously to enhance differences in tissue density,
show vascular structures, or detect areas of bloodbrain barrier breakdown. CT differentiates between white and gray matter, shows the main divisions of the basal
ganglia and thalamus and, after infusion of a contrast agent, depicts the major arteries and veins. CT is especially useful for identifying acute hemorrhage, which
appears as much higher density than normal brain or cerebrospinal fluid (CSF).
A scanner gantry houses the x-ray source and detectors; it can be tilted to perform scans at a range of angles from axial to coronal, depending on head position, but
not in the sagittal plane. Scan time can be shortened to less than 1 second to minimize motion artifact if the patient is restless. The major limitation of CT is in the
posterior fossa, where linear artifacts appear because bone selectively attenuates the x-ray beam; the resulting beam hardening creates dense or lucent streaks that
project across the brainstem and may obscure underlying lesions.
MAGNETIC RESONANCE IMAGING
A magnetic field causes alignment of atomic nuclei, such as hydrogen protons, into one of two (or more) magnetic states. In proton-based MRI, radiowaves (the
radiofrequency pulse) are applied at a frequency that resonates with the hydrogen nucleus in tissue water, resulting in a shift of a small percentage of protons into
higher energy states. Following the radiofrequency pulse, relaxation of these protons back to their original energy state is accompanied by the emission of radiowave
signals that are characteristic of the particular tissue. Two tissue-specific relaxation-time constants are important. T1 is the longer time constant, generally from 500 to
2,000 milliseconds in the brain, and is a measure of the rate of proton reorientation back along the Z-axis of the magnetic field. T2 is the shorter time constant, usually
40 to 100 milliseconds in the brain, and is a measure of the interaction of protons during the relaxation process. The differences in tissue T1 and T2 relaxation times
enable MRI to distinguish between fat, muscle, bone marrow, and gray or white matter of the brain. Most lesions in the brain prolong these relaxation times by
increasing the volume or changing the magnetic properties of tissue water.
MR images are displayed as maps of tissue signal intensity values. Spatial localization is achieved by application of a magnetic field gradient across the magnet bore,
creating slight variations in radiofrequency across the object being imaged. The specific location of the radiowave emissions can be determined by measurement of
the exact radiofrequency. In addition, MR images can be modified for T1 or T2 relaxation characteristics or proton-density characteristics. Factors that influence the
results include (1) the imaging technique or pulse sequence (e.g., spin echo, gradient echo, or inversion recovery), (2) the repetition time (the interval between
repeated pulse sequences), and (3) the echo time (the interval between radiofrequency excitation and measurement of the radiowave emission or signal).
T1-weighted images are most useful for depicting anatomy and show CSF and most lesions as low signal, except for areas of fat, subacute hemorrhage, or gadolinium
(Gd) enhancement, which appear as high signal. T2-weighted images are more sensitive for lesion detection and show CSF and most lesions as high signal, except
areas of acute hemorrhage or chronic hemosiderin deposits, which appear as low signal. Proton-density images show mixed contrast characteristics, reflecting both
T1 and T2 weighting. All three types of images show rapidly flowing blood, dense calcification, cortical bone, and air as signal voids because of flow effects or
absence of protons.
The most useful basic MRI technique is the spin-echo (SE) pulse sequence, which repeats the sequence of 90- and 180-degree pulses and measures the signal after
each 180-degree pulse. The 90-degree pulse creates the radiowave perturbation of the tissue, and the following 180-degree pulse rephases the signal to produce an
echo, which is the signal used for image reconstruction. A double SE method allows both proton-density and T2-weighted images to be obtained at the same time.
Fast spin-echo (FSE) methods have reduced 8- to 10-minute acquisition times to 2 to 3 minutes for high-resolution images through the entire brain. The addition of an
inversion 180-degree pulse before the 90-degree pulse, timed to suppress CSF signal, results in the fluid-attenuated inversion recovery (FLAIR) pulse sequence.
FLAIR images are T2-weighted with low-signal CSF and are more sensitive in detecting lesions than SE or FSE pulse sequences. Gradient-echo (GRE) images are
created by angles of less than 90 degrees without the 180-degree pulse; gradient switching generates the signal echoes. GRE imaging allows fast acquisition and is
useful for detecting subtle magnetic field variations around hemorrhage; it is used primarily for specialized applications, such as MRA.
USES OF COMPUTED TOMOGRAPHY
For reasons of cost, speed, and availability, CT is still widely used for screening in the acute evaluation of stroke, head injury, or acute infections. It is especially
useful for patients who are neurologically or medically unstable, uncooperative, or claustrophobic, as well as for patients with pacemakers or other metallic implants. If
a mechanical ventilator is being used, CT is used for imaging because most respirators will not function in the high magnetic field of the MR scanner. Although some
MR methods are sensitive to acute hemorrhage, its appearance is variable, and in daily clinical practice CT remains superior to MRI for detecting acute extravascular
collections of blood, especially subarachnoid hemorrhage ( Fig. 13.1). CT is also superior for evaluating cortical bone of the skull and spine, although MRI is superior
in studying the bone marrow.
FIG. 13.1. Acute intracerebral hemorrhage with resorption over 6 weeks. A: Noncontrast axial CT in acute phase shows left parietal hyperdensity with mild mass effect
and mild sulcal and ventricular effacement. B: Follow-up noncontrast axial CT 1 week later. Note the decrease in density of hemorrhage. Surrounding lucency is due
to edema with persistent mass effect. Noncontrast (C) and contrast-enhanced (D) axial CT images 3 weeks posthemorrhage show further decrease in density of
hemorrhage, which appears isodense in this phase with less surrounding lucency and mass effect. D: Peripheral ring enhancement postcontrast. T2-weighted (E) and
T1-weighted (F) axial MR scans 6 weeks posthemorrhage demonstrate near-complete resolution of mass effect. In this subacute phase, hemorrhage typically appears
hyperintense on both T2 and T1 pulse sequences, surrounded by a hypointense hemosiderin ring. (Courtesy of Dr. J.A. Bello and Dr. S.K. Hilal.)
Contrast-enhanced CT (CECT) is used to detect lesions that involve breakdown of the bloobrain barrier, such as brain or spinal tumors, infections, and other
inflammatory conditions. CECT is often used to rule out cerebral metastases. However, it is less sensitive than Gd-enhanced MRI (Gd-MRI), which is also better for
detection of other intracranial tumors and infections.
Intravenous CT contrast agents are based on iodine, and the older and cheaper agents are classified as high-osmolar contrast media (HOCM). Newer, nonionic
agents, classified as low-osmolar contrast media (LOCM), are more expensive but less allergenic, and they cause less morbidity than do HOCM. LOCM are especially
useful in patients at high risk for adverse reaction, such as those with severe heart disease, renal insufficiency, asthma, severe debilitation, or previous allergic
reaction to iodinated contrast (HOCM).
Spiral or helical scanning increases scannning speed to less than 1 second per section and provides large-volume acquisitions that can be used for three-dimensional
(3D) presentation of anatomic information. Single and multislice spiral scanning is now fast enough to allow acquisition of the entire neck or head during intravenous
infusion of a bolus of contrast agent for reconstruction of CT angiography (CTA). Maximum intensity projection (MIP) reformations, often with 3D surface shading,
display vascular features such as stenosis or aneurysm. Advantages of CTA over catheter angiography include more widely available technology, less specialized
skill requirements, and less invasive intravenous administration of contrast material. However, the use of CTA has been growing slowly because of competition from
existing MRA. In contrast to MRA, the iodinated contrast used is potentially more toxic because of allergic reactions and direct cardiac volume stress, as well as renal
toxicity. Another limitation of CTA is the time-consuming processing required to edit out bone and calcium and to generate 3D surface renderings. Rapid CT is also
used to generate brain perfusion studies during a bolus contrast injection. This method suffers from limited volume coverage and the risks of iodinated contrast
injection, in contrast to MRI tissue perfusion methods.
USES OF MAGNETIC RESONANCE IMAGING
MRI is the neuroimaging method of choice for most intracranial and intraspinal abnormalities. The technical advantages of MRI are threefold: (1) Greater soft tissue
contrast provides better definition of anatomic structures and greater sensitivity to pathologic lesions; (2) multiplanar capability displays dimensional information and
relationships that are not readily available on CT; and (3) MRI can better demonstrate physiologic processes such as blood flow, CSF motion, and special properties
of tissue such as water diffusion or biochemical makeup (using MRS). Other advantages include better visualization of the posterior fossa, lack of ionizing radiation,
and better visualization of intraspinal contents.
There are some disadvantages of MRI. The most practical problem is the need for cooperation from the patient because most individual MRI sequences require
several minutes and a complete study lasts 20 to 60 minutes. However, EPI and single-shot FSE methods can acquire low-resolution images in as little as 75
milliseconds and whole brain studies in 30 to 40 seconds. These can be used to salvage an adequate study for identifying or excluding major lesions in uncooperative
patients. In addition, about 5% of all persons are claustrophobic inside the conventional MR unit. Oral or intravenous sedation can be used to ensure cooperation, but
closer patient monitoring is then required. Development of low-magnetic-field, open MRI systems has improved patient acceptance, but these systems sacrifice
image quality because of the lower signal-to-noise ratio. High-field (1.5 T), short-bore MR systems reduce patient perception of a closed tube while maintaining full
MR capabilities.
MRI is absolutely contraindicated in patients with some metallic implants, especially cardiac pacemakers, cochlear implants, older-generation aneurysm clips, metallic
foreign bodies in the eye, and implanted neurostimulators. Newer aneurysm clips have been designed to be nonferromagnetic and nontorqueable at
high-magnetic-field strengths, but the U.S. Food and Drug Administration still urges caution in performing MRI in all patients with aneurysm clips. Individual clips may
develop unpredictable magnetic properties during manufacture, and careful observation of initial images for magnetic artifacts should be used as an additional
precaution. Published lists of MR-compatible clips and metallic objects provide advice about specific clip types and any unusual metallic implants.
Some authorities consider pregnancy (especially in the first trimester) a relative contraindication to MRI, primarily because safety data are incomplete. To date, no
harmful effect of MRI has been demonstrated in pregnant women or fetuses, and late-pregnancy fetal MRI has been used clinically. An additional unknown risk to the
fetus is the effect of intravenous MR contrast agents such as Gd- and iron-based agents. The urgency, need, and benefits of the MRI study for the patient should be
considered in relation to potential unknown risks to the fetus in early pregnancy.
Indications for Gadolinium-enhanced MRI
Most intravenous contrast agents for MRI are chelates of gadolinium, a rare-earth heavy metal. The most commonly used agent is gadopentetate dimeglumine
(Gd-DTPA), which is water-soluble and crosses the damaged bloodbrain barrier in a manner similar to that of iodinated CT contrast media. The local accumulation of
Gd-DTPA shortens both T1 and T2 relaxation times, an effect best seen on T1-weighted images. Lesions that accumulate extravascular Gd-DTPA appear as areas of
high signal intensity on T1-weighted images. Comparison with precontrast images is needed to exclude preexisting high signal, such as hemorrhage, fat, and,
occasionally, calcification. Specialized MR methods can improve detection of Gd-DTPA enhancement. For instance, magnetization transfer improves contrast
enhancement, and fat suppression helps in the evaluation of the skull base and orbital regions. Unlike iodinated contrast material, Gd-DTPA administration is
associated with few adverse reactions.
Gd-MRI has been most useful in increasing sensitivity to neoplastic and inflammatory lesions. This high sensitivity can show brain tumors that are often difficult to
detect on CT, such as small brain metastases, schwannomas (especially within the internal auditory canal), optic nerve or hypothalamic gliomas, and meningeal
carcinomatosis. In addition, the multiplanar capability of Gd-MRI delineates the extent of neoplastic lesions so well that the images can be used directly to plan
neurosurgery and radiation therapy ( Fig. 13.2).
FIG. 13.2. Functional MRI for surgical planning. A: Axial T2*-weighted EPI image acquired during a left-hand grasping task shows activation of the precentral gyrus
(arrow) immediately anterior to a region of high-signal cortical dysplasia scheduled for surgical resection. B: Timeintensity curves show three phases of increased
signal, each during a 30-second period of repeated hand grasping separated by 30-second periods of rest. The rise in signal is produced by the BOLD effect, as local
increases in blood flow in areas of cortical activation produce increased levels of oxyhemoglobin (decreased levels of deoxyhemoglobin) in capillaries and venules.
(Y-axis represents signal intensity; X-axis shows sequential image numbers, each separated by 3 seconds. EPI GRE pulse sequence with TR 3000 ms, TE 90 ms, flip
90 degrees.)
Gd-MRI is superior to CECT in detecting cerebral metastases, but even Gd-MRI at standard dosages can miss metastatic lesions. Newer nonionic Gd-based contrast
agents allow up to three times as much contrast agent to be used. In some cases, triple-dose Gd-MRI detects metastases not seen with the standard method. Similar
high detection rates can be achieved with standard-dose Gd-DTPA when it is combined with magnetization-transfer MRI. Maximizing lesion sensitivity is especially
significant in patients with solitary metastases, for whom surgical resection is a therapeutic option, in contrast to multiple lesions, for which radiation or chemotherapy
may be better options.
MRI is the imaging method of choice for detecting the demyelinating plaques of multiple sclerosis in both the brain and spinal cord. Multiple sclerosis plaques are
characteristically seen on T2-weighted images as multifocal hyperintense lesions within the periventricular white matter and corpus callosum. They appear ovoid and
oriented along medullary veins, perpendicular to the long axis of the lateral ventricles ( Dawson fingers). Gd-MRI can identify active inflammation by contrast
enhancement of acute demyelinating plaques and distinguish them from nonenhancing chronic lesions. Serial Gd-MRI studies allow the progress of the disease to be
monitored. Magnetization-transfer imaging, without Gd contrast injection, has also been used to identify abnormal white matter regions that appear normal on
T2-weighted images.
Gd-MRI is vastly superior to CECT in the detection of meningitis, encephalitis (especially herpes simplex encephalitis and acute disseminated encephalomyelitis), and
myelitis. Epidural abscess or empyema may also be better delineated on Gd-MRI. In acquired immunodeficiency syndrome, many kinds of lesions show increased
signal intensity within the cerebral white matter on noncontrast T2-weighted images. These lesions can be further characterized by Gd-MRI. For example, if a single
large or dominant enhancing mass is seen on Gd-MRI, the favored diagnosis is cerebral lymphoma. If multiple, small enhancing nodules are found, the possible
diagnoses include cerebral toxoplasmosis, granulomas, or fungal infection. When no enhancement is present, the white matter lesions may be the result of human
immunodeficiency virus encephalitis (if symmetric) or progressive multifocal leukoencephalopathy (if asymmetric). Thus, the presence or absence of contrast
enhancement, the character of contrast enhancement, and the pattern of signal abnormality are all important features in the differential diagnosis.
Gd-MRI is also useful in evaluation of the spine. Herniated discs and degenerative spondylosis can be well evaluated on noncontrast MRI in the unoperated patient,
but Gd-MRI is needed in patients with a failed back syndrome to separate nonenhancing recurrent disc herniation from enhancing postsurgical scarring or fibrosis.
Identification and delineation of spinal tumors and infections are also improved with Gd-MRI. However, Gd enhancement of vertebral bone marrow metastases may
make them isointense with normal fatty marrow. Screening precontrast T1-weighted images of the spine should always be obtained. MRI is much more sensitive to
bone marrow metastases than conventional radionuclide bone scans. The emergency evaluation of spinal cord compression is also best done with pre- and
postcontrast Gd-MRI because multilevel disease can be directly visualized and definitive characterization of lesions can be done immediately (i.e., intra- versus
extramedullary, dural and spinal involvement). For these reasons, the indications for conventional and CT-myelography are decreasing. Outside the spine,
fat-suppressed MRI of spinal nerve roots and peripheral nerves, known as MR neurography, identifies compressive or traumatic nerve injuries.
Appropriate Utilization of Gadolinium-Enhanced MRI
Some experts have proposed universal administration of Gd for MRI. The use of Gd, however, adds to the direct costs of MRI and increases imaging time, as well as
patient discomfort from the intravenous injection. Others recommend that Gd-MRI should be restricted to specific clinical situations in which efficacy has been
demonstrated (except when a significant abnormality on routine noncontrast MRI requires further characterization).
In some clinical situations, Gd-MRI is not very useful because relatively few contrast-enhancing lesions are typically found. These clinical situations include complex
partial seizures, headache, dementia, head trauma, psychosis, low back or neck pain (in unoperated patients), and congenital craniospinal anomalies. MRI evaluation
in many of these conditions would be improved by special MR pulse sequences directed to the structures of greatest interest. For example, patients with temporal lobe
epilepsy or Alzheimer disease benefit most by high-resolution imaging of the temporal lobes for evidence of hippocampal atrophy or sclerosis ( Fig. 13.3). Patients
who have experienced remote head trauma or child abuse might be best served by a T2-weighted GRE pulse sequence, which is more sensitive than the SE pulse
sequence in detecting lesions associated with hemosiderin deposition, such as axonal shear injuries or subarachnoid hemosiderosis from repeated subarachnoid
hemorrhages.
FIG. 13.3. High-resolution image of the temporal lobes. A: High-resolution (512 512 matrix) coronal MR scan through the temporal lobes obtained with the use of
short-tau inversion recovery (STIR) pulse sequence shows increased signal intensity within the right hippocampus (arrow). The normal left hippocampus is well
visualized, with clear definition of internal architecture. B: Magnification view allows close inspection of the hippocampi with no significant distortion because a
high-resolution image was obtained. Patient has presumed right mesial temporal sclerosis associated with a clinical and electroencephalogram-defined syndrome of
right temporal lobe epilepsy.
Magnetic Resonance Angiography
On standard SE images, the major arteries and veins of the neck and brain are usually seen as areas of signal void because of relatively fast blood flow. A GRE pulse
sequence can show flowing blood as areas of increased signal intensity known as flow-related enhancement (not to be confused with Gd contrast enhancement). In
these images, the soft tissues appear relatively dark. After a series of contiguous thin sections is obtained with either two-dimensional or 3D GRE techniques, a map
of the blood vessels is reconstructed as a set of MIP angiograms that can be viewed in any orientation and displayed with 3D surface shading. These MRA images,
like a conventional angiogram, can show the vascular anatomy but also have the advantage of multiple viewing angles that provide oblique and other nonstandard
angiographic views. An advantage of MRA over CTA is that it is completely noninvasive, requiring no contrast injection. MRA does not require specialized catheter
skills and avoids the 0.5% to 3% risk of neurologic complications associated with arterial catheter angiography.
In the evaluation of the carotid arteries in the neck or the arteries of the circle of Willis, the most commonly used MRA technique is the time-of-flight (TOF) method.
TOF is sensitive to T1 relaxation effects and may produce false-positive or obscuring high-signal artifacts from orbital fat, hemorrhage, or areas of Gd enhancement.
Another important MRA technique, the phase-contrast (PC) technique, depends on the phase (rather than magnitude) of the MR signal. PC technique shows the
direction and velocity of blood flow, may be adjusted to low or high flow sensitivity, and is useful for evaluating altered hemodynamics, such as flow reversal after
major vessel occlusion or stenosis.
MRA occasionally overestimates cervical carotid stenosis because of local turbulent flow, but it compares favorably with conventional angiography in detecting carotid
stenosis. Conventional angiography is still the gold standard for cerebrovascular imaging, but extracranial carotid evaluation is now done primarily with ultrasound
and MRA.
Indications for MRA include stroke, transient ischemic attack (TIA), possible venous sinus thrombosis, arteriovenous malformation (AVM), and vascular tumors (for
delineation of vascular supply and displacements). It is thought that MRA reliably detects aneurysms as small as 3 mm. Conventional angiography, however, is still
the most sensitive examination for evaluation of intracranial aneurysms or AVMs because of its higher spatial resolution and ability to observe the rapid sequence of
vascular filling, especially the early venous filling seem with AVMs.
Functional MRI
The term functional is used here in a broad sense to encompass several MRI methods that are used to image physiologic processes such as tissue blood flow, water
diffusion, and biochemical makeup (with MRS), as well as cerebral activation with sensory, motor, and cognitive tasks. Tissue blood flow is most commonly imaged
with MRI using a first-pass or bolus-tracking method that records the signal changes occurring when rapidly repeated images are acquired during the first passage of
an intravascular bolus of paramagnetic contrast material through the brain, usually Gd-DTPA. Using T2*- or T2-weighted EPI or fast GRE techniques, MR images are
acquired every 1 to 3 seconds over the whole brain, and the signal decreases that occur in each tissue with passage of the contrast bolus are plotted against time.
The area under this timeintensity curve is proportional to cerebral blood volume (CBV), and other manipulations of the data can give cerebral blood flow (CBF),
mean transit time (MTT), and other measures of tissue perfusion. This method has been used most extensively with primary brain tumors, where CBV seems to
correlate well with histologic tumor grade and demonstrates responses to treatment of the tumor. The obvious application to cerebral ischemic disease has become
more widespread, and measures of perfusion delay, such as MTT and time to peak, are sensitive indicators of small reductions in cerebral perfusion. A second
method of MR perfusion imaging is called spin tagging or TOF imaging and, like TOF MRA, depends on T1 relaxation and flow enhancement phenomena, without the
use of injected contrast agents. This method is less widely used than bolus tracking but gives more quantitative CBF measurements.
A second important functional MRI technique is diffusion-weighted imaging (DWI). This is most commonly performed using an EPI SE pulse sequence with gradients
added before and after the 180-degree pulse. On DW images, areas of high diffusion show up as low signal, and those with low diffusion appear as high signal.
Quantitative apparent diffusion coefficient (ADC) maps can be generated to display diffusion with the opposite polarity: high ADC as high signal and low ADC as low
signal. Severe cerebral ischemia causes a rapid decrease in intracellular diffusion, and high signal appears on DWI within minutes of cell injury. After the initial
reduction in diffusion, there is a gradual rise through normal to prolonged diffusion rates during the 1 to 2 weeks after infarction, as cells disintegrate and freely
diffusible water dominates the encephalomalacic tissue. A minor pitfall of DWI is called T2 shine-through, where high signal on T2-weighted images may produce
high signal on DWI, falsely indicating reduced diffusion. This error can be avoided by the use of calculated ADC maps. DWI is an essential part of acute stroke
imaging, and because it takes less than 1 minute to acquire a whole-brain study, it is widely used. DWI can be combined with perfusion imaging to identify the
so-called penumbra zone of potentially salvageable tissue within the area of reduced perfusion but outside the unrecoverable infarct, represented by DWI high signal.
MRS can be performed with clinical high-field MR scanners. Proton spectroscopy is most widely used and produces semiquantitative spectra of common tissue
metabolites, including N-acetylaspartate (NAA; a marker of healthy neurons and axons), creatine (the molecular storage depot for high-energy phosphates), choline
(a component of cell membranes and myelin), and lactate (elevated with normal tissue energetic stress and in many pathologic tissues). Proton spectra can be
obtained from as little as 0.5 cc of tissue at 1.5 T and MRS images can be generated to show metabolite distributions, albeit at lower spatial resolution than anatomic
MR images. The most widely accepted clinical use of proton MRS is the identification of brain neoplasms that tend to show a characteristic but not completely specific
pattern of elevated choline, reduced NAA, and elevated lactate. MRS is also used to characterize multiple sclerosis plaques, degenerative diseases such as
Alzheimer disease or amyotrophic lateral sclerosis, and metabolic disorders such as MELAS.
Using MRI to map cerebral activation is specifically called functional MRI (fMRI). The technique most widely used is the blood-oxygen-level-dependent (BOLD)
method, which is based on local increases in CBF and the consequent shift from deoxyhemoglobin to oxyhemoglobin in areas of cerebral activation. With T2*- or
T2-weighted EPI or fast GRE images and rapidly repeated acquisitions (every 1 to 3 seconds), MR images show small increases in signal in areas of cerebral
activation. BOLD fMRI has been used in research on motor, sensory, and cognitive activation. Growing clinical applications of fMRI include mapping of motor,
sensory, and language function prior to surgery, radiation therapy, or embolization procedures; monitoring recovery of function after brain injury or stroke; and
mapping specific cognitive changes in degenerative brain diseases.
PARADIGM: DIAGNOSTIC WORKUP FOR STROKE
In the first evaluation of patients with stroke, either CT or MRI can be used. In many centers, CT is the primary choice because of availability, immediate access, less
need for patient cooperation, and lower cost. In addition, hemorrhage, calcification, and skull fracture are easy to recognize on CT. CT is less sensitive than MRI,
however, in showing nonhemorrhagic infarction in the first 24 hours after the ictus. In addition, infarcts within the brainstem and cerebellum are usually better
demonstrated by MRI.
MRI is the modality of choice for acute ischemic stroke because of the high sensitivity and specificity of DWI. As noted above, DWI can specifically identify cerebral
infarction within minutes of onset, and, when combined with quantitative ADC maps, can specify the age of a lesion to within a few days. FLAIR imaging also shows
high signal in acute infarcts and is sensitive to lesions within the first 6 to 12 hours. A comparison of T2-weighted and proton-density MRI to CT found that within the
first 24 hours 82% of lesions were seen on MRI, whereas only 58% were seen on CT. The earliest changes are seen on proton-density-weighted images, with
hyperintensity present within the affected cortical gray matter. During the first 5 days after stroke onset, Gd enhancement may be seen within the small arteries of the
ischemic vascular territory, with gyral cortical enhancement present 5 days to several months after onset. The focal reversible lesions of TIAs are also more frequently
seen on MRI than on CT.
MRA and duplex ultrasonography of the carotid arteries are then used to evaluate possible underlying carotid stenosis. If necessary, invasive angiography can
corroborate the presence of carotid stenosis and may depict ulcerations that are not well seen on MRA or duplex ultrasonography.
MRA of the brain is also useful in determining patency of the vessels of the circle of Willis. Acute occlusions of the major vessels of the circle of Willis or of the
superior portions of the internal carotid arteries and basilar artery can be detected, but occlusion of small distal branches is not as well demonstrated ( Fig. 13.4).
Arterial and venous flow can be separated to identify venous occlusion. MRA can also be used serially for evaluation of therapy, such as intraarterial thrombolysis, but
conventional angiography may still be useful in early diagnostic evaluation and is necessary for intraarterial thrombolytic therapy.
FIG. 13.4. A,B: T2-weighted axial MR scans demonstrate increased signal intensity within the opercular areas of the left frontal and temporal lobes, consistent with
acute ischemia or infarction. Note the decreased visualization of left middle cerebral artery flow void as compared to right. C: Collapsed (base) view of an MR
angiogram of the circle of Willis shows marked stenosis of the M1 (first) segment of the left middle cerebral artery (MCA). D: Follow-up collapsed (base) view of an
MR angiogram of the circle of Willis demonstrates virtually complete occlusion of the left MCA. Progression occurred despite aggressive medical therapy, including
anticoagulation.
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CHAPTER 14. ELECTROENCEPHALOGRAPHY AND EVOKED POTENTIALS
MERRITTS NEUROLOGY
CHAPTER 14. ELECTROENCEPHALOGRAPHY AND EVOKED POTENTIALS

RONALD G.EMERSON,THADDEUS S.WALCZAK AND TIMOTHY A.PEDLEY
Electroencephalography
Clinical Utility of Electroencephalography
Evoked Potentials
Digital Eeg Technology and Computerized Eeg
Suggested Readings
Electroencephalography (EEG) and evoked potentials (EPs) are measures of brain electric activity. EEG reflects spontaneous brain activity, whereas EPs reflect
activity of the central nervous system in response to specific stimuli. In contrast to anatomic imaging techniques, such as computed tomography and magnetic
resonance imaging, which provide information about brain structure, EEG and EP studies provide information about brain function. Functional and structural
investigations are often complementary. Electrophysiologic studies are particularly important when neurologic disorders are unaccompanied by detectable alteration
in brain structure. This chapter provides an overview of the current capabilities and limitations of these techniques in clinical practice.
ELECTROENCEPHALOGRAPHY
Normal Adult EEG
EEG activity is characterized by the frequency and voltage of the signals. A major feature of the EEG during wakefulness is the alpha rhythm, an 8- to
12-cycles-per-second (cps) parietooccipital rhythm ( Fig. 14.1). The alpha rhythm is best seen when the patient is awake and relaxed with eyes closed. It attenuates
when the eyes are opened, or the subject is alerted. Beta activity, between 13 and 25 cps, is usually maximal in the frontal and central regions. High-voltage beta
activity suggests the effect of sedative-hypnotic medication. A small amount of slower frequencies may be diffusely distributed.
FIG. 14.1. Normal EEG in an awake 28-year-old man.
Sleep is divided into five stages on the basis of the combinations of EEG patterns, eye movements, and axial electromyography (EMG). Stage 1 is a transitional
period between wakefulness and sleep. The alpha rhythm disappears during stage 1 and is replaced by low-voltage, slower activity. Vertex waves, high-voltage,
sharp transients, are recorded maximally at the vertex. Stage 2 sleep is characterized by sleep spindles (symmetric 12- to 14-cps sinusoidal waves). The EEG in
stages 3 and 4 is composed of high-voltage, widely distributed, slow-wave activity. Rapid eye movement (REM) sleep is characterized by low-voltage,
mixed-frequency activity, similar to that in early stage 1, together with REM and generalized atonia. REM occurs about 90 minutes after sleep onset in adults and is
not usually seen in routine studies. The presence of REM in a daytime EEG suggests sleep deprivation, withdrawal from REM-suppressant drugs, alcohol withdrawal,
or narcolepsy (Chapter 145).
Common EEG Abnormalities
Diffuse slowing of background rhythms is the most common EEG abnormality (Fig. 14.2). This finding is nonspecific and is present in patients with diffuse
encephalopathies of diverse causes, including toxic, metabolic, anoxic, and degenerative. Multiple structural abnormalities can also cause diffuse slowing.
FIG. 14.2. Diffuse slowing in a 67-year-old patient with dementia. Six- to seven-cps activity predominates over the parietooccipital regions. Although reactive to eye
closure, the frequency of this rhythm is abnormally slow.
Focal slowing suggests localized parenchymal dysfunction ( Fig. 14.3). Focal neuroradiologic abnormalities are found in 70% of patients with significant focal slowing
and must always be suspected in this situation. Focal slowing may also be seen in patients with focal seizure disorders, even when no lesions are found. Focal
voltage attenuation usually indicates localized lesions of gray matter but may also be seen with focal subdural, epidural, or even subgaleal fluid collections ( Fig. 14.3).
FIG. 14.3. Focal slow activity with attenuation of the alpha rhythm over the left hemisphere in a 67-year-old patient with an acute left hemispheral infarction.
Triphasic waves typically consist of generalized synchronous waves occurring in brief runs ( Fig. 14.4). Approximately one-half the patients with triphasic waves have
hepatic encephalopathy, and the remainder have other toxic-metabolic encephalopathies.
FIG. 14.4. Triphasic waves in a 61-year-old patient with hepatic failure. (Courtesy of Bruce J. Fisch.)
Epileptiform discharges (EDs) are the interictal hallmark of epilepsy. They are strongly associated with seizure disorders and are uncommon in normal adults. The
type of ED may also suggest a specific epileptic syndrome (see the following).
Periodic lateralizing epileptiform discharges (PLEDs) suggest the presence of an acute destructive cerebral lesion. Focal EDs recur at 1 to 2 cps in the setting of a
focally slow or attenuated background ( Fig. 14.5). In a study of nearly 600 patients with PLEDs, the finding was related to an acute cerebral infarction in 35%, to other
mass lesions in 26%, and to cerebral infection, anoxia, or other causes in the the remainder. Clinically, PLEDs are associated with seizures, obtundation, and focal
neurologic signs.
FIG. 14.5. Right hemispheral PLEDs in a 65-year-old patient with herpes simplex encephalitis. (From Pedley TA, Emerson RG. Clinical neurophysiology. In: Bradley
WG, Daroff RB, Fenichel GM, Marsden CD, eds. Neurology in clinical practice, 2nd ed. Boston: Butterworth-Heinemann, 1996:460; with permission.)
Generalized periodic sharp waves typically recur at 0.5 to 1 cps on an attenuated background. This pattern is most commonly seen following cerebral anoxia. It is also
recorded in about 90% of patients with Creutzfeldt-Jakob disease.
CLINICAL UTILITY OF ELECTROENCEPHALOGRAPHY
Epilepsy
The EEG is the most useful laboratory test to help establish the diagnosis of epilepsy and assist in the accurate classification of specific epileptic syndromes.
Characteristic interictal EDs strongly support the diagnosis of epilepsy, but absence of EDs does not rule out this diagnosis. EDs are recorded in 30% to 50% of
epileptic patients on the first routine EEG and in 60% to 90% by the third routine EEG. Further EEGs do not appreciably increase the yield. Thus, 10% to 40% of
patients with epilepsy do not demonstrate interictal discharges, even on several EEGs. Sleep, sleep deprivation, hyperventilation, and photic stimulation increase the
likelihood of recording EDs in some patients.
Conversely, interictal EDs are infrequent in healthy normal subjects or patients without epilepsy. EDs occur in only 1.5% to 3.5% of healthy normal children. Siblings
of children with benign focal epilepsy or petit mal absence without seizures may also have interictal EDs recorded incidentally. EDs occur in 2.7% of adult patients
with various illnesses, including neurologic diseases, but with no history of seizures. The presence of EDs with the appropriate clinical findings strongly supports the
diagnosis of epilepsy but does not establish it unequivocally.
The type of interictal ED, together with the patient's clinical features, often allows diagnosis of a specific epileptic syndrome. Confident diagnosis of an epileptic
syndrome leads to proper treatment and provides information regarding prognosis. Table 14.1 summarizes specific characteristics of epileptiform abnormalities in
some common epileptic syndromes. Clinical features of the syndromes are summarized in Chapter 140). A useful example is the distinction between generalized
3-cps spike and wave and temporal spike and wave. Three-cps spike and wave is seen in childhood absence epilepsy, an epileptic syndrome with early age of onset,
absence and tonic-clonic seizures, and relatively good prognosis ( Fig. 14.6). Either ethosuximide (Zarontin) or valproic acid (Depakene) is the medication of choice.
In contrast, temporal-lobe spikes are seen in complex partial seizures or complex partial seizures with secondary generalization ( Fig. 14.7). Prognosis is poorer, and
phenytoin sodium (Dilantin), carbamazepine (Tegretol), or barbiturates are the medications of choice.
TABLE 14.1. EPILEPTIFORM ABNORMALITIES IN THE COMMON EPILEPSY SYNDROMES
FIG. 14.6. Ten-second absence seizure in an 11-year-old with staring spells. Three- to four-cps generalized spike wave is seen at the beginning of the seizure. The
rate gradually slows toward the end of the seizure. Then patient was asked to follow a simple command 6 seconds after seizure onset and was unable to do so.
FIG. 14.7. Right anterior temporal epileptiform discharge in a 32-year-old patient with complex partial seizures emerging from the right temporal lobe.
Dementia and Diffuse Encephalopathies
The EEG provides useful clues in obtunded patients. Triphasic waves suggest a toxic-metabolic cause. High-voltage beta activity suggests the presence of
sedative-hypnotic medications. Generalized voltage attenuation is seen in Huntington disease. Generalized periodic sharp waves are seen in about 90% of patients
with Creutzfeldt-Jakob disease within 12 weeks of clinical onset. EEG is critical when spike-wave stupor is the cause of obtundation. EEG may be normal early in the
course of Alzheimer disease, when cognitive changes are minor and the diagnosis is still uncertain. As moderate to severe symptoms appear, diffuse slowing is seen
(see Fig. 14.2). Almost all patients with biopsy-proven Alzheimer disease have unequivocal EEG abnormalities within 3 years of the onset of symptoms. Focal slowing
is uncommon and, if present, suggests multiinfarct dementia or another multifocal cause.
Focal Brain Lesions
As neuroimaging has become widely available, EEG has come to play a less important role in the diagnosis of structural lesions. EEG is necessary, however, to
assess the epileptogenic potential of mass lesions. Focal EEG abnormalities accompany one-half of hemispheral transient ischemic attacks. Normal EEG in a patient
with a neurologic deficit strongly suggests a lacunar infarction. EEG slowing in hemispheral infarcts gradually improves with time, whereas focal slowing in neoplasms
remains the same or worsens. This difference can be useful when neuroradiologic findings do not distinguish between semiacute infarction and neoplasm.
Cerebral Infections
Focal changes are noted in more than 80% of patients with herpes encephalitis, and PLEDs are seen in more than 70% (see Fig. 14.5). PLEDs typically appear 2 to
15 days after onset of illness, but the interval may be as long as 1 month. Serial EEG is therefore useful if early studies are nonfocal. Early focal findings strongly
suggest this diagnosis if the clinical picture is compatible, and may indicate the appropriate site for biopsy. Virtually diagnostic EEG changes are seen in subacute
sclerosing panencephalitis: stereotyped bursts of high-voltage delta waves at regular intervals of 4 to 10 seconds. Early in the disease, slow-wave bursts may be
infrequent or confined to sleep, so serial EEG may be useful. EEG findings in patients infected with human immunodeficiency virus are nonspecific. Diffuse slowing
may precede clinical neurologic manifestations. The slowing becomes more persistent in patients with dementia related to acquired immunodeficiency syndrome.
Focal slowing suggests the presence of a superimposed cerebral lesion, such as lymphoma or toxoplasmosis.
EVOKED POTENTIALS
Principles of Evoked Potential Recording
Visual, auditory, and somatosensory stimuli cause small electric signals to be produced by neural structures along the corresponding sensory pathways. These EPs
are generally of much lower voltage than ongoing spontaneous cortical electric activity. They are usually not apparent in ordinary EEG recordings and are detected
with the use of averaging techniques. Changes in EPs produced by disease states generally consist of delayed responses, reflecting conduction delays in responsible
pathways, or attenuation or loss of component waveforms, resulting from conduction block or dysfunction of the responsible generator.
Clinically, EP tests are best viewed as an extension of the neurologic examination. Abnormalities identify dysfunction in specific sensory pathways and suggest the
location of a responsible lesion. They are most useful when they identify abnormalities that are clinically inapparent or confirm abnormalities that correspond to vague
or equivocal signs or symptoms.
Visual Evoked Potentials
The preferred stimulus for visual evoked potential (VEP) testing is a checkerboard pattern of black and white squares. Pattern reversal (i.e., change of the white
squares to black and the black squares to white) produces an occipital positive signal, the P100, approximately 100 milliseconds after the stimulus. Because fibers
arising from the nasal portion of each retina decussate at the optic chiasm ( Fig. 14.8), an abnormality in the P100 response to stimulation of one eye necessarily
implies dysfunction anterior to the optic chiasm on that side. Conversely, delayed P100 responses following stimulation of both eyes separately may result from
bilateral abnormalities either anterior or posterior to the chiasm or at the chiasm. Unilateral hemispheral lesions do not alter the latency of the P100 component
because of the contribution of a normal response from the intact hemisphere.
FIG. 14.8. Primary visual pathways illustrating decussation of nasal retinal fibers at the optic chiasm and projections to the visual cortex. (From Epstein CM. Visual
evoked potentials. In: Daly DD, Pedley TA, eds. Current practice of clinical electroencephalography, 2nd ed. New York: Raven Press, 1997:565; with permission.)
Acute optic neuritis is accompanied by loss or severe attenuation of the VEP. Although the VEP returns, the latency of the P100 response almost always remains
abnormally delayed, even if vision returns to normal ( Fig. 14.9). Pattern-reversal VEPs (PRVEPs) are abnormal in nearly all patients with a definite history of optic
neuritis. More important, PRVEPs are abnormal in about 70% of patients with definite multiple sclerosis who have no history of optic neuritis.
FIG. 14.9. Pattern shift VEP in a patient with right optic neuritis. The response to left eye stimulation is normal. Right eye stimulation produces a marked delay of the
P100 response. The relative preservation of waveform morphology despite pronounced latency prolongation is typical of demyelinating optic neuropathies. Unless
otherwise specified, electrode positions are standard locations of the International 1020 System. MPz corresponds to an electrode positioned midway between Oz
and Pz. M1 is an electrode on the left mastoid process.
Despite the sensitivity of PRVEPs to demyelinating lesions of the optic nerve, the VEP changes produced by plaques are often not distinguishable from those
produced by many other diseases that affect the visual system; these include ocular disease (major refractive error, media opacities, glaucoma, retinopathies),
compressive lesions of the optic nerve (extrinsic tumors, optic nerve tumors), noncompressive optic nerve lesions (ischemic optic neuritis, nutritional and toxic
amblyopias), and diseases affecting the nervous system diffusely (adrenoleukodystrophy, Pelizaeus-Merzbacher disease, spinocerebellar degenerations, Parkinson
disease). VEPs can help distinguish blindness from hysteria and malingering. If a patient reports visual loss, a normal VEP strongly favors a psychogenic disorder.
Brainstem Auditory Evoked Potentials
Brainstem auditory evoked potentials (BAEPs) are generated by the auditory nerve and the brainstem in response to a click stimulus. The normal BAEP includes a
series of signals that occurs within 7 milliseconds after the stimulus, comprising three components important to clinical interpretation ( Fig. 14.10): wave I arising from
the peripheral portion of the auditory nerve; wave III generated in the tegmentum of the caudal pons, most likely the superior olive or the trapezoid body; and wave V
generated in the region of the inferior colliculus. Although brainstem auditory pathways decussate at multiple levels, unilateral abnormalities of waves III and V are
most often associated with ipsilateral brainstem disease.
FIG. 14.10. BAEP study in a patient with a left intracanalicular acoustic neuroma. The BAEP to right ear stimulation is normal. The I to III interpeak latency is
prolonged following left ear stimulation, reflecting delayed conduction between the distal eighth nerve and the lower pons.
BAEPs in Neurologic Disorders
The clinical utility of BAEPs derives from (1) the close relationship of BAEP waveform abnormalities and structural pathology of their generators and (2) the resistance
of BAEPs to alteration by systemic metabolic abnormalities or medications. BAEPs are often abnormal when structural brainstem lesions exist ( Fig. 14.11). They are
virtually always abnormal in patients with brainstem gliomas. Conversely, brainstem lesions that spare the auditory pathways, such as ventral pontine infarcts
producing the locked-in syndrome or lateral medullary infarcts, do not produce abnormal BAEPs. Barbiturate levels high enough to produce an isoelectric EEG leave
BAEPs unchanged, as do hepatic and renal failure. BAEPs are therefore useful for demonstrating brainstem integrity in toxic and metabolic perturbations that severely
alter the EEG.
FIG. 14.11. Abnormal BAEP recorded in a patient with a brainstem hemorrhage sparing the lower one-third of the pons. Waves IV and V are lost, but waves I, II, and
III are preserved. (From Chiappa KH. Evoked potentials in clinical medicine. In: Baker AB, Baker LH, eds. Clinical neurology. New York: Harper & Row, 1990:22; with
permission.)
BAEPs are sensitive for detection of tumors of the eighth cranial nerve; abnormalities are demonstrated in more than 90% of patients with acoustic neuroma. BAEP
abnormalities seen with acoustic neuromas and other cerebellopontine angle tumors range from prolongation of the I to III interpeak interval, thereby indicating a
conduction delay between the distal eighth cranial nerve and lower pons (see Fig. 14.10), to preservation of wave I with loss of subsequent components, to loss of all
BAEP waveforms. The sensitivity of the BAEP to acoustic nerve lesions can be extended by decreasing the stimulus intensity over a prescribed range and evaluating
the effects on the BAEP waveforms (latency-intensity function). Some patients with small intracanalicular tumors have normal standard BAEPs, and abnormality is
revealed only by latency-intensity function testing.
BAEPs help establish the diagnosis of multiple sclerosis when they detect clinically unsuspected or equivocal brainstem lesions. BAEPs are abnormal in about 33% of
patients with multiple sclerosis, including 20% of those who have no other signs or symptoms of brainstem lesions. The BAEP findings in multiple sclerosis consist of
the absence or decreased amplitude of BAEP components, or an increase in the III to V interpeak latency.
BAEPs may be useful in demonstrating brainstem involvement in generalized diseases of myelin, such as metachromatic leukodystrophy, adrenoleukodystrophy, and
Pelizaeus-Merzbacher disease. BAEP abnormalities may also be demonstrable in asymptomatic heterozygotes for adrenoleukodystrophy.
BAEPs are also used to evaluate hearing in infants and others who cannot cooperate for standard audiologic tests. The latency-intensity test permits determination of
the wave V threshold, as well as the relationship of wave V latency to stimulus intensity, and often allows characterization of hearing loss as sensorineural or
conductive.
Somatosensory Evoked Potentials
Somatosensory evoked potentials (SSEPs) are generally elicited by electric stimulation of the median and posterior tibial nerves, and reflect sequential activation of
structures along the afferent sensory pathways, principally the dorsal columnlemniscal system. The components of median nerve SSEP testing important to clinical
interpretation include the Erb point potential, recorded as the afferent volley tranverses the brachial plexus; the N13, representing postsynaptic activity in the central
gray matter of the cervical cord; the P14, arising in the lower brainstem, most likely in the caudal medial lemniscus; the N18, attributed to postsynaptic potentials
generated in the rostral brainstem; and the N20, corresponding to activation of the primary cortical somatosensory receiving area ( Fig. 14.12). The posterior tibial
SSEP is analogous to the median SSEP and includes components generated in the gray matter of the lumbar spinal cord, brainstem, and primary somatosensory
cortex.
FIG. 14.12. Median SEPs in a patient with a right putamen hemorrhage. Following right median nerve stimulation, the SEP is normal. Following left median nerve
stimulation, the N20 cortical response is absent, while more caudally generated potentials are preserved.
SSEPs are altered by diverse conditions that affect the somatosensory pathways, including focal lesions (strokes, tumors, cervical spondylosis, syringomyelia) or
diffuse diseases (hereditary system degenerations, subacute combined degeneration, and vitamin E deficiency). Of patients with multiple sclerosis, 50% to 60% have
SSEP abnormalities, even in the absence of clinical signs or symptoms. SSEP abnormalities are also produced by other diseases affecting myelin
(adrenoleukodystrophy, adrenomyeloneuropathy, metachromatic leukodystrophy, Pelizaeus-Merzbacher disease). In adrenoleukodystrophy and
adrenomyeloneuropathy, SSEP abnormalities may be present in asymptomatic heterozygotes. Abnormally large-amplitude SSEPs, reflecting enhanced cortical
excitability, are seen in progressive myoclonus epilepsy, in some patients with photosensitive epilepsy, and in late-infantile ceroid lipofuscinosis.
SSEPs are commonly used to monitor the integrity of the spinal cord during neurosurgical, orthopedic, and vascular procedures that generate risk of injury; SSEPs
can detect adverse changes before they become irreversible. Although SSEPs primarily reflect the function of the dorsal columns, they are generally sensitive to
spinal cord damage produced by compression, mechanical distraction, or ischemia.
Motor Evoked Potentials
It is possible to assess the descending motor pathways by motor evoked potential (MEP) testing. MEP studies entail stimulation of the motor cortex and recording the
compound muscle action potential of appropriate target muscles. The cortex is stimulated either by direct passage of a brief high-voltage electric pulse through the
scalp or by use of a time-varying magnetic field to induce an electric current within the brain. Although the clinical utility of this technique is not defined, MEPs
evaluate the integrity of the descending motor pathways, complementing data about sensory pathways provided by SSEPs. MEPs also provide information about
diseases of the motor system.
DIGITAL EEG TECHNOLOGY AND COMPUTERIZED EEG
Traditional EEG machines record EEG signals as waveforms on paper with pens driven by analog amplifiers. These devices are gradually being replaced by
computerized systems that convert EEG data to a digital format, store the transformations on digital media, and display them on computer screens. These systems
facilitate interpretation by allowing the physician to manipulate EEG data at the time of interpretation and to supplement standard methods of EEG analysis with
display and signal-processing techniques that emphasize particular findings to optimal advantage.
Digital EEG technology has not fundamentally altered the manner in which EEG is interpreted. Rather, it allows standard interpretative strategies to be used more
effectively. In conventional paper-based EEG, a technologist sets all recording parameters, including amplification, filter settings, and montages, at the time EEG is
performed. In contrast, digital EEG systems permit these settings to be altered off-line when the EEG is interpreted. The EEG technician can select the best settings
for viewing a particular waveform or pattern of interest, or examine it at different instrument settings.
Digital technology has also made it possible to implement computerized pattern-recognition techniques to identify clinically significant electric activities during
continuous recordings. For example, automated spike- and seizure-detection algorithms are routinely used in epilepsy monitoring units during video-EEG recording.
Currently available software results in a high rate of false-positive detections, and careful manual review of computer-detected events is mandatory. Similar
techniques may be useful in intensive care units.
Digital systems also permit use of signal-processing and computer-graphic techniques to reveal features of the EEG that may not be apparent from visual inspection
of raw waveforms. For example, computer averaging improves the signal-to-noise ratio of interictal spikes, revealing details of the electric-field distributions and
timing relationships that cannot be discerned from the routine EEG ( Fig. 14.13). The fast Fourier transform (FFT) can quantify frequencies in EEG background activity,
and computer-graphic techniques display these data in an appealing and easily understood manner ( Fig. 14.14). Dipole source localization has been applied to both
interictal spikes and ictal discharges in patients with epilepsy. While these and other forms of processed EEG are at present best used to supplement conventional
visual analysis, many computerized techniques are based on specific critical assumptions that, if misapplied, may lead to erroneous conclusions. Therefore, at
present, findings from computer-processed EEG should be used clinically with caution and generally only when standard visual analysis is supportive and consistent.
FIG. 14.13. Averaged left temporal spike in a patient with complex partial seizures associated with mesial temporal sclerosis. Note the time-locked signal over the
right frontaltemporal regions occurring after a 20 millisecond delay. This most likely reflects propagation of the spike discharge from the left temporal lobe along
neural pathways to the right side. Such time delays cannot be appreciated in routine EEG recordings.
FIG. 14.14. Compressed spectral array (CSA) depicting the voltage spectra derived from two channels of EEG in a patient in nonconvulsive status epilepticus. The
abscissa of each chart represents time as indicated, and the ordinate represents frequency from 0 to 30 Hz. Voltage is encoded with use of a gray scale, as
illustrated. There is an abrupt change in the CSA, corresponding to a decrease in the voltage of low-frequency ictal activity when diazepam is administered
intravenously (arrow). The accompanying EEG samples correspond to representative epochs before (left) and after (right) treatment.
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3rd ed. New York: LippincottRaven Publishers, 1997:647660.
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1989;73:59.
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CHAPTER 15. ELECTROMYOGRAPHY AND NERVE CONDUCTION STUDIES IN NEUROMUSCULAR DISEASE
MERRITTS NEUROLOGY
CHAPTER 15. ELECTROMYOGRAPHY AND NERVE CONDUCTION STUDIES IN NEUROMUSCULAR

DISEASE
DALE J. LANGE AND WERNER TROJABORG
Electromyography
Neuromuscular Transmission Disorders
Suggested Readings
Needle electromyography (EMG) and nerve conduction studies are extensions of the neurologic examination. The primary role for electrophysiologic studies is to
separate neurogenic from myogenic disorders. For example, the characteristic EMG findings of stiff-man syndrome (Moersch-Woltman syndrome) and Issac
syndrome are the basis for these diagnoses. Repetitive stimulation abnormalities define the Lambert-Eaton syndrome. Characteristic abnormalities in nerve
conduction define some entrapment neuropathies or multifocal motor neuropathy with conduction block. EMG and nerve conduction findings may provide important
information to confirm a diagnosis, such as myasthenia gravis, Guillain-Barr syndrome, or polymyositis. Even normal EMG and nerve conduction findings may
provide essential information for diagnosis. For example, normal sensory studies in an anesthetic limb after trauma suggest nerve root avulsion. Normal repetitive
stimulation studies in the presence of severe weakness is strong evidence against myasthenia gravis.
However, EMG and nerve conduction studies are subject to many technical errors that can affect interpretation. For example, low limb temperature can lead to a false
diagnosis of neuropathy or may fail to reveal excessive decrement during repetitive nerve stimulation in patients with myasthenia gravis. These and other technical
considerations and normal variants, discussed in monographs listed in the references, are essential for performing and interpreting these tests.
Nerve conduction studies are performed on motor and sensory nerves, usually in the distal portions of limbs (hand and feet). Conduction, however, can also be
measured to biceps, deltoid, quadriceps, and muscles of the trunk (diaphragm and rectus abdominis). High-voltage electrical and magnetic stimulators activate spinal
roots and descending pathways from the brain and spinal cord.
Similar techniques are used for motor and sensory nerve conduction studies ( Fig. 15.1). An electrical stimulus is applied to the skin directly over a nerve. One
electrical response is recorded from the innervated muscle (motor) or a more proximal portion of the nerve (sensory). The stimulus intensity is increased until the
response no longer grows in amplitude (supramaximal response). The interval between the onset of the stimulus and the onset of the evoked response is the latency.
Because nerve fibers vary in diameter and speed of conduction, a supramaximal stimulus ensures that all nerve fibers are activated, facilitating comparison of
latencies in different people or in serial studies of the same person. The calculated conduction velocity corresponds to the fastest conducting fibers. Conduction
studies may therefore fail to show an abnormality in a disease that affects only small-diameter nerve fibers if surface recording methods are used. Near nerve
recording, however, can assess these slower components of the sensory response from smaller diameter myelinated fibers. Direct recording from the small- est
myelinated and unmyelinated fibers is called micro- neurography.
FIG. 15.1. Technique for motor and sensory conduction studies of the median nerve. A: Components of the evoked compound muscle action potential. B: Electrode
placement for motor nerve stimulation (S1, S2) and recording (R1, R2). C: Electrode placement for sensory nerve stimulation (S3) and recording (R3). S1, motor
stimulation at wrist; S2, motor stimulation at elbow; S3, sensory stimulation at finger; R1, motor response after stimulation at S1; R2, motor response after stimulation
at S2; R3, sensory nerve evoked response after stimulating finger; ML, motor latency or the time between onset of stimulation and onset of motor response; SL,
sensory latency or the time between onset of stimulus to onset of sensory response.
The distal motor latency is the time between the onset of the stimulus and the onset of the muscle response. Stimulation at a more proximal point produces an evoked
response with a longer latency (proximal latency). Both distal and proximal motor latencies include the time needed to cross the neuromuscular junction. Therefore,
when the distal latency is subtracted from the proximal latency, the effect of neuromuscular transmission is eliminated, and the resulting time represents the speed of
conduction of the nerve in that specific segment. The distance between the two points of nerve stimulation is measured to calculate segmental conduction velocity
(distance/latency difference = velocity). In contrast, sensory nerve conduction in peripheral nerve does not involve synaptic transmission, so velocity measurements
are calculated directly from the distance and latency ( Fig. 15.1).
Conduction velocity is determined by the size of the largest diameter (and therefore fastest conducting) axon and the presence of normal myelin, the component of
peripheral nerves that provides the structural basis for saltatory conduction. In demyelinating diseases, the segmental velocity slows to approximately half of the
normal mean. In axonal disease, if the large-diameter fibers are preferentially lost, velocity can also slow but not to less than 50% of the normal mean.
The evoked response has a biphasic (motor) or triphasic (sensory) waveform. The size of the evoked response depends on the number of fibers activated under the
electrode, the surface area of the electrode, and the synchrony of firing. If the firing of motor nerve fibers is well synchronized, the muscle response is also
synchronized, and the duration of the muscle evoked response is short. If nerve conduction is pathologically slow, nerve fibers that conduct at different speeds may
be affected differently, resulting in poorly synchronized arrival of nerve impulses to the muscles, and duration of the waveform increases and the amplitude decreases
because of phase cancellation between individual action potentials. In chronic partial denervation, individual axons are not all affected to the same extent, and
reinnervation augments the dispersion of conduction velocities. Therefore, in chronic neuropathy or motor neuron disease, proximal stimulation may evoke a response
of lower amplitude than distal stimulation even though the same number of fibers is activated.
The excessive loss (>50%) of amplitude between two points of stimulation is a suspicious sign of conduction block, which is pathognomonic of a demyelinating
neuropathy (Fig. 15.2). In chronic partial denervation, however, the lower evoked response amplitude may only be due to phase cancellation and temporal dispersion.
To differentiate the effects of temporal dispersion from conduction block in chronic partial denervation, the area under the negative phase is measured. Computerized
models of conduction in the rat sciatic nerve suggest that a loss of more than 50% of the area of the response indicates that both temporal dispersion and conduction
block are present.
FIG. 15.2. Motor conduction block. A: Normal. Evoked compound muscle action potential amplitude shows little change at all points of stimulation. (Calibration, 1 cm =
10 mV.) B: Conduction block with amplitude reduction and temporal dispersion in the nerve segment between axilla and elbow. (Calibration, 1 cm = 5 mV.) W, wrist;
E, elbow; Ax, axilla; Erb's, Erb's point.
If both distal and proximal stimulation result in a response of low amplitude, the pattern implies a diffuse (proximal and distal) process and a generalized loss of axons,
as in an axonal neuropathy. Axonal neuropathies usually show normal distal motor latency, normal or borderline normal segmental velocity, no conduction block, or
dispersion. Demyelinating neuropathies show prolonged distal latency, slow segmental velocity, normal or reduced evoked response amplitude, conduction block, and
increased temporal dispersion.
F response and H reflexes evaluate conduction in the proximal portions of nerve fibers. The F response, so named because it was first observed in small foot
muscles, is a measure of conduction along the entire length of nerve from the distal point of stimulation to the anterior horn cells and back to the distal recording
electrode. This technique uses the same recording setup as standard motor nerve conduction studies except that the stimulator is rotated 180 degrees (cathode
proximal). Normal values depend on limb length but are usually less than 32 ms in the arms and 60 ms in the legs. The waveform is characteristically present at
supramaximal stimulation and varies in latency, shape, and presence. Although F responses are often prolonged in neurogenic conditions, they are of most value
when distal conduction is normal; that is, if the F response latency is prolonged and velocity in distal segments is normal, slowing occurs in proximal segments. This
pattern is seen in proximal polyradiculopathies, such as the Guillain-Barr syndrome. In chronic demyelinating neuropathies, the proximal segments may also be
involved, and the F response latency may be longer than expected from the velocity calculated in distal portions.
The H reflex is considered to be the electrical counterpart of the Achilles reflex, although the pathways are not identical. The H reflex is sometimes seen in the
absence of the Achilles reflex and vice versa. In contrast to the F response, which uses only the efferent motor nerve pathway, the H reflex is thought to be a
monosynaptic reflex with an afferent and efferent limb. It is recorded from multiple muscles in infants, but as the nervous system matures, the H reflex is found only in
the tibial nerve or soleus system (absent in 10% of normal subjects) or in the median nerve or flexor carpi radialis system. The H reflex occurs during submaximal
stimulation, does not vary in shape, and disappears with supramaximal stimulation. It is one of the few measures of afferent nerve conduction in proximal portions of
sensory nerves and identifies dorsal root pathology when the H reflex is prolonged in conjunction with normal F response latency in the same nerve. Additionally, the
H reflex may reappear in muscle or nerve systems other than the tibial or soleus system as part of upper motor neuron diseases, such as multiple sclerosis or
primary lateral sclerosis.
ELECTROMYOGRAPHY
The electrical activity of muscle may be recorded with surface electrodes, but spontaneous electrical activity (fibrillations and positive sharp waves) and individual
voluntary motor units cannot be seen with surface electrodes. EMG is therefore performed with a needle electrode (either monopolar or concentric) placed directly in
the muscle for extracellular recording of action potentials generated by the muscle fibers spontaneously or during voluntary movement. Needle recording can also be
used to measure evoked potentials after motor nerve stimulation when the surface recorded potential is too low for reliable measurements. Needle recording of
evoked potentials, however, is less reliable because the waveform is affected by movement of the activated muscle.
Diagnostic information includes the type and amount of spontaneous activity, evaluation of motor unit form with minimal volitional activity, and the density of motor
units during maximal activation. After denervation, muscle fibers discharge spontaneously. These extracellular potentials recorded at rest are called positive sharp
waves and fibrillation potentials. Although characteristic of denervating conditions (peripheral neuropathy, traumatic neuropathy, plexopathy, radiculopathy, and motor
neuron disease), spontaneous potentials are also seen in some myogenic disorders (polymyositis and even in dystrophinopathies) but rarely in disorders of
neuromuscular transmission (myasthenia gravis, Lambert-Eaton syndrome, and botulism). Fibrillation potentials are biphasic or triphasic and of short duration and are
generated by discharges of single muscle fibers. Positive sharp waves are thought to have the same implications as fibrillation potentials but are differently shaped
because the traveling wave terminates at the point of needle recording, so there is no upward negative phase.
Fasciculations are spontaneous discharges of an entire motor unit that comprise all the muscle fibers innervated by a single axon. The amplitude and duration of the
fasciculation potential are therefore greater than the fibrillation. Fibrillations are never seen clinically, but fasciculations can usually be seen with the naked eye.
Fasciculations are of neurogenic origin and are most often associated with proximal diseases, such as anterior horn cell disease or radiculopathy. They are
occasionally found, however, in generalized peripheral neuropathy and even in normal individuals (benign fasciculations).
Other types of spontaneous activity include myotonia (high-frequency muscle fiber discharge of waxing and waning amplitude), complex repetitive discharges (which
are spontaneous discharges of constant shape and frequency with abrupt onset and abrupt cessation), and myokymia and neuromyotonia (bursts of muscle activity
that often, but not always, are associated with cramps and visible twitching). Clinically, these electrical phenomena occur in Isaac syndrome and myokymia. EMG is
useful in the difficult clinical differentiation of facial myokymia and facial hemispasm.
Motor unit configuration changes depending on the particular disease. In neurogenic disease, the motor unit territory increases and the motor unit potentials increase
in duration and amplitude. Standard monopolar and concentric needles record only from a portion of the motor unit, but the change in amplitude and duration is
diagnostic. In myogenic disease, motor unit potentials decrease in amplitude and duration. Quantitative motor unit potential analysis provides more reliable correlation
with muscle and nerve disease than muscle biopsy. Normal extracellularly recorded motor unit potentials are triphasic in shape; polyphasic motor units occur in both
neurogenic and myogenic disease and are normally found in small numbers in all muscles. They are therefore nonspecific findings.
The recruitment pattern refers to the electrical activity generated by all activated motor units within the recording area of a maximally contracting muscle. Normally, the
recruitment pattern on maximal effort is dense with no breaks in the baseline. The amplitude of the envelope (excluding single high-amplitude spikes) is normally 2 to
4 mV using a concentric needle with standard recording area (0.07 mm 2). In neurogenic disease, the density of the recruitment is reduced and the firing frequency of
the remaining units increases. Sometimes only one unit can be recruited by maximal effort, and this unit may fire faster than 40 Hz (discrete recruitment). In myogenic
disease, the number of motor units is unchanged by the disease, but the amplitude and duration of the motor units are reduced. Therefore, recruitment density is
normal, but the envelope amplitude is reduced, leading to the pathognomonic finding of myopathy: full recruitment in a weak wasted muscle.
NEUROMUSCULAR TRANSMISSION DISORDERS
Weakness occurs only if muscle fibers fail to contract or generate less than normal tension. Muscle fibers may fail to contract because of impaired nerve conduction,
neuromuscular transmission, or muscle conduction. If muscle fibers are not activated because neuromuscular transmission fails, the abnormality is called blocking. If
a sufficient number of muscle fibers is blocked, the amplitude of the evoked response is reduced. For example, in myasthenia gravis, repetitive electrical stimulation at
2 to 3 Hz causes progressive loss of the compound muscle action potential amplitude until the fourth or fifth response because of increasing numbers of
neuromuscular junctions with blocking (Fig. 15.3). After the fifth potential, the compound muscle action potential usually shows no further decline or may slightly
increase. Decrement also improves immediately after 10 to 15 seconds of intense exercise (postactivation facilitation; Fig. 15.3). If the muscle is exercised manually
for 1 minute, the decrement becomes more pronounced at 3 to 4 minutes (postactivation exhaustion; Fig. 15.3).
FIG. 15.3. Muscle action potentials evoked by repetitive stimulation at 3 Hz in myasthenia gravis. A: Showing decrement at rest. B: Postactivation facilitation. C:
Postexercise exhaustion. (Calibration, 1 cm = 5 mV.)
In Lambert-Eaton syndrome and botulism, release of acetylcholine is impaired at rest, but during exercise or rapid rates of stimulation, acetylcholine release is
facilitated. This is reflected by a positive edrophonium test and electrophysiologic decrement at low rates of stimulation and increment at fast rates.
Single-fiber EMG is a technique that identifies dysfunction of the muscle fibers before any blocking or overt weakness occurs ( Fig. 15.4). When weakness appears,
blocking is usually demonstrable. A normal single-fiber EMG study in a weak muscle rules out a disorder of neuromuscular transmission.
FIG. 15.4. Single-fiber EMG recordings showing normal (A) and increased (B) jitter.
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CHAPTER 16. NEUROVASCULAR IMAGING
MERRITTS NEUROLOGY
CHAPTER 16. NEUROVASCULAR IMAGING

J. P. MOHR AND ROBERT DELAPAZ
Computed Tomography
Magnetic Resonance Imaging
Magnetic Resonance Angiography
Catheter Angiography
Doppler Measurements
Regional Cerebral Blood Flow
Stable-Xenon Computed Tomography
Single Photon Emission Computed Tomography
Positron Emission Tomography
Discussion
Suggested Readings
Brain imaging plays a central role in the diagnosis, classification, and prognosis of stroke. As technology advances, so do the applications. Conventional radiology
plays little role now, and current techniques include computed tomography (CT) and magnetic resonance imaging (MRI) with or without contrast enhancement, MR
diffusion and perfusion imaging, CT or MR angiography (MRA), ultrasonic Doppler insonation of blood flowing in the extra- or intracranial arteries and veins, MR
spectroscopy (MRS), and single photon emission computed tomography (SPECT) by agents that assess blood flow or specific chemical reactions or receptors of the
brain.
COMPUTED TOMOGRAPHY
Acute hematomas have a characteristic high-density (high-attenuation) appearance (bright) on CT in the first week; CT reliably differentiates the low-attenuation
lesion (dark) typical of bland infarction from the high-attenuation of hematoma or grossly hemorrhagic infarction ( Fig. 16.1 and Fig 16.2). The volume of an acute
parenchymal hematoma can be estimated accurately by CT. As the high signal of fresh blood is lost in days or weeks (hemoglobin breakdown) at the site, the CT
appearance evolves from initial hyperdensity through an isodense (subacute) phase to hypodensity in the chronic state (see Fig. 13.1). In the subacute phase,
contrast administration may result in ring enhancement around the hemorrhage ( Fig. 16.3), a pattern different from the gyral enhancement typical of infarction ( Fig.
16.1). This ring or rim enhancement may appear similar to tumor or abscess, a pitfall that is especially misleading with isodense or hypodense late hematomas. In the
chronic state, a hematoma is usually reduced to a slitlike cavity after phagocytic clearing of hemorrhagic and tissue debris. Many hematomas disappear without
creating a cavity, leaving isodense tissue. Subarachnoid hemorrhage is even more transient and may not be visible unless it is particularly dense; lumbar puncture
can make the diagnosis of subarachnoid bleeding in those with normal CTs.
FIG. 16.1. Hyperacute cerebral infarct (3 hours). A: Axial noncontrast computed tomography appears normal except for the low density in the left medial parietal
cortex representing a chronic infarct. B: Axial T2-weighted fast spin echo magnetic resonance (MR) image shows slight elevation of signal in the left insular cortex,
high curvilinear signal at the deep margin of the chronic left parietal infarct, and high signal with central low signal in a subacute hemorrhagic infarct in the medial right
parietal lobe. C: Axial fluid attenuated inversion recovery MR image shows slightly increased signal in the left periventricular region and high signal at the margin of
the chronic infarct and mixed signal in the subacute infarct. D: Axial diffusion-weighted image (b = 1,000) shows a large region of high signal, representing low water
proton diffusion rates, in the large middle cerebral artery infarct produced by carotid dissection 3 hours before the study. (Courtesy of Dr. R. L. DeLaPaz.)
FIG. 16.2. Acute cerebral infarct (24 hours). A: Axial diffusion-weighted image (DWI, b = 1,000) shows a patchy region of high signal, representing low water proton
diffusion rates, in an acute deep left basal ganglia and corona radiata infarct. B: The exponential apparent diffusion coefficient (ADC) map represents the ratio of
signal on the DWI to the T2-weighted (b = 0) image. This map corrects for high signal on the DWI produced by high signal on the T2-weighted image, the T2 shine
through effect. This acute infarct produces high signal on both the DWI and exponential ADC maps, confirming reduced tissue water diffusion. C: This map of relative
perfusion delay, time to peak, was produced by rapid scanning with T2*-weighted images during an intravenous gadolinium contrast bolus injection. The high signal
area in the region of the left-sided infarct represents a large zone of relatively delayed arrival of the peak signal change produced by the gadolinium bolus as it
passes through the tissue capillary bed. D: The time-intensity curves show the transient drop in signal on T2*-weighted images as the gadolinium bolus passes
through and indicate a substantial delay in the left-sided ischemic zone (9-second peak arrival delay; x-axis is image number with TR = 3 seconds and y-axis is signal
intensity). E: Axial fluid attenuated inversion recovery magnetic resonance (MR) image shows patchy increased signal in the infarct. The square outline represents the
voxel used for proton MR spectroscopy. F: Proton MR spectrum (TR 2,000, TE 144) shows a slight elevation of choline (Cho), a slight decrease in N-acetylaspartate
(NAA), and a marked elevation of lactate (peak inversion is due to J-coupling of lactate doublet). Peak areas represent relative concentrations of tissue metabolites.
(Courtesy of Dr. R. L. DeLaPaz.)
FIG. 16.3. Chronic cerebral infarct with T2 shine through. A: Axial T2-weighted fast spin echo (FSE) magnetic resonance (MR) image shows high signal in a chronic
left middle cerebral artery (MCA) territory infarct. B: Axial fluid attenuated inversion recovery (FLAIR) MR image also shows high signal in the chronic left MCA
territory infarct. C: Axial diffusion-weighted image (DWI, b = 1,000) shows a region of high signal corresponding to the MCA infarct and the high signal seen on the
FSE and FLAIR images. D: The exponential apparent diffusion coefficient (ADC) map represents the ratio of signal on the DWI to the T2-weighted (b = 0) image. This
map corrects for high signal on the DWI produced by high signal on the T2-weighted image, the T2 shine through effect. The exponential ADC map shows low signal
in the lesion, indicating high water diffusion rates, as would be expected in a chronic infarct. Acute infarcts produce high signal on both the DWI and exponential ADC
maps, indicating reduced tissue water diffusion (see Fig. 16.2). (Courtesy of Dr. R. L. DeLaPaz.)
With nonhemorrhagic infarction, CT may appear normal for several days. When there is collateral supply to the region, CT is usually positive within 24 hours, showing
hypodensity due to edema. Ischemic infarcts with little collateral flow or edema may remain isodense or may not enhance for days or weeks, later appearing only as
focal atrophy. Although CT may overestimate the size of deep lesions, it better approximates the volume of discrete surface infarcts, especially after several months
when the acute effects of edema and necrotic tissue reabsorption have subsided ( Fig. 16.4). Contrast-enhanced infarction is usually seen within 1 week and may
persist for 2 weeks to 2 months. A characteristic gyriform enhancement pattern is often seen when cortical gray matter is involved.
FIG. 16.4. Cerebral infarction, acute and chronic phases. A: Axial noncontrast computed tomography reveals focal regions of discrete lucency in left basal ganglia and
right occipital regions without mass effect, suggesting nonacute infarcts. A fainter less well-defined left occipital lucency is also noted, with effacement of cortical
sulci and the atrium of the ventricle, suggesting more recent infarction. B: Follow-up noncontrast scan 2 months later demonstrates interval demarcation of the left
occipital infarct with evidence of focal atrophy, negative mass effect on the atrium, which appears larger. Similar change is noted in left frontal horn. (Courtesy of
Drs. J. A. Bello and S. K. Hilal.)
Standard CT techniques do not distinguish partial ischemia from actual infarction. In the early stages, the physician may be frustrated by the difficulty determining how
much tissue is viable and how much damage is permanent. Spiral CT provides serial scans during the first pass of an intravenous contrast bolus and can give relative
measures of ischemia from derived blood volume and perfusion delay maps. Stable xenon-enhanced CT may also be useful.
Spiral CT can also scan the entire neck or head with a bolus intravenous infusion of contrast agent for a CT angiogram. Maximum intensity projection reformations,
often with three-dimensional surface shading, display vascular features such as stenosis or aneurysm. Advantages of CT angiogram over catheter angiography
include more widely available technology, less specialized skill requirements, and relatively noninvasive intravenous administration of contrast material. However, use
of CT angiogram has been growing slowly because of competition from MRA. In contrast to MRA, the iodinated contrast agent is potentially more toxic because of
allergic reactions, direct cardiac volume stress, or renal toxicity. Another limitation of CT angiogram is the time-consuming postprocessing required to edit out bone
and calcium and to generate three-dimensional surface rendering.
Within the brain, CT may differentiate abnormal from normal soft tissues, particularly after intravenous administration of iodinated contrast agents; abnormal
enhancement implies a breakdown of the bloodbrain barrier. MRI is more sensitive than CT in demonstrating parenchymal abnormalities and can also be augmented
by a contrast agent, gadolinium.
MAGNETIC RESONANCE IMAGING
MRI is rapidly overtaking CT in imaging of both hemorrhagic and ischemic stroke. The physics of MRI are discussed in Chapter 13. Selection of the pulse sequence
and plane of imaging is necessary to achieve the maximum utility of the technique. To diagnose and date hemorrhage, T1- and T2-weighted images are necessary
(Fig. 13.1 and Fig. 16.5). The appearance of parenchymal hemorrhage on MRI is much more complicated than on CT and varies as the hemorrhage evolves.
Hyperacute hemorrhage, within the first 12 to 24 hours, usually appears as isointense to slightly hypointense on T1-weighted images and isointense to hypointense
on T2-weighted images (also hypointense on fluid attenuated inversion recovery [FLAIR] and gradient echo [GRE] images). This pattern arises because a clot is first
composed of intact red blood cells with fully oxygenated hemoglobin, giving it the same signal characteristics as brain tissue. Rapid deoxygenation generates
deoxyhemoglobin, which is paramagnetic and produces low signal on T2-weighted images (shortens T2 relaxation) with little effect on T1-weighted images. After this
hyperacute period, the hemoglobin within the red cells evolves into methemoglobin, which has a stronger paramagnetic effect and produces high signal on
T1-weighted images (shortens T1 relaxation) with persistent low signal on T2-weighted images. After several days, the red cells break down in the subacute
hematoma, resulting in a more uniform distribution of methemoglobin and dominance of the shortened T1 relaxation time, producing high signal on both T1-weighted
and T2-weighted images. This appearance remains stable for weeks to months until the hemorrhagic debris is cleared by phagocytes, leaving only hemosiderin at the
site of the hemorrhage. The chronic hemorrhagic site is isointense on T1-weighted images and hypointense to isointense on T2-weighted images. GRE images are
especially sensitive to hemosiderin deposits and often show sites of chronic hemorrhage as low signal when both T1-weighted and T2-weighted images are
isointense. GRE images are particularly useful as a screen for occult prior hemorrhage associated with suspected vascular malformations, amyloid angiopathy,
trauma, or anticoagulation.
FIG. 16.5. Hemorrhagic infarction. A: Axial precontrast computed tomography shows focal left parietal gyral density consistent with hemorrhagic infarction. Note
edema and sulcal effacement in left frontoparietal cortical region. B: Postcontrast enhancement in area of recent hemorrhagic infarction. (Courtesy of Drs. J. A. Bello
and S. K. Hilal.)
The appearance of subarachnoid and other extraaxial hemorrhage follows similar stages of signal change but may evolve more rapidly or slowly, depending on
location and cerebrospinal fluid dilution effects. The diagnosis of acute subarachnoid hemorrhage is still made most reliably with CT; recent experience with FLAIR
indicates a high sensitivity to subarachnoid hemorrhage. FLAIR may identify subarachnoid hemorrhage as abnormal high signal in sulci that appear normal on CT.
However, this high signal is less specific than high density on CT and may also represent cells or elevated protein content in cerebrospinal fluid caused by infection or
meningeal neoplasm. GRE images are not sensitive or specific for acute subarachnoid hemorrhage but may show signs of repeated prior subarachnoid hemorrhage
as low signal along the pial surface caused by deposition of hemosiderin (hemosiderosis).
MRI is unquestionably more sensitive and more specific than CT for the diagnosis of acute brain ischemia and infarction. The multiplanar capability, lack of artifact
from bone, and the greater sensitivity to tissue changes provide MRI a particular advantage over CT for imaging infarcts in the brainstem ( Fig. 16.6). Diffusion
weighted imaging (DWI), described in more detail in Chapter 13, has revolutionized acute infarct detection. Severe cerebral ischemia and infarction cause a rapid
decrease in intracellular diffusion that consistently produces high signal on DWI within minutes of cell injury. T2-weighted and FLAIR images show high signal in
acute infarction only after a delay of 6 to 12 hours. DWI is also more specific for acute infarction. High signal lesions on FLAIR or T2-weighted images may represent
acute, subacute, or chronic infarction, whereas the DWI shows high signal only in acute lesions. After the initial reduction in diffusion, there is a gradual rise through
normal to prolonged diffusion rates during the 1 to 2 weeks after infarction, as cells disintegrate and freely diffusable water dominates the encephalomalacic tissue. A
minor pitfall of DWI in subacute infarcts is the phenomenon called T2 shine through, where high signal on T2-weighted images may produce high signal on DWI,
falsely indicating reduced diffusion. This pitfall can be avoided by the use of calculated apparent diffusion coefficient maps. DWI has become an essential part of
acute stroke imaging and, because it takes less than a minute to acquire a whole brain study, is being used for screening a variety of clinical presentations for
possible ischemic injury.
FIG. 16.6. Brainstem infarction. Noncontrast axial computed tomographies reveal possible infarcts in left brachium pontis (A) and right midbrain (B). Axial (C) and
coronal (D) T2-weighted magnetic resonance scans of the same patient clearly show these and additional small infarcts not seen on CT. (Courtesy of Drs. J. A. Bello
and S. K. Hilal.)
MRI methods for assessing cerebral perfusion, described in more detail in Chapter 13, have also transformed the evaluation of acute cerebral ischemia. Tissue blood
flow is most commonly imaged with MRI using a first pass or bolus tracking method that records the signal changes that occur when rapidly repeated images are
acquired during the first passage of an intravascular bolus of paramagnetic contrast material through the brain, usually gadolinium-diethylenetriamine pentaacetic
acid. This rapid imaging can be done during routine contrast administration, adding minimal time to the routine examination. This method provides maps of relative
cerebral blood volume, cerebral blood flow, and bolus mean transit time or time to peak. Measures of perfusion delay such as mean transit time and time to peak are
proving to be sensitive indicators of subtle reductions in cerebral perfusion. A second method of MR perfusion imaging is called spin tagging or time of flight
imaging and, like time-of-flight MRA, depends on T1 relaxation and flow enhancement phenomena without the use of injected contrast agents. This method is less
widely used than bolus tracking but is capable of giving more quantitative cerebral blood flow measurements but with more limited coverage of the brain. These
methods can be used to identify relatively underperfused brain regions distal to arterial stenoses or occlusions. They can also give an indication of the potentially
salvageable penumbra of ischemic, but not yet infarcted, brain around an infarction, as indicated by high signal on DWI.
MRS (also described in Chapter 13), using either proton ( 1H) or phosphorus ( 31P), has limited application in the evaluation of acute ischemia. Although changes
characteristic of injured or dead tissue can be seen, such as reduced N-acetylaspartate and elevated lactate on proton MRS and reduced energy metabolites on
phosphorus MRS, the long duration (3 to 20 minutes) and low resolution (2 to 8 cm voxel size) of these methods limit practical application in the acute stroke patient.
Proton MRS may be helpful with enhancing subacute infarction in deep white matter where routine imaging may suggest primary brain tumor. Although both infarct
and tumor may show reduced N-acetylaspartate and elevated lactate, a markedly elevated choline peak is strong evidence for tumor and against infarction. Adding
DWI may also be helpful because diffusion rates are usually normal to prolonged in tumor (iso to low signal on DWI) in contrast to low diffusion rates in acute to
subacute infarction (high signal on DWI).
MAGNETIC RESONANCE ANGIOGRAPHY
MRA, also described in Chapter 13, is rapidly becoming the method of choice for screening the extracranial and intracranial vasculature. MRA, with Doppler
ultrasound, is commonly used for the initial evaluation of carotid bifurcation stenosis. Depending on the institution and surgeon, these may be the only preoperative
imaging studies done. Although MRA generally depicts a similar degree of stenosis to that on the Doppler ultrasound, there are artifacts on MRA that can be
misleading. High flow rates can produce signal loss within the lumen, exaggerating the degree of stenosis, and turbulent flow can mimic complex plaque anatomy or
ulceration. When the MRA and Doppler disagree substantially, catheter angiography is indicated for a definitive diagnosis.
MRA is also used for screening the intracranial circulation. Large vessels of the circle of Willis can be imaged effectively and rapidly, but current resolution precludes
detailed observation of vessels more distal than the second-order branches of the middle cerebral artery. Conventional angiography remains the gold standard for
evaluation of subtle segmental stenoses produced by arteritis, especially in small distal branches. Although MRA images are not as sharp as those of conventional
angiography, all vessels are visualized simultaneously and can be viewed from any angle; most important, MRA is completely safe, noninvasive, and can be added to
the routine MRI examination. The use of MRA as a screening technique for intracranial aneurysms is also increasing. Although MRA can detect aneurysms as small
as 3 mm under optimal conditions, a practical lower limit in clinical usage is probably 5 mm diameter. A pitfall with time-of-flight MRA is the high signal produced by
subacute parenchymal or subarachnoid hemorrhage that can mimic an aneurysm or AVM. Phase contrast MRA may be a better choice in patients with known
hemorrhage. Conventional angiography is the definitive examination for evaluation of intracranial aneurysms and arteriovenous malformations. Other indications for
screening MRA include stroke, transient ischemic attack, and possible venous sinus thrombosis.
CATHETER ANGIOGRAPHY
Analysis of cerebrovascular disease has become increasingly precise with new technologies. As a result, many changes have occurred in practice, especially in the
use of cerebral catheter angiography, once the mainstay of vascular imaging. Before the availability of CT and MRI, angiography was used routinely to outline intra-
and extraaxial hematomas, evaluate vasospasm after ruptured aneurysms, and estimate degree of extracranial arterial stenosis. With the advent of CT, MRI, and
Doppler studies, the diagnostic role of angiography is now more restricted. In many centers, angiography is used only to study intracranial vascular disease that is not
visualized by MRI, MRA, or Doppler techniques. Catheter angiography involves the intraarterial injection of water-soluble iodinated contrast agents; transient
opacification of the arterial lumen is filmed by conventional radiographic or digital subtraction techniques. Angiography is unsurpassed in the detailed anatomic
depiction of stenosis, occlusion, recanalization, ulceration, or dissection of large and small intra- and extracranial arteries ( Fig. 16.7).
FIG. 16.7. Proximal internal carotid stenosis. Lateral arteriogram of the common carotid shows an ulcerated plaque of the proximal internal carotid with
hemodynamically significant stenosis. Anterior circulation failed to fill and cross-filled from the contralateral side. (Courtesy of Drs. J. A. Bello and S. K. Hilal.)
Because catheter angiography is expensive, requires specialized catheter skills, and carries a 0.5% to 3% risk of embolic stroke, it is often undertaken only once in
the course of hemorrhage or infarct evaluation. For a diagnosis of embolism, angiography should be carried out within hours of the ictus because the embolic particle
may fragment early, changing the appearance of the affected vessel from occlusion to stenosis or a normal lumen, depending on the delay time. When atheromatous
stenosis of large arteries is suspected, preangiographic studies of central retinal artery pressure or Doppler ultrasound (see the following) help to tailor the
angiographic study and enable the angiographer to concentrate on the major territories thought to be affected. Catheter angiography is the primary method for
preoperative evaluation of intracranial aneurysms and arteriovenous malformations, especially if interventional catheter therapies are being considered.
Catheter angiography techniques have become more sophisticated and now include interventional methods for the treatment of neurovascular disease. Thrombolytic
agents can be delivered directly to intravascular clots, including higher order intracranial vessel branches using superselective microcatheter techniques and to major
dural sinuses using retrograde venous approaches. Arterial stenosis can be treated with angioplasty, which involves catheter placement of an intravascular balloon at
the stenotic site and then inflating the balloon to expand the vessel. Angioplasty is used mostly for atherosclerotic disease in the extracranial vessels, sometimes
followed by placement of a wire mesh stent to help keep the lumen patent. Angioplasty is also used to expand a stenosis caused by vasospasm with subarachnoid
hemorrhage. Occlusion of abnormal vessels and aneurysms can also be performed using intravascular techniques. Arteriovenous malformations and fistulas can be
treated by occlusion of the feeding arteries with coils (flexible metal spiral coils that induce local thrombosis), and the AVM nidus can be occluded with bucrylate, a
rapidly setting polymer glue. Aneurysms can be treated by catheter placement of coils and occasionally balloons within them when surgical treatment is not feasible
because of aneurysm anatomy, location, or the patient's medical status. Emergency arterial occlusions are also performed for uncontrollable epistaxis and
postoperative hemorrhage in the neck, paranasal sinus, and skull base regions.
DOPPLER MEASUREMENTS
The simplest Doppler devices pass a high-frequency continuous wave sound signal over the tissues in the neck, receive the reflected signal, and process them
through a small speaker. Technicians using a continuous wave Doppler listen for the pitch of the sound and make a rough judgment of the degree of the Doppler shift
to infer whether the blood moving through the artery beneath the probe is normal, decreased, or increased and, if increased, whether blood flow is smooth or
turbulent. Little experience is required to separate the high-frequency arterial signal from the low-frequency venous sound or to recognize the extremely high
frequencies of severe stenosis. More effort is required to quantitate the signal for comparison with a test at a later date. Because the Doppler shift equation depends
on the cosine of the beam versus the flowing blood within the artery, casual angulation of the probe can have major effects on signal production.
To assist in proper probe angulation, duplex Doppler devices have two crystals, one atop the other, in a single probe head; one crystal handles the Doppler shift for
spectral analysis and the other, the B-mode image of the vessel walls. Improvement in crystal designs have reduced the size of the probe, but it is still so bulky that it
is difficult to image and insonate the carotid artery high up under the mandible. The Doppler shift crystal has an adjustable range gate to permit analysis of flow
signals from specific depths in the tissues, eliminating conflicting signals where arteries and veins overlie one another. Some even have two range gates, providing an
adjustable volume or window to insonate the moving blood column in an artery at volumes as small as 0.6 mm, the size of the tightest stenosis. The capacity to
interrogate the flow pattern from wall to wall across the lumen has made this technique useful for detecting, measuring, and monitoring degrees of stenosis ( Fig. 16.8).
Because duplex Doppler is sensitive to cross-sectional area and not to wall anatomy, if it is used before angiography, it can alert the angiographer to seek stenotic
lesions that might be missed on a survey angiogram. Unfortunately, B-mode vessel imaging is insensitive to most minor ulcerations, which are better seen by
conventional angiography. Although duplex Doppler methods were developed to insonate the carotid, they can assess the extracranial vertebral artery through the
intervertebral foramina.
FIG. 16.8. Four studies, each showing different degrees of stenosis of the extracranial internal carotid. The studies, obtained with the Diasonics DRF 400 instrument,
image the carotid by B-mode ultrasound (upper left-hand corner of each of the four pictures) by passing the ultrasound beam through the tissues ( angled line) and
sampling the flow velocity at a point within the lumen of the vessel ( horizontal bracketed line). From this sample, the device displays the waveforms representing the
velocity profile calculated from the Doppler shift (waveforms shown with velocity in cm/s in each picture). The mean velocities are then calculated from a sample taken
near the peak of each waveform (small arrow under each waveform line) and the spectrum of velocities (i.e., degree of turbulence) is displayed as peak vel (i.e.,
velocity), mean vel, and vel range (shown in graphic form in the upper right-hand corner of each picture). Examples of varying degrees of stenosis are shown:
normal flow, left upper corner; moderate (60% to 80%) stenosis with moderate turbulence, right upper corner; severe (80% to 90%) stenosis with marked turbulence,
left lower corner; extremely severe (90% to 99%) stenosis with extreme turbulence, right lower corner.
Using a probe with great tissue penetration properties, it is possible to insonate the major vessels of the circle of Willis, the vertebrals, and the basilar. Current
transcranial Doppler devices are range gated, and the latest models give a color-coded display of the major intracranial arteries ( Fig. 16.9). The signals accurately
document the direction and velocity of the arterial flow insonated by the narrow probe beam. Spectrum analysis of the signal allows estimation of the degree of
stenosis as does extracranial duplex Doppler. Hemodynamically important extracranial stenosis may damp the waveform in the ipsilateral arteries above, allowing the
effect of the extracranial disease to be measured and followed serially. A challenge test of contralateral compression can be done to determine whether the effects of
unilateral extracranial stenosis are compensated or lack anatomic collaterals. Care must be taken to determine which artery is being insonated; the middle cerebral
and posterior cerebral are often misinsonated. The technique is user sensitive, requiring patience to detect the signal and then find the best angle for insonation at a
given depth. Minor anatomic variations can cause misleading changes in signal strength. Because the procedure is safe, fast, and uses a probe and microprocessor
of tabletop size, the device can be taken to the bedside even in an intensive care unit and used to diagnose developing vasospasm, collateral flow above occlusions,
recanalization of an embolized artery, and the presence of important basilar or cerebral artery stenosis. When combined with MRI, it is possible to make a
noninvasive diagnosis of stenosis of the basilar artery on the stem of the middle cerebral artery.
FIG. 16.9. Two examples of transcranial Doppler insonations of the middle cerebral artery, obtained at a depth of 50 mm from the side of the head overlying the
temporal bone, using the Carolina Medical Electronics TC-64B device. The velocity profile of the Doppler shift is insonated at this depth from the blood in the middle
cerebral artery flowing toward the probe (upper arrow directed to the right in each picture). The left picture shows a normal peak (cursor 44 [cm/s], left) and mean (30)
and pulsatility index (0.72 PI, i.e., the difference between the peak systolic velocity and the end diastolic velocity divided by the mean velocity). Right: The peak (200
cursor) and mean (128 mean) velocities and the pulsatility index (0.93) are higher, consistent with local stenosis at this point in the course of the middle cerebral
artery.
REGIONAL CEREBRAL BLOOD FLOW
This oldest and least expensive of the techniques uses 133Xe, inhaled or injected, to generate precise measurements of cortical blood flow. This is one method that
can be used at the bedside, in the operating room, or in the intensive care unit, but its spatial resolution is inferior to that of positron emission tomography (PET) or
SPECT and it provides no information about subcortical perfusion. It is commonly used with hypercapnia or hypotension to test autoregulatory capacity of resistance
vessels. For instance, focal failure of vasodilatory response, if distributed in the territory of a major vessel, has been taken as evidence of maximal dilatation and
therefore reduced perfusion pressure. This finding is correlated with elevated cerebral blood volume by SPECT and oxygen extraction fraction by PET and may
indicate hemodynamic insufficiency.
STABLE-XENON COMPUTED TOMOGRAPHY
CT can measure changes in tissue density over a period of minutes when nonradioactive xenon gas (essentially a freely diffusible high-attenuation contrast agent) is
inhaled and circulates through the capillary bed. This method measures flow in both deep and surface structures at high resolution and provides automatic registration
to the anatomic information in the baseline CT. It is limited by problems of signal-to-noise ratio and also by the physiologic and anesthetic effects of the high xenon
concentrations (approximately 30%).
SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY
Like PET, SPECT consists of tomographic imaging of injected radioisotopes. However, these isotopes emit single photons rather than positrons, a difference that
gives SPECT a more favorable cost-to-benefit ratio and makes it more widely available and clinically useful. However, SPECT is limited in application and is used
widely only for imaging cerebral perfusion. Cerebral blood volume imaging is also available, and combined flow and volume scans are possible. Metabolic and
receptor agents are being developed. SPECT imaging of infarction and ischemia appears to offer high sensitivity and early detection, but specificity is not yet
established. In contrast to PET, SPECT can be used hours after an injection of the tracer; cerebral blood flow can be assessed under unique circumstances (e.g.,
during an epileptic seizure). Another promising use may be determination of cerebrovascular reserve through dilatory challenge (CO 2 or acetazolamide) or combined
flow and volume imaging (Fig. 16.10). These techniques may identify the areas where blood flow is reduced because of perfusion pressure, and therefore possibly of
causal relevance, as opposed to the areas where flow is reduced because of diminished metabolic demand (e.g., due to infarction) and therefore of less therapeutic
significance. Similar to cardiac methods, these techniques may indicate regions of tissue viability.
FIG. 16.10. Single photon emission computed tomography (SPECT) study of a 64-year-old woman after 2 weeks of progressive saltatory aphasia and right
hemiparesis. The syndrome was attributed to a distal field infarct in the left hemisphere, and the left internal carotid artery was occluded. SPECT simultaneously
imaged cerebral blood flow (CBF) with 123I-IMP and cerebral blood volume (CBV) with 99mTc-labeled red blood cells. Top: CBF; bottom: CBV. Four areas of interest
(AD) were selected on the CBF image and samples on the CBV image. In the frontal cortex, blood flow was reduced and volume was increased on the left. The
CBV/CBF ratio was 0.76 for A and D and 0.66 for B and C, thus implying a lower perfusion pressure on the left. (As is conventional for computed tomography and
magnetic resonance imaging figures, the left side of brain is on the right of the figure.)
POSITRON EMISSION TOMOGRAPHY
PET generates axial images using physical and mathematical principles similar to those used in CT, but the source of radiation is internal to the imaged organ,
originating in injected or inhaled radioisotopes. The radioisotopes are short lived and require an adjacent cyclotron. The expense and technical complexity limit the
availability of PET. On the other hand, the biochemical flexibility and sensitivity of PET are unparalleled. PET is superior to any other technique in imaging specific
receptors or protein synthesis and turnover.
DISCUSSION
All these laboratory methods can be summarized with respect to their information content under four headings: vascular anatomy, tissue damage, hemodynamics, and
biochemistry (Table 16.1). Although most techniques provide information in many domains, Table 16.1 indicates only the predominant applications. All
cerebrovascular laboratory techniques can be assigned to one or more of the four main categories, but overlap is common and the boundaries are sometimes diffuse.
For instance, tissue damage visualized by CT or MRI can be either hemorrhagic or ischemic infarction. Although the information may be useful in suggesting the more
likely cause, vascular anatomy and local hemodynamics are usually more informative. For example, carotid occlusion or local absence of vascular reserve are two
distinctly different causes of ischemic infarction and may lead to distinctly different treatment options. Finally, the assessment of local metabolism and biochemistry,
best performed by PET and MRS, is not known to be clinically useful, but it is an area of active research.
TABLE 16.1. PREDOMINANT APPLICATIONS OF NEUROVASCULAR IMAGING TECHNIQUES
SUGGESTED READINGS
Beauchamp NJ Jr, Ulug AM, Passe TJ, van Zijl PC. MR diffusion imaging in stroke: review and controversies. Radiographics 1998;18:12691283; discussion 12831285.
Brant-Zawadzki M, Heiserman JE. The roles of MR angiography, CT angiography, and sonography in vascular imaging of the head and neck. AJNR Am J Neuroradiol 1997;10:18201825.
Bryan RN, Levy LM, Whitlow WD, et al. Diagnosis of acute cerebral infarction: comparison of CT and MR imaging. AJNR Am J Neuroradiol 1991;12:611620.
Go JL, Zee CS. Unique CT imaging advantages. Hemorrhage and calcification. Neuroimaging Clin N Am 1998;8:541558.
Gomori JM, Grossman RI. Mechanisms responsible for the MR appearance and evolution of intracranial hemorrhage. Radiographics 1988;8: 427440.
Gonzalez RG, Schaefer PW, Buonanno FS, et al. Diffusion-weighted MR imaging: diagnostic accuracy in patients imaged within 6 hours of stroke symptom onset. Radiology 1999;210:155162.
Hacein-Bey L, Kirsch CF, DeLaPaz R, et al. Early diagnosis and endovascular interventions for ischemic stroke. New Horizons 1997;5:316331.
Hagen T, Bartylla K, Piepgras U. Correlation of regional cerebral blood flow measured by stable xenon CT and perfusion MRI. J Comput Assist Tomogr 1999;23:257264.
Hunter GJ, Hamberg LM, Ponzo JA, et al. Assessment of cerebral perfusion and arterial anatomy in hyperacute stroke with three-dimensional functional CT: early clinical results. AJNR Am J
Neuroradiol 1998;19:2937.
Irino T, Tandea M, Minami T. Angiographic manifestations in postrecanalized cerebral infarction. Neurology 1977;27:471.
Kaps M, Damian MS, Teschendorf U, Dorndorf W. Transcranial Doppler ultrasound findings in middle cerebral artery occlusion. Stroke 1990;21:532537.
Koenig M, Klotz E, Luka B, Venderink DJ, Spittler JF, Heuser L. Perfusion CT of the brain: diagnostic approach for early detection of ischemic stroke. Radiology 1998;209:8593.
Kushner MJ, Zanette EM, Bastianello S, et al. Transcranial Doppler in acute hemispheric brain infarction. Neurology 1990;41:109113.
Lennihan L, Petty GW, Mohr JP, et al. Transcranial Doppler detection of anterior cerebral artery vasospasm. Stroke 1989;20:151.
Mattle HP, Kent KC, Edelman RR, et al. Evaluation of the extracranial carotid arteries: correlation of magnetic resonance angiography, duplex ultrasonography, and conventional angiography. J Vasc
Surg 1991;13: 838.
Mohr JP, Biller J, Hilal SK, et al. MR vs CT imaging in acute stroke. Presented at the 17th International Conference on Stroke and the Cerebral Circulation, Phoenix, 1992.
Nussel F, Wegmuller H, Huber P. Comparison of magnetic resonance angiography, magnetic resonance imaging and conventional angiography in cerebral arteriovenous malformation.
Neuroradiology 1991;33:5661.
Pessin MS, Hinton RC, Davis KR, et al. Mechanisms of acute carotid stroke: a clinicoangiographic study. Ann Neurol 1979;6:245.
Ricci PE Jr. Proton MR spectroscopy in ischemic stroke and other vascular disorders. Neuroimaging Clin N Am 1998;8:881900.
Schwartz RB, Tice HM, Hooten SM, Hsu L, Stieg PE. Evaluation of cerebral aneurysms with helical CT: correlation with conventional angiography and MR angiography. Radiology 1994;192:717722.
Singer MB, Atlas SW, Drayer BP. Subarachnoid space disease: diagnosis with fluid-attenuated inversion-recovery MR imaging and comparison with gadolinium-enhanced spin-echo MR
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Sorensen AG, Copen WA, Ostergaard L, et al. Hyperacute stroke: simultaneous measurement of relative cerebral blood volume, relative cerebral blood flow, and mean tissue transit time. Radiology
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Steinke W, Hennerici M, Rautenberg W, Mohr JP. Symptomatic and asymptomatic high-grade carotid stenosis in Doppler color flow imaging. Neurology 1992;42:131138.
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Zyed A, Hayman LA, Bryan RN. MR imaging of intracerebral blood: diversity in the temporal pattern at 0.5 and 1.0 T. AJNR Am J Neuroradiol 1991;12:469474.
CHAPTER 17. LUMBAR PUNCTURE AND CEREBROSPINAL FLUID EXAMINATION
MERRITTS NEUROLOGY
CHAPTER 17. LUMBAR PUNCTURE AND CEREBROSPINAL FLUID EXAMINATION

ROBERT A. FISHMAN
Indications
Contraindications
Hazards of Bleeding Disorders
Complications
Cerebrospinal Fluid Pressure
Cerebrospinal Fluid Cells
Blood in the Cerebrospinal Fluid: Differential Diagnosis and the Three-Tube Test
Microbiologic and Serologic Reactions
Suggested Reading
INDICATIONS
Lumbar puncture (LP) should be performed only after clinical evaluation of the patient and consideration of the potential value and hazards of the procedure.
Cerebrospinal fluid (CSF) findings are important in the differential diagnosis of the gamut of central nervous system (CNS) infections, meningitis, and encephalitis and
subarachnoid hemorrhage, confusional states, acute stroke, status epilepticus, meningeal malignancies, demyelinating diseases, and CNS vasculitis. CSF
examination usually is necessary in patients with suspected intracranial bleeding to establish the diagnosis, although computed tomography (CT), when available,
may be more valuable. For example, primary intracerebral hemorrhage or posttraumatic hemorrhage is often readily observed with CT, thus making LP an
unnecessary hazard. In primary subarachnoid hemorrhage, however, LP may establish the diagnosis when CT is falsely negative. LP can ascertain whether the CSF
is free of blood before anticoagulant therapy for stroke is begun. (Extensive subarachnoid or epidural bleeding is a rare complication of heparin anticoagulation that
starts several hours after a traumatic bloody tap. Therefore, heparin therapy should not commence for at least 1 hour after a bloody tap.) LP has limited therapeutic
usefulness (e.g., intrathecal therapy in meningeal malignancies and fungal meningitis).
CONTRAINDICATIONS
LP is contraindicated in the presence of infection in skin overlying the spine. A serious complication of LP is the possibility of aggravating a preexisting, often
unrecognized brain herniation syndrome (e.g., uncal, cerebellar, or cingulate herniation) associated with intracranial hypertension. This hazard is the basis for
considering papilledema to be a relative contraindication to LP. The availability of CT has simplified the management of patients with papilledema. If CT reveals no
evidence of a mass lesion or edema, then LP is usually needed in the presence of papilledema to establish the diagnosis of pseudotumor cerebri and to exclude
meningeal inflammation or malignancy.
HAZARDS OF BLEEDING DISORDERS
Thrombocytopenia and other bleeding diatheses predispose patients to needle-induced subarachnoid, subdural, and epidural hemorrhage. LP should be undertaken
only for urgent clinical indications when the platelet count is depressed to about 50,000/mm 3 or below. Platelet transfusion just before the puncture is recommended if
the count is below 20,000 mm3 or dropping rapidly. The administration of protamine to patients on heparin and of vitamin K or fresh frozen plasma to those receiving
warfarin is recommended before LP to minimize the hazard of the procedure.
COMPLICATIONS
Complications of LP include worsening of brain herniation or spinal cord compression, headache, subarachnoid bleeding, diplopia, backache, and radicular
symptoms. Post-LP headache is the most common complication, occurring in about 25% of patients and usually lasting 2 to 8 days. It results from low CSF pressures
caused by persistent fluid leakage through the dural hole. Characteristically, the head pain is present in the upright position, promptly relieved by the supine position,
and aggravated by cough or strain. Aching of the neck and low back, nausea, vomiting, and tinnitus are common complaints. Post-LP headache is avoided when a
small styletted needle is used and if multiple puncture holes are not made. The management of the problem depends on strict bedrest in the horizontal position,
adequate hydration, and simple analgesics. If conservative measures fail, the use of a blood patch is indicated. The technique uses the epidural injection of
autologous blood close to site of the dural puncture to form a fibrinous tamponade that apparently seals the dural hole.
CEREBROSPINAL FLUID PRESSURE
The CSF pressure should be measured routinely. The pressure level within the right atrium is the reference level with the patient in the lateral decubitus position. The
normal lumbar CSF pressure ranges between 50 and 200 mm (and as high as 250 mm in extremely obese subjects). With the use of the clinical manometer, the
arterially derived pulsatile pressures are obscured, but respiratory pressure waves reflecting changes in central venous pressures are visible. Low pressures occur
after a previous LP, with dehydration, spinal subarachnoid block, or CSF fistulas. Intracranial hypotension may be a technical artifact when the needle is not inserted
in the subarachnoid space. Increased pressures occur in patients with brain edema, intracranial mass lesions, infections, acute stroke, cerebral venous occlusions,
congestive heart failure, pulmonary insufficiency, and hepatic failure. Benign intracranial hypertension (pseudotumor cerebri) and spontaneous intracranial
hypotension are discussed elsewhere.
CEREBROSPINAL FLUID CELLS
Normal CSF contains no more than 5 lymphocytes or mononuclear cells/mm 3. A higher white cell count is pathognomonic of disease in the CNS or meninges. A
stained smear of the sediment must be prepared for an accurate differential cell count. Various centrifugal and sedimentation techniques have been used. A
pleocytosis occurs with the gamut of inflammatory disorders. The changes characteristic of the various meningitides are listed in Table 17.1. The heterogeneous
forms of neuro-AIDS are associated with a wide range of cellular responses. Other disorders associated with a pleocytosis include brain infarction, subarachnoid
bleeding, cerebral vasculitis, acute demyelination, and brain tumors. Eosinophilia most often accompanies parasitic infections, such as cysticercosis, and may reflect
blood eosinophilia. Cytologic studies for malignant cells are rewarding with some CNS neoplasms.
TABLE 17.1. CEREBROSPINAL FLUID FINDINGS IN MENINGITIS
Bloody CSF due to needle trauma contains increased numbers of white cells contributed by the blood. A useful approximation of a true white cell count can be
obtained by the following correction for the presence of the added blood: If the patient has a normal hemogram, subtract from the total white cell count (cells/mm 3) 1
white cell for each 1,000 red blood cells present. Thus, if bloody fluid contains 10,000 red cells/mm 3 and 100 white cells/mm3, 10 white cells would be accounted for by
the added blood and the corrected leukocyte count would be 90/mm 3. If the patient's hemogram reveals significant anemia or leukocytosis, the following formula may
be used to determine more accurately the number of white cells (W) in the spinal fluid before the blood was added:
The presence of blood in the subarachnoid space produces a secondary inflammatory response, which leads to a disproportionate increase in the number of white
cells. After an acute subarachnoid hemorrhage, this elevation in the white cell count is most marked about 48 hours after onset, when meningeal signs are most
striking.
To correct CSF protein values for the presence of added blood resulting from needle trauma, subtract 1 mg for every 1,000 red blood cells. Thus, if the red cell count
is 10,000/mm3 and the total protein is 110 mg/dL, the corrected protein level would be about 100 mg/dL. The corrections are reliable only if the cell count and total
protein are both made on the same tube of fluid.
BLOOD IN THE CEREBROSPINAL FLUID: DIFFERENTIAL DIAGNOSIS AND THE THREE-TUBE TEST
To differentiate between a traumatic spinal puncture and preexisting subarachnoid hemorrhage, the fluid should be collected in at least three separate tubes (the
three-tube test). In traumatic punctures, the fluid generally clears between the first and the third collections. This change is detectable by the naked eye and should
be confirmed by cell count. In subarachnoid bleeding, the blood is generally evenly admixed in the three tubes. A sample of the bloody fluid should be centrifuged and
the supernatant fluid compared with tap water to exclude the presence of pigment. The supernatant fluid is crystal clear if the red count is less than about 100,000
cells/mm3. With bloody contamination of greater magnitude, plasma proteins may be sufficient to cause minimal xanthochromia, an effect that requires enough serum
to raise the CSF protein concentration to about 150 mg/dL.
After an acute subarachnoid hemorrhage, the supernatant fluid usually remains clear for 2 to 4 hours or even longer after the onset of subarachnoid bleeding. The
clear supernatant may mislead the physician to conclude erroneously that the observed blood is the result of needle trauma in patients who have had an LP within 4
hours of aneurysmal rupture. After an especially traumatic puncture, some blood and xanthochromia may be present for as long as 2 to 5 days. In pathologic states
associated with a CSF protein content exceeding 150 mg/dL and in the absence of bleeding, faint xanthochromia may be detected. When the protein is elevated to
much higher levels, as in spinal block, polyneuritis, or meningitis, the xanthochromia may be considerable. A xanthochromic fluid with a normal protein level or a minor
elevation to less than 150 mg/dL usually indicates a previous subarachnoid or intracerebral hemorrhage. Xanthochromia may be caused by severe jaundice,
carotenemia, or rifampin therapy.
Pigments
The two major pigments derived from red cells that may be observed in CSF are oxyhemoglobin and bilirubin. Methemoglobin is seen only spectrophotometrically.
Oxyhemoglobin, released with lysis of red cells, may be detected in the supernatant fluid within 2 hours after subarachnoid hemorrhage. It reaches a maximum in
about the first 36 hours and gradually disappears over the next 7 to 10 days. Bilirubin is produced in vivo by leptomeningeal cells after red cell hemolysis. Bilirubin is
first detected about 10 hours after the onset of subarachnoid bleeding. It reaches a maximum at 48 hours and may persist for 2 to 4 weeks after extensive bleeding.
The severity of the meningeal signs associated with subarachnoid bleeding correlates with the inflammatory response (i.e., the severity of the leukocytic pleocytosis).
Total Protein
The normal total protein level of CSF ranges between 15 and 50 mg/dL. Although an elevated protein level lacks specificity, it is an index of neurologic disease
reflecting a pathologic increase in endothelial cell permeability. Greatly increased protein levels, 500 mg/dL and above, are seen in meningitis, bloody fluids, or spinal
cord tumor with spinal block. Polyneuritis (Guillain-Barr syndrome), diabetic radiculoneuropathy, and myxedema also may increase the level to 100 to 300 mg/dL.
Low protein levels, below 15 mg/dL, occur most often with CSF leaks caused by a previous LP or traumatic dural fistula and uncommonly in pseudotumor cerebri.
Immunoglobulins
Although many proteins may be measured in CSF, only an increase in immunoglobulins is of diagnostic importance. Such increases are indicative of an inflammatory
response in the CNS and occur with immunologic disorders and bacterial, viral, spirochetal, and fungal diseases. Immunoglobulin assays are most useful in the
diagnosis of multiple sclerosis, other demyelinating diseases, and CNS vasculitis. The CSF level is corrected for the entry of immunoglobulins from the serum by
calculating the IgG index ( Table 17.1). More than one oligoclonal band in CSF with gel electrophoresis (and absent in serum) is also abnormal, occurring in 90% of
multiple sclerosis cases and in the gamut of inflammatory diseases.
Glucose
The CSF glucose concentration depends on the blood level. The normal range of CSF is between 45 and 80 mg/dL in patients with a blood glucose between 70 and
120 mg/dL (i.e., 60% to 80% of the normal blood level). CSF values between 40 and 45 mg/dL are usually abnormal, and values below 40 mg/dL are invariably so.
Hyperglycemia during the 4 hours before LP results in a parallel increase in CSF glucose. The CSF glucose approaches a maximum, and the CSF-to-blood ratio may
be as low as 0.35 in the presence of a greatly elevated blood glucose level and in the absence of any neurologic disease. An increase in CSF glucose is of no
diagnostic significance apart from reflecting hyperglycemia within the 4 hours before LP.
The CSF glucose level is abnormally low (hypoglycorrhachia) in several diseases of the nervous system apart from hypoglycemia. It is characteristic of acute purulent
meningitis and is a usual finding in tuberculous and fungal meningitis. It is usually normal in viral meningitis, although reduced in about 25% of mumps cases and in
some cases of herpes simplex and zoster meningoencephalitis. The CSF glucose is also reduced in other inflammatory meningitides, including cysticercosis, amebic
meningitis (Naegleria), acute syphilitic meningitis, sarcoidosis, granulomatous arteritis, and other vasculitides. The glucose level is also reduced in the chemical
meningitis that follows intrathecal injections and in subarachnoid hemorrhage, usually 4 to 8 days after the onset of bleeding. The major factor responsible for the
depressed glucose levels is increased anaerobic glycolysis in adjacent neural tissues and to a lesser degree by a polymorphonuclear leukocytosis. Thus, the
decrease in CSF glucose level is characteristically accompanied by an inverse increase in CSF lactate level. A low CSF glucose with a decreased lactate level
indicates impairment of the glucose transporter responsible for the transfer of glucose across the bloodbrain barrier.
MICROBIOLOGIC AND SEROLOGIC REACTIONS
The use of appropriate stains and cultures is essential in cases of suspected infection. Tests for specific bacterial and fungal antigens and countercurrent
immunoelectrophoresis are useful in establishing a specific cause. DNA amplification techniques using polymerase chain reaction have improved diagnostic
sensitivity. Serologic tests on CSF for syphilis include the reagin antibody tests and specific treponemal antibody tests. The former are particularly useful in evaluating
CSF because positive results occur even in the presence of a negative blood serology. There is no logical basis for applying specific treponemal antibody tests to
CSF because these antibodies are derived from the plasma, where they are present in greater concentration.
SUGGESTED READING
Fishman RA. Cerebrospinal fluid in diseases of the nervous system, 2nd ed. Philadelphia: W.B. Saunders, 1992.
CHAPTER 18. MUSCLE AND NERVE BIOPSY
MERRITTS NEUROLOGY
CHAPTER 18. MUSCLE AND NERVE BIOPSY

ARTHUR P. HAYS
Skeletal Muscle Biopsy

Peripheral Nerve Biopsy
Suggested Readings
Biopsy of skeletal muscle or peripheral nerve is performed in patients with neuromuscular disorders, chiefly those with myopathy or peripheral neuropathy. At the
least, the findings may indicate whether a syndrome of limb weakness is neurogenic or myopathic. This determination is made in conjunction with the findings on
electromyography and nerve conduction studies; the interpretations based on biopsy and physiologic study are usually congruent with each other and also with
clinical indicators from the history and examination. At best, the biopsy of muscle and nerve may give a specific tissue diagnosis. Sometimes, however, the findings
are not diagnostic because the defining lesion has been missed in the biopsy, which is only a tiny sample of a voluminous tissue, and the lesions may be present in
one area but not in another. Also, the pathologic changes may be too mild to distinguish from normal or too advanced to draw conclusions (end-stage muscle, for
instance).
The yield of a specific diagnosis is low, but the percentage has increased through the application of technologic innovations. In myopathies, histochemical and
immunohistochemical stains applied to frozen tissue sections and biochemical analysis of enzymes, structural proteins, or DNA have transformed the prospects of
tissue-based diagnosis. Precise diagnoses in peripheral nerve disorders often require immunohistochemical stains to localize human antigens, resin histology
(semithin plastic sections), electron microscopy, and teased preparations of myelinated nerve fibers.
The performance and analysis of a muscle and nerve biopsy are time-consuming and expensive. Therefore, the decision for biopsy is made only after a thorough
evaluation that includes neurologic examination, family history, laboratory tests, cerebrospinal fluid examination, and electrodiagnostic studies. This workup obviates
the need for biopsy in typical cases of myasthenia gravis, myotonic dystrophy, dermatomyositis, amyotrophic lateral sclerosis, Guillain-Barr syndrome, diabetic
neuropathy, or any defined toxic neuropathy. Additionally, a rapidly expanding number of diseases can be diagnosed by DNA analysis of blood leukocytes without
recourse to tissue analysis (e.g., McArdle disease, Duchenne or Becker muscular dystrophy, mitochondrial disorders, and Charcot-Marie-Tooth disease type IA, as
described in Chapter 84, Chapter 96, Chapter 102, and Chapter 125).
If a biopsy is deemed necessary, the neurologist should formulate a preliminary diagnosis and inform the pathologist to direct evaluation of the specimen most
efficiently. The surgical procedure should be performed by an experienced neurologist or surgeon, identifying the tissue correctly and avoiding mechanically induced
artifacts or insufficient quantity for examination. If special methods are not available locally, the service usually can be provided by a regional research center.
SKELETAL MUSCLE BIOPSY
Muscle biopsy is performed in patients with limb weakness, infantile hypotonia, exercise intolerance, myoglobinuria, or cramps. Evaluation should include serum
creatine kinase assay, family history, and electromyography. A biopsy is also indicated in the final assessment of patients with a presumptive diagnosis of a muscular
dystrophy, polymyositis, inclusion body myositis, congenital myopathy, or spinal muscular atrophy; glycolytic or oxidative enzyme defect; or myopathies associated
with alcohol, electrolyte disturbance, drug toxicity, carcinoma, endocrine overactivity or underactivity, or long-term treatment with steroids. It is also justified in
polymyalgia rheumatica and eosinophilic fasciitis and to show the extent of denervation associated with peripheral neuropathy in conjunction with sural nerve biopsy.
Muscles preferred for biopsy are the vastus lateralis, biceps, or deltoid in disorders of proximal limb weakness and the gastrocnemius, tibialis anterior, or peroneus
brevis when symptoms are pronounced distally. The muscle should be affected clinically and electrophysiologically. However, to avoid obtaining an end-stage picture,
the muscle should not be severely wasted and paralyzed.
Routine histology of muscle can demonstrate groups of atrophic myofibers in a neurogenic disorder or myopathic features that include necrotic fibers, regenerating
fibers, excessive sarcoplasmic glycogen, or centrally located myonuclei. Lymphocytic infiltration of connective tissue is seen in dermatomyositis, polymyositis, and
inclusion body myositis. The diagnosis of vasculitis or amyloidosis is occasionally established by finding changes in the muscle biopsy, even if neuropathy is evident
clinically and physiologically.
Histochemical techniques applied to cryosections of muscle permit the recognition of fiber-type grouping; target fibers; fiber-type predominance; selective fiber
atrophy; central cores; nemaline rods; excessive sarcoplasmic glycogen, lipid, or mitochondria (ragged red fibers) as a result of a disorder of metabolism; deficiency of
phosphorylase, phosphofructokinase, adenylate deaminase, or cytochrome c oxidase activity; and other structurally specific abnormalities that are not visible by
conventional light microscopy of paraffin-embedded tissue. An example is provided by the finding of rimmed vacuoles and the intracellular amyloid inclusions of
inclusion body myositis.
Biochemical assays of muscle can detect a quantitative reduction of enzymes of intermediary metabolism, including enzymes of the glycolytic pathway, acid maltase,
adenylate deaminase, and enzymes of mitochondria (carnitine palmitoyl transferase, enzymes of the citric acid cycle, and electron transport chain).
Immunohistochemical stains can detect the absence of dystrophin in Duchenne muscular dystrophy and a mosaic pattern of dystrophin in girls or women who carry
the mutation. Discontinuities of sarcolemmal dystrophin are found in Becker dystrophy. These dystrophinopathies must be confirmed by DNA analysis of blood
leukocytes or by electrophoresis of a muscle homogenate (Western blot) to show quantitative or qualitative abnormalities of the protein. Dystrophin analysis is
indicated in any syndrome of limb weakness of unknown cause, including possible limb-girdle dystrophy, polymyositis, inclusion body myositis, myoglobinuria, or
spinal muscular atrophy. Genetic lack of sarcoglycans, merosin, emerin, or other proteins can be demonstrated by immunohistochemistry in the appropriate muscular
dystrophies and confirmed by DNA analysis. Also, evaluation of mitochondrial DNA of muscle or blood can detect deletions in Kearns-Sayre syndrome and point
mutations in other mitochondrial encephalomyopathies.
PERIPHERAL NERVE BIOPSY
Nerve biopsy is indicated in patients with peripheral neuropathy when additional information about the nature and severity of the disorder is needed. The biopsy is
most likely helpful in mononeuritis multiplex or in patients with palpably enlarged nerves; biopsy is often uninformative in distal symmetric axonal neuropathies. In
children, the pathologic features in nerve can be diagnostic in three diseases (metachromatic leukodystrophy, adrenoleukodystrophy, and Krabbe disease), but the
biopsy can usually be avoided by making a diagnosis with tests of a blood sample. Several central nervous system disorders are also expressed pathologically in
nerve: neuronal ceroid lipofuscinosis, Lafora disease, infantile neuroaxonal dystrophy, and lysosomal storage diseases. The best source of tissue, however, is not a
nerve but rather skin and conjunctiva, which may show distinctive features in terminal nerve fibers and skin appendages.
The human sural nerve is the most widely studied nerve in health and disease, and it is most frequently recommended for biopsy. If mononeuritis multiplex spares the
sural nerve, other cutaneous nerves can be selected (e.g., a branch of the superficial peroneal nerve at the head of the fibula or the radial sensory nerve at the wrist).
Motor nerve fibers can be examined specifically in a nerve that supplies a superfluous or accessory muscle, such as the gracilis muscle in the medial thigh.
Neurologists often choose simultaneous biopsy of both sural nerve and gastrocnemius muscle in patients with neuropathy because vasculitis, amyloidosis, sarcoid,
lymphoma, and other systemic disorders are focal and lesions may be encountered in either tissue. The muscle also can demonstrate the degree of denervation.
Diagnosis can often be established by microscopic examination of paraffin-embedded tissue in nine conditions: vasculitis, amyloidosis, leprosy, sensory perineuritis,
cholesterol emboli, infiltration of nerve by leukemic or lymphoma cells, malignant angioendotheliomatosis (intravascular lymphoma), giant axonal neuropathy, or adult
polyglucosan body disease. Amyloid deposits in plasma cell dyscrasia can be identified by antibodies to immunoglobulin light chains. Amyloid deposits in the familial
neuropathy resulting from transthyretin mutations can be distinguished by antibodies to the mutant protein. Small cell lymphoma and chronic lymphocytic leukemia
can be separated from inflammatory reactions by application of lymphocyte markers.
Most neuropathies do not have distinctive pathologic findings and usually require examination of semithin sections of epoxy-resinembedded tissue. Teased nerve
fibers and electron microscopy are necessary to identify the focal thickening of myelin sheaths ( tomacula) of hereditary neuropathy with liability to pressure palsy, and
they can detect subtle degrees of demyelination, remyelination, or axonal degeneration and regeneration. These features occur in normal nerves with increasing age,
and evaluation may require formal quantitative study (morphometry). Electron microscopy also demonstrates accumulation of neurofilaments, widened myelin
lamellae, and various intracellular inclusions in neuropathies, and it is needed to assess unmyelinated nerve fibers.
Axonal neuropathy is recognized by marked depletion of fibers and interstitial fibrosis, with or without myelin debris or regeneration of axons. It is most likely caused
by a toxic or metabolic disorder, such as alcoholism or diabetes. Other axonopathies include vasculitis, amyloidosis, paraneoplastic syndromes, and infection
(including the distal symmetric neuropathy of AIDS). Segmental demyelination and remyelination, recognized by thinly myelinated fibers and onion bulbs, are most
often the result of an immunologically mediated or hereditary neuropathy. If demyelination is not pronounced in semithin plastic sections, it may be proved by electron
microscopy or analysis of teased myelinated nerve fibers. Sural nerve biopsy is recommended in all patients with a clinical diagnosis of chronic inflammatory
demyelinating polyneuropathy to confirm the suspected demyelination before commencing therapy with intravenous gamma globulin, plasmapheresis, or steroids. The
pathologic findings do not distinguish chronic inflammatory demyelinating polyneuropathy from Charcot-Marie-Tooth disease type I, but an acquired myelinopathy is
favored by finding prominent variability of abnormalities among nerve fascicles, inflammatory infiltrates, and endoneurial edema. The neuropathies associated with
IgM paraproteinemia and antibody to myelin-associated glycoprotein resemble chronic inflammatory demyelinating polyneuropathy clinically and pathologically;
deposits of the C3 component of complement may be seen along the periphery of myelin sheaths, usually with IgM located at the same site. Other demyelinative
neuropathies include diphtheria, hereditary disorders other than Charcot-Marie-Tooth disease type I, Guillain-Barr syndrome, and acute or chronic inflammatory
neuropathies in the early phase of human immunodeficiency virus infection. The inflammatory neuropathies are multifocal, and the sural nerve may be normal or show
only axonal degeneration.
Complications of sural nerve biopsy include annoying causalgia in about 5% of patients. Many patients experience twinges of pain when bending forward for several
days caused by stretching of the nerve. All patients should anticipate permanent loss of discriminative sensation in the lateral border of the foot extending to the fifth
toe, heel, and lateral malleolus. In weeks or months, however, the sensory symptoms subside completely or to a tolerable level.
SUGGESTED READINGS
Asbury AK, Johnson PC. Pathology of peripheral nerve. Philadelphia: W.B. Saunders, 1978.
Dubowitz V. Muscle biopsy. A practical approach. London: Churchill Livingstone, 1984.
Dubowitz V. Muscle disorders in childhood, 2nd ed. Philadelphia: W.B. Saunders, 1995.
Dyck PJ, Thomas PK, Griffin JW, et al. Peripheral neuropathy, 3rd ed. Philadelphia: W.B. Saunders, 1993.
Engel AG, Franzini-Armstrong C. Myology, 2nd ed. New York: McGraw-Hill, 1994.
Graham DI, Lanatos PI. Greenfield's neuropathology, 6th ed. New York: Oxford University Press, 1997.
Midroni G, Bilbao JM. Biopsy diagnosis of peripheral neuropathy. Boston: Butterworth-Heinemann, 1995.
Schaumburg HH, Berger AR, Thomas PK. Disorders of peripheral nerves, 2nd ed. Philadelphia: FA Davis, 1992.
CHAPTER 19. NEUROPSYCHOLOGIC EVALUATION
MERRITTS NEUROLOGY
CHAPTER 19. NEUROPSYCHOLOGIC EVALUATION

YAAKOV STERN
Strategy of Neuropsychologic Testing

Test Selection
Tests Used in a Neuropsychological Evaluation
Referral Issues
Expectations from a Neuropsychologic Evaluation
How to Refer
Suggested Readings
Neuropsychologic testing is a valuable adjunct to neurologic evaluation, especially for the diagnosis of dementia and to evaluate or quantify cognition and behavior in
other brain diseases. The tests are therefore important in research as well.
STRATEGY OF NEUROPSYCHOLOGIC TESTING
Conditions that affect the brain often cause cognitive, motor, or behavioral impairment that can be detected by appropriately designed tests. Defective performance on
a test may suggest specific pathology. Alternately, patients with known brain changes may be assessed to determine how the damaged brain areas affect specific
cognitive functions. Before relating test performance to brain dysfunction, however, other factors that can affect test performance must be considered.
Typically, performance is compared with values derived from populations similar to the patient in age, education, socioeconomic background, and other variables.
Scores significantly below mean expected values imply impaired performance. Performance sometimes can be evaluated by assumptions about what can be expected
from the average person (e.g., repeating simple sentences or simple learning and remembering).
Comparable data may not exist for the patient being tested. This problem is common in older populations or for those with language and cultural differences. This
situation may be addressed by collecting local norms that are more descriptive of the served clinical population or by evaluating the cognitive areas that remain
intact. In this way, the patient guides the clinician in terms of the level of performance that should be expected in possibly affected domains.
Other factors that also influence test performance must be considered, including depression or other psychiatric disorders, medication, and the patient's motivation.
Patterns of performance, such as strengths in some cognitive domains and weaknesses in others, have been associated with specific conditions based on empirical
observation and knowledge of the brain pathology associated with those conditions. Observation of these patterns can aid in diagnosis.
TEST SELECTION
Neuropsychologic tests in an assessment battery come from many sources. Some were developed for academic purposes (e.g., intelligence tests), and others from
experimental psychology. The typical clinical battery consists of a series of standard tests that have been proved useful and are selected for the referral issue. A
trade-off exists between the breadth of application and ease of interpretation available from standard batteries and the ability to pinpoint specific or subtle disorders
offered by more experimental tasks that are useful in research but have not been standardized.
Most tests are intended to measure performance in specific cognitive or motor domains, such as memory, spatial ability, language function, or motor agility. These
domains can be subdivided (e.g., memory can be considered verbal or nonverbal; immediate, short-term, long-term, or remote; semantic or episodic; public or
autobiographic; or implicit or explicit). No matter how focused a test is, however, multiple cognitive processes are likely to be invoked. An ostensibly simple task, such
as the Wechsler Adult Intelligence Scale Digit SymbolCoding subtest (using a table of nine digitsymbol pairs to fill in the proper symbols for a series of numbers),
taps learning and memory, visuospatial abilities, motor abilities, attention, and speeded performance. In addition, tests can be failed for more than one reason:
Patients may draw poorly because they cannot appreciate spatial relationships or because they plan the construction process poorly. Relying solely on test scores
can lead to spurious conclusions.
TESTS USED IN A NEUROPSYCHOLOGICAL EVALUATION
Intellectual Ability
Typically, the Wechsler Adult Intelligence Scale-III (WAIS-III) or the Wechsler Intelligence Scale for Children-III is used to assess the present level of intellectual
function. These tests yield a global intelligence quotient (IQ) score and verbal and performance IQ scores that are standardized, so that 100 is the mean expected
value at any age with a standard deviation of 15. The WAIS-III also groups some of the subtests, based on more refined domains of cognitive functioning, into four
index scales: Verbal Comprehension, Perceptual Organization, Working Memory, and Processing Speed. The index scales have the same psychometric properties as
the traditional IQ scores.
The WAIS-III consists of seven verbal and seven performance subtests. Scaled scores range from 1 to 19, with a mean of 10 and a standard deviation of 3; the
average range for subtest scaled scores is from 7 to 13 ( Table 19.1).
TABLE 19.1. SUBTESTS OF THE WECHSLER ADULT INTELLIGENCE SCALE-III
The overall IQ score supplies information about the level of general intelligence, but the neuropsychologist is usually more interested in the scatter of subtest
scores, which indicate strengths and weaknesses. The subtests are better considered as separate tests, each tapping specific areas of cognitive function. There are
also other tests of general intelligence, including some that are nonverbal.
Memory
The subclassifications of memory have evolved from clinical observation and experimentation; most are important to the assessment ( Table 19.2). Preservation of
remote memories despite inability to store and recall new information is the hallmark of specific amnestic disorders. Other subclassifications are used to evaluate
different clinical syndromes.
TABLE 19.2. TYPICAL SUBCLASSIFICATIONS OF MEMORY ADDRESSED BY NEUROPSYCHOLOGIC TESTS
Construction
Construction, typically assessed by drawing or assembly tasks, requires both accurate spatial perception and an organized motor response. The Block Design and
Object Assembly subtests of the WAIS-R are examples of assembly tasks. In the Rosen Drawing Test, the patient is asked to copy 15 drawings that range in difficulty
from simple shapes to complex three-dimensional figures. In addition to the scores these tests yield, the clinician attends to the patient's construction performance to
determine factors that may underlie poor performance (e.g., a disorganized impulsive strategy may be more related to anterior brain lesions, whereas difficulty
aligning angles may arise in parietal lobe injury).
Language
Mapping of different aphasic disorders to specific brain structures was one of the early accomplishments of behavioral neurology. In neuropsychologic assessment,
this model is often followed. Comprehension, fluency, repetition, and naming are assessed in spoken or written language.
Perceptual
Neuropsychologists may provide a standardized version of the neurologists' perceptual tasks: double simultaneous stimulation in touch, hearing, or sight;
stereognosis; graphesthesia; spatial perception; or auditory discrimination.
Executive
The ability to plan, sequence, and monitor behavior has been called executive function. These functions, linked to the prefrontal cortex, rely on and organize other
intact cognitive functions that are required components for performance. Formal tests of executive function may be divided into set switching and set maintenance. For
set switching, the Wisconsin Card Sort uses symbols that can be sorted by color, number, or shape. Based only on feedback about whether each card was or was not
correctly placed, the subject must infer an initial sort rule. At intervals, the sort rule is changed without the subject's knowledge; subjects must switch based only on
their own observation that the current rule is no longer effective.
The Stroop Color-Word Test assesses set maintenance. The subject is given a series of color names printed in contrasting ink colors (e.g., the word blue printed in
red ink) and is asked to name the color of the ink. The response set must be maintained while the subject suppresses the alternate (and more standard) inclination to
read words without regard to the color of the print.
Motor
Tests of motor strength, such as grip strength, and of motor speed and agility, such as tapping speed and peg placement, establish laterality and focality of
impairment. In some diseases, such as the dementia of AIDS, reduced motor agility is part of the diagnosis. Higher order motor tasks, such as double alternating
movements or triple sequences, are used to assess motor sequencing or programming as opposed to pure strength or speed.
Attention
The ability to sustain attention is often tested by cancellation tasks in which the patient must detect and mark targets embedded in distractors or by reaction time
tasks. Speed and accuracy are the outcome measures.
Mood
Mood may affect test performance. At minimum, the neuropsychologist notes the psychiatric history and probes for current psychiatric symptoms. Standardized mood
rating scales are also available.
Clinical Observation
Along with the formal scores, testing affords an extensive period to observe the patient under controlled conditions. These clinical observations are valuable for
diagnosis. Formal test scores capture only certain aspects of performance. The patient's problem-solving approach or the nature of the errors made can be telling.
Also important in timed tasks is whether the patient can complete them with additional time or is actually incapable of solving them. Another important dimension is the
ability to learn and follow directions for the many tests.
More subtle aspects of behavior include responses or coping abilities when confronted with difficult tasks, ability to remain socially appropriate as the session
progresses, and the subjects' appreciation of their own capacities.
REFERRAL ISSUES
Neuropsychologic testing is useful for the diagnosis of some conditions and is a tool for evaluating or quantifying the effects of disease on cognition and behavior.
The tests can assess the beneficial or adverse effects of drug therapy, radiation, or surgery. Serial evaluations give quantitative results that may change with time. In
temporal lobectomy for intractable epilepsy, tests are required in presurgical evaluation to minimize the possibility of adverse effects. Specific referral issues are
summarized in the following paragraphs.
Dementia
Testing can detect early dementing changes and discriminate them from normal performance; obtain information contributing to differential diagnosis either between
dementia and nondementing illness, such as depression versus dementia, or between alternate forms of dementia (e.g., Alzheimer disease, dementia with Lewy
bodies, or vascular dementia); or confirm or quantify disease progression and measure efficacy of clinical interventions.
Other Brain Disease
The effects of stroke, cancer, head trauma, or other conditions on cognitive function can be investigated. This typical reason for testing may be prompted by the
patient's complaints. The evaluation helps to clarify the cause or extent of the condition.
Epilepsy
Testing is needed for presurgical evaluation, because lateralization of memory and language, as well as focality of cognitive impairments, is an important concern.
Pre- and postoperative evaluations after other types of neurosurgery are also common.
Toxic Exposure
Testing can evaluate consequences of toxic or potentially toxic exposures, either on an individual basis or for particular exposed groups (e.g., factory workers).
Exposures can include metals, solvents, pesticides, alcohol and drugs, or any other compounds that may affect the brain.
Medication
The potential effect of medications on the central nervous system can be evaluated in therapeutic trials or clinical practice. For example, in trials of agents to treat
Alzheimer disease, neuropsychologic tests are typically primary measures of drug efficacy. In clinical practice, adverse or therapeutic effects of newly introduced
medications can be evaluated.
Psychiatric Disorders
Testing can help in the differential diagnosis of psychiatric and neurologic disorders, especially affective disorders and schizophrenia.
Learning Disability
Testing will evaluate learning disabilities and the residua of these disabilities in later life. Behavioral disorders, attention deficit disorder, autism, dyslexia, and learning
problems are common referral issues.
EXPECTATIONS FROM A NEUROPSYCHOLOGIC EVALUATION
The minimum that a neuropsychologic evaluation yields is an extensive investigation of the abilities of the patient. In these cases, although the studies do not lead to
a definite diagnosis, they help to determine the patient's capacities, track the future, and advise the patient and family.
Sometimes the evaluation suggests that additional diagnostic tests would be useful. For example, if a patient's pattern of performance deviates substantially from that
typically expected at the current stage of dementia, a vascular contribution may be considered. Similarly, evaluation can suggest the value of psychiatric consultation
or more intensive electroencephalographic recording.
Many times the neuropsychologist can offer a tentative diagnosis or discuss the possible diagnoses compatible with the test findings. Neuropsychologic evaluation
cannot yield a diagnosis without appropriate clinical and historical information. In the context of a multidisciplinary testing, however, it may provide evidence to confirm
or refute a specific diagnosis. Testing might best be considered an additional source of information to be used by the clinician for diagnosis in conjunction with the
neurologic examination and laboratory tests.
HOW TO REFER
The more information the examiner has at the start, the more directly the issues can be addressed. For example, if magnetic resonance imaging has revealed a
particular lesion, tests can be tailored specifically. The examination is not an exploration of ability to detect a lesion, but a contribution to understanding the
implications of the lesion. Similarly, the more explicit the referral question, the more likely the evaluation can yield useful information. A useful referral describes the
differential diagnosis being entertained. Alternately, the neurologist or the family may simply want to document the current condition or explore some specific aspect of
performance, such as language.
SUGGESTED READINGS
Berg E. A simple objective test for measuring flexibility in thinking. J Gen Psychol 1948;39:1522.
Ron MA, Toone BK, Garralda ME, Lishman WA. Diagnostic accuracy in presenile dementia. Br J Psychiatry 1979;134:161168.
Rosen WG. The Rosen drawing test. New York: Veterans Administration Medical Center, 1981.
Stroop JR. Studies of interference in serial verbal reactions. J Exp Psychol 1935;18:643662.
Wechsler D. Wechsler intelligence scale for children, 3rd ed. San Antonio, TX: The Psychological Corp., 1991.
Wechsler D. Wechsler adult intelligence scale, 3rd ed. San Antonio, TX: The Psychological Corp., 1997.
CHAPTER 20. DNA DIAGNOSIS
MERRITTS NEUROLOGY
CHAPTER 20. DNA DIAGNOSIS

LEWIS P. ROWLAND
Suggested Readings
We are still in the midst of the whirlwind created by molecular genetics. A little more than a decade ago, the diagnosis of an inherited disease depended primarily on
clinical recognition. For some diseases, biochemical tests were available that identified the disease by the excretion or storage of an abnormal metabolite or, best of
all, by finding decreased activity of the responsible enzyme.
That was the era of biochemical genetics, and one of the clinical lessons we learned was the recognition of genetic heterogeneity. The same enzyme abnormality
might be associated with totally different clinical manifestations. For instance, the original clinical concept of muscle phosphorylase deficiency was a syndrome of
muscle cramps and myoglobinuria induced by exertion, usually starting in adolescence. Later, however, we recognized totally different disorders as manifestations of
phosphorylase deficiency. Infantile and late-onset forms have symptoms of limb weakness but no myoglobinuria.
Biochemical analysis in these diseases, as described in the chapters on metabolic diseases, is still important. Even in those conditions (mostly autosomal recessive),
however, evidence from DNA analysis now reveals that different point mutations can result in the same biochemical abnormality. Already, 16 mutations in the muscle
phosphorylase gene are known. Moreover, DNA analysis of circulating white blood cells may obviate the need for muscle biopsy.
Also, we can now diagnose autosomal dominant diseases by DNA analysis. For some conditions, we are in the peculiar position of trying to decide whether the
disease should be named according to the change in DNA or, as in the past, by the clinical features. The problem arises because of two kinds of genetic
heterogeneity. One is called allelic heterogeneity, which results from mutations in the same gene locus on one or both chromosomes. As a result, more than one
clinical syndrome can be caused by mutations in the same gene. Conversely, the second type is locus heterogeneity, that is, the same clinical syndrome may be
caused by mutations in different genes on different chromosomes.
DNA analysis is used in either of two ways to diagnose an individual who is at risk. In one way, haplotype analysis, gene tracking, or linkage analysis is applied when
linked markers indicate the region of the disease gene but the gene itself has not been identified. Under these circumstances, we depend on DNA markers that are
polymorphic, that is, there are two alleles for the particular marker, and many individuals are heterozygous so that the marker is informative. Using a set of
markers, investigators define different types, one pattern labeled A, another B, and so on, depending on the number of markers. In this way, maternal and paternal
genes can be identified, and one pattern tracks consistently with the disease (phenotype). In this way, an asymptomatic individual or a carrier of the gene can be
identified. The method was used fruitfully for the study of families with Huntington disease or Duchenne dystrophy, among others. Chromosome maps of neurologic
diseases indicate which diseases are amenable to this approach.
Haplotype analysis, however, has several drawbacks as a diagnostic test. Most important, it cannot be used for an individual, only for families. Moreover, the family
must include people who are both affected by the disease and also alive. The more, the better. For such late-onset or rapidly fatal diseases as Parkinson disease,
amyotrophic lateral sclerosis, or Alzheimer disease, however, many affected individuals in a family are no longer alive; sometimes, no affected family member is alive,
only those at risk. If DNA is available from only one affected person, the investigation should include samples from at least three generations. Moreover, the test is
labor intensive and expensive. Therefore, banking of DNA from affected people in families with heritable diseases is important.
The second kind of DNA analysis is more precise and can be used for individuals who may have a particular disease. This analysis can be done when the gene has
been cloned and sequenced so that point mutations can be identified. Other mutations of diagnostic value include deletions, insertions, amplifications, and
trinucleotide repeats. The number of diseases so identified has increased vastly in the past decade and seems to be augmented daily. In the ninth edition of this book,
we provided a list of 41 individual diseases. Now several hundred individual diseases are amenable to DNA diagnosis, and it would take a booklet to tabulate them
one by one. Instead, they can be grouped into 22 broad clinical categories ( Table 20.1). More information is given in the specific chapters about these diseases.
TABLE 20.1. DNA DIAGNOSIS IN NEUROLOGIC DISEASE
Cloning a gene has more than diagnostic value; for many of these diseases, candidate gene products were suggested because they were mapped close to the
position of the disease gene, were then linked to the gene, and are presumed to account for the manifestations of the disease. These characteristics are described in
the chapters on specific diseases.
As a result of both locus heterogeneity and allelic heterogeneity, several different types of syndromes have been identified. Relying on the molecular differences,
there are seven different forms of spinocerebellar atrophy, SCA 1 through SCA 7. It is difficult for clinicians to communicate about numerical names like these, but no
alternative is in sight unless clinical manifestations emerge to provide old-fashioned names for diseases (i.e., in plain words).
Another problem of nomenclature arises from the diverse clinical syndromes caused by similar mutations, such as expansion of trinucleotide repeats or mutations in
ion channel genes. Although the molecular changes are similar, there is little clinical similarity, for instance, between hemiplegic migraine and periodic paralysis
(except that they are intermittent).
At present, there are still major impediments to widespread applicability of DNA analysis for diagnosis. First, reimbursement for the test is not established in many
parts of the United States or elsewhere. Second, as a result, a systematic development of diagnostic laboratories has not yet emerged, not even commercially.
Consequently, testing is often left to research laboratories, which is an inefficient use of resources; finding the appropriate laboratory may be a problem for the
clinician and the patients. In time, this should be corrected.
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CHAPTER 21. BACTERIAL INFECTIONS
MERRITTS NEUROLOGY
SECTION III. INFECTIONS OF THE NERVOUS SYSTEM

CHAPTER 21. BACTERIAL INFECTIONS
JAMES R.MILLER AND BURK JUBELT
Acute Purulent Meningitis

Subacute Meningitis
Subdural and Epidural Infections
Rickettsial Infections
Other Bacterial Infections
Suggested Readings
The parenchyma, coverings, and blood vessels of the nervous system may be invaded by virtually any pathogenic microorganism. It is customary, for convenience of
description, to divide the syndromes produced according to the major site of involvement. This division is arbitrary because the inflammatory process frequently
involves more than one of these structures.
Involvement of the meninges by pathogenic microorganisms is known as leptomeningitis, because the infection and inflammatory response are generally confined to
the subarachnoid space and the arachnoid and pia. Cases are divided into acute and subacute meningitis, according to the rapidity with which the inflammatory
process develops. This rate of development, in part, is related to the nature of the infecting organism.
ACUTE PURULENT MENINGITIS
Bacteria may gain access to the ventriculosubarachnoid space by way of the blood in the course of septicemia or as a metastasis from infection of the heart, lung, or
other viscera. The meninges may also be invaded by direct extension from a septic focus in the skull, spine, or parenchyma of the nervous system (e.g., sinusitis,
otitis, osteomyelitis, and brain abscess). Organisms may gain entrance to the subarachnoid space through compound fractures of the skull and fractures through the
nasal sinuses or mastoid or after neurosurgical procedures. Introduction by lumbar puncture is rare. The pathologic background, symptoms, and clinical course of
patients with acute purulent meningitis are similar regardless of the causative organisms. The diagnosis and therapy depend on the isolation and identification of the
organisms and the determination of the source of the infection.
Acute purulent meningitis may be the result of infection with almost any pathogenic bacteria. Isolated examples of infection by the uncommon forms are recorded in
the literature, In the United States, Streptococcus pneumoniae now accounts for about one-half of cases when the infecting organism is identified and Neisseria
meningitidis about one-fourth (Table 21.1). In recent years, there has been an increase in the incidence of cases in which no organism can be isolated. These patients
now comprise the third major category of purulent meningitis. This may be due to the administration of therapy before admission to the hospital and the performance
of lumbar puncture. In the neonatal period, Escherichia coli and group B streptococci are the most common causative agents. Approximately 60% of the postneonatal
bacterial meningitis of children used to be due to Hemophilus influenzae. The impact of H. influenzae B vaccine has been dramatic. In the past decade there has been
a 100-fold decrease in incidence. In 1997 there were less that 300 cases reported. Overall fatality rate from bacterial meningitis is now 10% or less. Many deaths
occur during the first 48 hours of hospitalization.
TABLE 21.1. CAUSES OF 248 CASES OF BACTERIAL MENINGITIS IN 1995 AND OVERALL FATALITY RATE ACCORDING TO ORGANISM
For convenience, special features of the common forms of acute purulent meningitis are described separately. Neonatal infections are reviewed in Chapter 74.
Meningococcal Meningitis
Meningococcal meningitis was described by Vieusseux in 1805, and the causative organism was identified by Weichselbaum in 1887. It occurs in sporadic form and
at irregular intervals in epidemics. Epidemics are especially likely to occur during large shifts in population, as in time of war.
Pathogenesis
Meningococci (N. meningitidis) may occasionally gain access to the meninges directly from the nasopharynx through the cribriform plate. The bacteria, however,
usually are recovered from blood or cutaneous lesions before the meningitis, thus indicating that spread to the nervous system is hematogenous in most instances.
The ventricular fluid may be teeming with organisms before the meninges become inflamed.
Recent studies have defined more clearly the role of bacterial elements in the initiation of meningitis with meningococcus and other bacteria. The bacterial capsule
appears most important in the attachment and penetration to gain access to the body. Elements in the bacterial cell wall appear critical in penetration into the
cerebrospinal fluid (CSF) space through vascular endothelium and the induction of the inflammatory response.
Pathology
In acute fulminating cases, death may occur before there are any significant pathologic changes in the nervous system. In the usual case, when death does not occur
for several days after the onset of the disease, an intense inflammatory reaction occurs in the meninges. The inflammatory reaction is especially severe in the
subarachnoid spaces over the convexity of the brain and around the cisterns at the base of the brain. It may extend a short distance along the perivascular spaces
into the substance of the brain and spinal cord but rarely breaks into the parenchyma. Meningococci, both intra- and extracellular, are found in the meninges and
CSF. With progress of the infection, the pia-arachnoid becomes thickened, and adhesions may form. Adhesions at the base may interfere with the flow of CSF from
the fourth ventricle and may produce hydrocephalus. Inflammatory reaction and fibrosis of the meninges along the roots of the cranial nerves are thought to be the
cause of the cranial nerve palsies that are seen occasionally. Damage to the auditory nerve often occurs suddenly, and the auditory defect is usually permanent. Such
damage may result from extension of the infection to the inner ear or thrombosis of the nutrient artery. Facial paralysis frequently occurs after the meningeal reaction
has subsided. Signs and symptoms of parenchymatous damage (e.g., hemiplegia, aphasia, and cerebellar signs) are infrequent and are probably due to infarcts as
the result of thrombosis of inflamed arteries or veins.
With effective treatment, and in some cases without treatment, the inflammatory reaction in the meninges subsides, and no evidence of the infection may be found at
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Haq RU, Speer MC, Chu ML, Tandan R. Respiratory involvement in Bethlem myopathy. Neurology 1999;52:174176.
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Elsevier Science, 1992:179195.
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1993;3:109118.
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Speer MC, Tandan R, Rao PN, et al. Evidence for locus heterogeneity in the Bethlem myopathy and linkage to 2q37. Hum Mol Genet 1996;5:10431046.
Distal Muscular Dystrophies
Barohn RJ, Amato AA, Griggs RC. Overview of distal myopathies: from the clinical to the molecular. Neuromuscul Disord 1998;8:309316.
Feit H, Silergleit A, Schneider LB, et al. Vocal cord and pharyngeal weakness with autosomal dominant distal myopathy: clinical description and gene localization to 5p31. Am J Hum Genet
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CHAPTER 126. FAMILIAL PERIODIC PARALYSIS
MERRITTS NEUROLOGY
CHAPTER 126. FAMILIAL PERIODIC PARALYSIS

LEWIS P. ROWLAND
Hypokalemic Periodic Paralysis

Hyperkalemic Periodic Paralysis
Suggested Readings
Familial periodic paralysis comprises diseases characterized by episodic bouts of limb weakness. On clinical grounds, there are three main types: hypokalemic
periodic paralysis (HoPP) (MIM 170400), hyperkalemic (HyPP) (MIM 170500), and periodic paralysis with cardiac arrhythmia (MIM 170390). HyPP maps to 17q13, the
locus of the gene for the alpha subunit of the sodium channel. HoPP maps to the gene for the dihydropyridine-sensitive L-type calcium channel of muscle, which is
localized at 1q31. A third type, with cardiac arrhythmia, maps to neither site. Locus heterogeneity validates the clinical classification, although many investigators now
lump the conditions as channelopathies, including paramyotonia congenita and other nondystrophic myotonias.
Attacks are similar in all three conditions but differ somewhat in severity and duration ( Table 126.1). The two main types were first separated by the level of serum
potassium during a spontaneous or induced attack. Provocative tests can be performed by intravenous administration of glucose and insulin to drive the potassium
level down or by administration of potassium salts to increase the serum level.
TABLE 126.1. CLINICAL FEATURES OF LOW- AND HIGH-SERUM POTASSIUM PERIODIC PARALYSIS AND PARAMYOTONIA
The greatest uncertainty concerns paramyotonia congenita, which most investigators consider a separate syndrome that is manifested only by myotonia, with no
attacks of paralysis. Some authorities believe that there are disease-specific mutations within the sodium channel gene. The word paramyotonia is used because the
condition is thought to differ from ordinary myotonia in two ways: Paramyotonia is brought on by cold (but so are other forms of myotonia), and it is paradoxic in that
it becomes more severe with exercise, whereas the myotonia of other diseases is ameliorated by exercise. In families with HyPP, however, many individuals have
myotonia, and in presumed families of paramyotonia congenita, some individuals have attacks of paralysis (including the original families described by Eulenberg in
Germany and Rich in the United States). Some people with paramyotonia congenita are susceptible to attacks induced by administration of potassium. The diseases
are allelic, mapping to the same gene. Similarly, the same gene accounts for paramyotonic variants, such as myotonia fluctuans, acetazolamide-responsive myotonia,
and painful myotonia.
The third type of familial periodic paralysis, now called Andersen syndrome, was first thought to be normokalemic, then hyperkalemic. In fact, spontaneous attacks
have been associated with high, low, or normal potassium levels. Nevertheless, patients are sensitive to administered potassium, which always provoked an attack
before the provocative test was deemed dangerous. The hazard is feared because affected children are likely to have cardiac arrhythmias that lead to the need for a
pacemaker. The syndrome was named after Andersen because she described a dysmorphic boy; since then dysmorphism has become one of five criteria for
diagnosis; the others are periodic paralysis, potassium sensitivity, myotonia (usually mild), and cardiac arrhythmia. The dysrhythmia may be preceded by an
asymptomatic prolonged QT interval on the ECG. The disease does not link to sodium or calcium channel genes or to the gene for the cardiac potassium channel that
is responsible for most long QT syndromes.
Vacuoles are found in the muscles in the early stages of both HoPP and HyPP. These vacuoles seem to arise both from the terminal cisterns of the sarcoplasmic
reticulum and from proliferation of the T tubules. In the later stage, there may be degeneration of the muscle fibers, possibly related to persistent weakness in the
intervals between attacks.
HYPOKALEMIC PERIODIC PARALYSIS
In HoPP, the potassium content decreases in a spontaneous attack to values of 3.0 mEq/L or lower. Attacks may be induced by the injection of insulin, epinephrine,
fluorohydrocortisone, or glucose, or they may follow ingestion of a meal high in carbohydrates. The potassium content of the urine is also decreased in an attack. It is
not clear why potassium shifts into muscle to cause the attack.
Incidence
The disease is rare. There are no large series reported in the literature, and only one or two new patients are seen each year in any of the large neurologic centers in
the United States. Males are affected two to three times as frequently as females. The first attack usually occurs at about the time of puberty, but it may occur as early
as age 4 years or be delayed until the sixth decade.
Symptoms and Signs
An attack usually begins after a period of rest. It commonly develops during the night or is present on waking in the morning. The extent of the paralysis varies from
slight weakness of the legs to complete paralysis of all the muscles of the trunk and limbs. The oropharyngeal and respiratory muscles are usually spared, even in
severe attacks. There may be retention of urine and feces during a severe attack. The duration of an individual attack varies from a few hours to 24 or 48 hours.
According to some patients, strength improves if they move around and keep active (walk it off). The interval between attacks may be as long as 1 year, or one or
more attacks of weakness may occur daily. Weakness is especially likely to be present in the morning after ingestion of a high-carbohydrate meal before retiring on
the previous night. Rarely, the disease may occur in association with peroneal muscular atrophies.
In the interval between attacks, patients are usually strong, and the potassium content of the serum is normal. In some patients, mild proximal limb weakness persists.
In a mild attack, tendon reflexes and electrical reactions of the muscles are diminished in proportion to the degree of weakness. In severe attacks, tendon and
cutaneous reflexes are absent and the muscles do not respond to electrical stimulation. Cutaneous sensation is not disturbed.
Course
Familial HoPP is not accompanied by any impairment of general health. As a rule, the frequency of the paralytic attacks decreases with the passage of years, and
they may cease altogether after age 40 or 50. Fatalities are rare, but death may occur from respiratory paralysis. The fixed myopathy, usually mild, may be severe and
disabling.
Diagnosis
The diagnosis can usually be made without difficulty on the basis of the familial occurrence of transient attacks of weakness. The diagnosis is usually confirmed by
finding low potassium and high sodium content in the serum during an attack, or by inducing an attack with an intravenous infusion of glucose (100 g) and regular
insulin (20 U). Now, the provocative test can be avoided by DNA testing. However, if a patient is in the hospital during a spontaneous attack, it is important to
determine which type of periodic paralysis is to be treated.
In sporadic cases, the first attack must be differentiated from other causes of hypokalemia ( Table 126.2). Persistent hypokalemia from any cause may manifest as an
acute attack of paralysis or persistent limb weakness with high levels of serum creatine kinase. Sometimes, there are attacks of myoglobinuria.
TABLE 126.2. POTASSIUM AND PARALYSIS: NONINHERITED FORMS
Repeated attacks of HoPP, identical clinically to the familial form, occur in patients with hyperthyroidism. Japanese and Chinese people seem to be especially
susceptible to this disorder. The paralytic attacks cease when the thyroid disorder has been successfully treated.
Treatment
Acute attacks, spontaneous or induced, may be safely and rapidly terminated by ingestion of 20 to 100 mEq of potassium salts. Intravenous administration of
potassium is usually avoided because of the hazard of inducing hyperkalemia.
The basis of prophylactic therapy is oral administration of the carbonic anhydrase inhibitor acetazolamide (Diamox), 250 to 1,000 mg daily. This regimen prevents
attacks in about 90% of patients with HoPP and also improves the interictal weakness attributed to the vacuolar myopathy. The mechanism of action of acetazolamide
is uncertain; the beneficial effect may be related to the mild metabolic acidosis it induces. For those not helped by acetazolamide, other effective agents include
triamterene (Dyrenium) or spironolactone (Aldactone), which promote retention of potassium. Another carbonic anhydrase inhibitor of value is dichlorphenamide
(Daranide). Dietary controls are usually not accepted by patients and are not effective.
Treatment of other forms of HoPP depends on the nature of the underlying renal disease, diarrhea, drug ingestion, or thyrotoxicosis. Patients with thyrotoxic periodic
paralysis are susceptible to spontaneous or induced attacks during the period of hyperthyroidism. When the patients become euthyroid, spontaneous attacks cease
and they are no longer sensitive to infusion of glucose and insulin. Glucose and insulin are useful in the interim between treatment of hyperthyroidism by drugs or
radioiodine, before the euthyroid state returns. Repeated attacks can be prevented by either acetazolamide or propranolol.
HYPERKALEMIC PERIODIC PARALYSIS
In 1951, Frank Tyler recognized a form of familial periodic paralysis in which attacks were not accompanied by a decrease in the serum potassium content. In 1957,
Gamstorp and colleagues drew attention to several other features of these cases that separated them from the usual cases of periodic paralysis. The disease is
transmitted by an autosomal-dominant gene with almost complete penetrance. In addition to the absence of hypokalemia in the attacks, the syndrome is characterized
by an early age of onset (usually before age 10). The attacks tend to occur in the daytime and are likely to be shorter and less severe than those in HoPP. Myotonia is
usually demonstrable by EMG, but abnormalities of muscular relaxation are rarely symptomatic. Myotonic lid lag ( Fig. 126.1) and lingual myotonia may be the sole
clinical evidence of the trait. Serum potassium content and urinary excretion of potassium may be increased during an attack, possibly the result of leakage of
potassium from muscle. The attacks tend to be precipitated by hunger, rest, or cold or by administration of potassium chloride.
FIG. 126.1. Paramyotonia congenita. Myotonia of muscles of the upper eyelids on looking downward. (Courtesy of Dr. Robert Layzer.)
Attacks may be terminated by administration of calcium gluconate, glucose, and insulin. Acetazolamide, 250 mg to 1 g orally daily, has been effective in reducing the
number of attacks or in abolishing them altogether. Other diuretics that promote urinary excretion of potassium are also effective. If acetazolamide therapy fails,
thiazides or fludrocortisone acetate (Florinef Acetate) may be beneficial. In addition, beta-adrenergic drugs may be effective prophylactic agents. Epinephrine,
Salbutamal, and metaproterenol have been used. They presumably act by increasing the activity of Na+,K+-ATPase.
Pathophysiology
The pathophysiology of the HyPP has been analyzed by the team of Rudel, Ricker, and Lehmann-Horn (1993); their findings led to the suspicion that a sodium
channel protein would be a good candidate gene. First, using microelectrode studies of intercostal muscle, they confirmed that muscle isolated from patients with
HyPP is partially depolarized at rest. The abnormal depolarization was blocked by tetrodotoxin, which specifically affects the alpha subunit of the sodium channel.
Patch clamp experiments showed faulty inactivation, leading to the conclusion that excessive sodium influx was accompanied by excessive efflux of potassium,
thereby raising levels in extracellular fluids. They found that muscle from patients with more paramyotonia than sensitivity to potassium was more sensitive to cold.
In contrast, the calcium channel gene for HoPP was found not by physiology but by a genome-wide search. The pathophysiology of HoPP is not clear but may include
an indirect effect on a sarcolemmal ATP-sensitive potassium channel.
The challenge now is to determine just how the single amino acid substitutions result in the altered function. Because periodic paralysis and potassium sensitivity are
seen in families with paramyotonia, it is important to determine whether disease-specific mutations exist. Alternatively, as in myotonic muscular dystrophy and other
autosomal-dominant diseases, there could be pleiotropic expression of the mutation, which is expressed by four abnormalities: paralytic attacks, myotonia, potassium
sensitivity, and cold sensitivity. In the same family, one or more of these manifestations may be dominant in different individuals.
SUGGESTED READINGS
Hypokalemic Periodic Paralysis
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Holtzapple GE. Periodic paralysis. JAMA 1905;45:12241231.
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Layzer RB, Goldfield E. Periodic paralysis caused by abuse of thyroid hormone. Neurology 1974;24:949952.
Links TP, Zwarts MJ, Oosterhuis HJGH. Improvement of muscle strength in familial hypokalemic periodic paralysis with acetazolamide. J Neurol Neurosurg Psychiatry 1988;51:11421145.
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Marx A, Ruppersberg JP, Pietrzyk C, Rudel R. Thyrotoxic periodic paralysis and the sodium-potassium pump. Muscle Nerve 1989;12:810815.
Minaker KL, Menelly GS, Flier JS, Rowe JW. Insulin-mediated hypokalemia and paralysis in familial hypokalemic periodic paralysis. Am J Med 1988;84:10011006.
Morrill JA, Brown RH Jr, Cannon SC. Gating of the L-type Ca channel in human skeletal myotubes: an activation defect caused by hypokalemic periodic paralysis mutation R528H. J Neurosci
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Roadma JS, Reidenberg MM. Symptomatic hypokalemia resulting from surreptitious diuretic ingestion. JAMA 1981;246:16871689.
Vern BA, Danon MJ, Hanlon K. Hypokalemic periodic paralysis with unusual responses to acetazolamide and sympathomimetics. J Neurol Sci 1987;81:159172.
Vroom FQ, Jarrell MA, Maren TH. Acetazolamide treatment of hypokalemic periodic paralysis: probable mechanisms of action. Arch Neurol 1975;32:385392.
Yazaki K, Kuribayashi T, Yamamura Y, et al. Hypokalemic myopathy associated with 17a-hydroxylase deficiency: a case report. Neurology 1982;32:9497.
Hyperkalemic Periodic Paralysis
Barchi RL. Phenotype and genotype in the myotonic disorders. Muscle Nerve 1998;21:11191120.
Bendheim PE, Reale EO, Berg BO. Beta-adrenergic treatment of hyperkalemic periodic paralysis. Neurology 1985;35:746749.
Benstead TJ, Camfield PR, Ding DB. Treatment of paramyotonia congenita with acetazolamide. Can J Neurol Sci 1987;14:156158.
Borg K, Hovmoller M, Larsson L, Edstrom L. Paramyotonia congenita (Eulenberg): clinical, neurophysiological and muscle biopsy observations in a Swedish family. Acta Neurol Scand 1993;87:3742.
Bradley WG. Adynamia episodica hereditaria: clinical, pathological, and electrophysiological studies in an affected family. Brain 1969;92:345378.
Christopher GA, Johnson JP, Palevsky PM, Greenberg A. Hyperkalemia in hospitalized patients. Arch Intern Med 1998;158:917924.
De Silva S, Kuncl RW, Griffin JW, et al. Paramyotonia congenita or hyperkalemic periodic paralysis? Clinical and electrophysiological features of each entity in one family. Muscle Nerve
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Eulenberg A. ber einer familire, durch 6 Generationen verfolgbare Form congenitaler Paramyotonie. Neurol Centralbl 1886;5:265272.
Evers S, Engelien A, Karsch V, Hund M. Secondary hyperkalemic paralysis. J Neurol Neurosurg Psychiatry 1998;64:249252.
Gamstorp I. Adynamia episodica hereditaria. Acta Pediatr (Uppsala) 1956;45(Suppl 108):1126.
Hanna MF, Stewart J, Schapira AH, Wood NW, Morgan-Hughes JA, Murray NM. Salbutamol treatment in a patient with hyperkalaemic periodic paralysis due to a mutation in the skeletal muscle
sodium channel gene (SCN4A). J Neurol Neurosurg Psychiatry 1998;65:248250.
Heine R, Pika U, Lehmann-Horn F. A novel SCN4A mutation causing myotonia aggravated by cold and potassium. Hum Mol Genet 1991;2:13491353.
Hoffman EH, Wang J. Duchenne-Becker muscular dystrophy and the nondystrophic myotonias. Arch Neurol 1993;50:12271237.
Layzer RB, Lovelace RE, Rowland LP. Hyperkalemic periodic paralysis. Arch Neurol 1967;16:455472.
Lisak RP, Lebeau J, Tucker SH, Rowland LP. Hyperkalemic periodic paralysis and cardiac arrhythmia. Neurology 1972;22:810815.
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CHAPTER 127. CONGENITAL DISORDERS OF MUSCLE
MERRITTS NEUROLOGY
CHAPTER 127. CONGENITAL DISORDERS OF MUSCLE

LEWIS P. ROWLAND
Myotonia Congenita
Chondrodystrophic Myotonia (Schwartz-Jampel Syndrome)
Congenital Myopathies
Suggested Readings
Several different categories of muscle disease are evident from birth; most of them are familial in mendelian patterns of inheritance, but some are characteristically
sporadic. The cause of such cases is uncertain. Terminology is currently unsatisfactory because there is no clear distinction between congenital muscular dystrophies
(see Chapter 125) and the congenital myopathies. The diseases in either group may be evident at birth or become evident because motor milestones are delayed,
and then remain static or be steadily progressive. The conditions called congenital myopathies here are mostly static or only slowly progressive. One group is
characterized by a disorder of contractility with little or no weakness (myotonia congenita); another combines myotonia with severe dysmorphic features
(Schwartz-Jampel syndrome). Others are defined by structurally specific histologic characteristics (congenital myopathies).
MYOTONIA CONGENITA
Myotonia congenita (MIM 160800), often called Thomsen disease, was described by a Danish physician in 1876. He had a close view of the condition, which affected
his own family in an autosomal-dominant pattern. Symptoms are caused only by myotonia or the consequences thereof. The disease differs from myotonic muscular
dystrophy in that there is no muscle weakness or wasting and no systemic disorder is present (i.e., no cataracts, electrocardiogram abnormalities, or endocrinopathy).
The myotonia tends to be more severe than that in myotonic MD, where myotonia is rarely sufficiently bothersome to warrant symptomatic treatment. In myotonia
congenita, however, the myotonia may be a functional handicap and more often leads to treatment. Presumably as a consequence of involuntary isometric
contraction, the muscles tend to hypertrophy and give the person an athletic appearance. The myotonia is also more widespread, and in addition to the characteristic
difficulty in relaxing the grip, the myotonia may affect the orbicularis oculi (difficulty opening the eyes after a forceful closure), leg muscles (difficulty in starting to walk
or run), or even muscles of the pharynx (difficulty in swallowing). Respiration is spared. The myotonia is painless. Patients usually adapt well to the condition and live
a normal life span.
The myotonia shows the usual physiologic characteristics of other forms of myotonia, including myotonic dystrophy and hyperkalemic periodic paralysis (HyPP). A
repetitive discharge of muscle fiber potentials occurs after a forceful contraction, and the myotonia originates in the muscle surface membrane, as demonstrated by
experiments in which percussion myotonia could still be evoked after the muscle had been isolated from the central and peripheral nervous systems by curarization.
Characteristically, the myotonia is worse on the initiation of exercise and is ameliorated by gradually increasing the vigor of movements by warming up.
Physiologic studies in a herd of myotonic goats implied an abnormality of the chloride channel (in contrast to the dysfunctional sodium channel in HyPP). As a result,
chloride conductance is decreased. The chloride channel was then found to be affected in symptomatic humans, and the gene for both channel and disease was
mapped to chromosome 7q35. In almost all cases, inheritance is autosomal-dominant, but a recessive pattern (MIM 255700) has been identified in a few families in
which mild weakness improves with exercise. Remarkably, both autosomal dominant and recessive forms seem to be linked to the same chloride channel gene,
CLCN1; the gene product is ClC-1. Other variants, such as painful myotonia or fluctuating myotonia, have been described clinically, but the relationship of these
conditions to myotonia congenita awaits clarification by genetic studies.
In contrast to the chloride channel myotonias, the sodium channel diseases are often associated with periodic paralysis and are grouped as nondystrophic myotonias
(see Chapter 126).
Myotonia congenita can be relieved by phenytoin sodium (Dilantin), 300 to 400 mg daily for serum level of 10 to 20 mg/mL, or quinine sulfate, 200 to 1,200 mg daily.
Acetazolamide (Diamox) is sometimes effective. Hexiletine, an antiarrhythmic agent, is also helpful. Procainamide hydrochloride ameliorates myotonia but may induce
systemic lupus erythematosus and is therefore avoided. The mode of action of these drugs is not clear, except that they seem to stabilize muscle membranes.
CHONDRODYSTROPHIC MYOTONIA (SCHWARTZ-JAMPEL SYNDROME)
Chondrodystrophic myotonia (Schwartz-Jampel syndrome) is an autosomal-recessive syndrome that is recognizable at birth because of the facial abnormalities:
narrow palpebral fissures (blepharophimosis), pinched nose, and micrognathia. Other skeletal anomalies include short neck, flexion contractures of the limbs, and
kyphosis. Limb muscles are clinically stiff and often hypertrophied. On EMG, the myotonia is often continuous, with little waxing and waning. Like other forms of
myotonia, the chondrodystrophic form persists after curarization. The myotonia can be treated, but the skeletal abnormalities are more disabling. The condition must
be differentiated from Isaacs syndrome (see Chapter 129).
Three forms of Schwartz-Jampel syndrome are recognized. The most common is autosomal-recessive and has been mapped to chromosome 1p34-p36.1; symptoms
begin in late infancy or childhood. A second, more severe type is the neonatal variety, which may be fatal and does not map to chromosome 1. The third type is
autosomal-dominant and unmapped.
CONGENITAL MYOPATHIES
In the 1960s, the application of histochemical stains to muscle biopsy specimens led to the recognition of unusual structures in children with mild myopathies. The
myopathies are determined by changes in the EMG and muscle biopsy, with only slight increase in serum creatine kinase. The syndromes are not usually evident in
the first 2 years of life, except for delayed walking. The persistent and relatively static weakness, however, suggests that the myopathy is congenital. Sometimes,
however, symptoms do appear in the neonatal period, especially difficulty in sucking. They may cause the floppy infant syndrome (see Chapter 75). Conversely, there
are later-onset forms, including some that appear first in adults. Whatever the clinical course, the disorders are named after the dominant structural abnormality
(Table 127.1).
TABLE 127.1. CONGENITAL MUSCULAR DYSTROPHIES AND CONGENITAL MYOPATHIES
In central core disease (MIM 117000), an amorphous area in the center of the fiber stains blue with the Gomori trichrome stain and contrasts with the red-staining
peripheral fibrils. The cores are devoid of enzymatic activity histochemically, and under the electron microscope, the area lacks mitochondria. In nemaline disease
(from the Greek word for thread) (MIM 161800), small rods near the sarcolemma stain bright red with the trichrome stain and seem to originate from Z-band material.
In myotubular or centronuclear myopathy (MIM 310400), the nuclei are situated centrally instead of in the normal sarcolemmal position, and are surrounded by a pale
halo. Cytoplasmic body myopathy is characterized by accumulations of desmin, and some authorities suggest a category of desmin-related myopathies. Fiber-type
disproportion, fingerprint bodies, tubular aggregates, and numerous other anomalies have been seen in different families, and variants of the original anomalies
include minicores and multicores. For most of these myopathies, the origin of the structure is not known. In some nonspecific congenital myopathies, myopathic
changes are found with no specific structure.
A few clinical clues might predict findings on muscle biopsy. In some patients, the usual static or slow progression of the disease with normal life expectancy gives
way to more serious weakness or even premature death. Skeletal abnormalities are seen in centronuclear or nemaline myopathies or with fiber-type disproportion; a
long, lean face, prognathism, kyphoscoliosis, pedal deformities, and congenital dislocation of the hip are characteristic. Centronuclear myopathy seems to be
associated more often than the other congenital disorders with progressive ophthalmoplegia. Nemaline myopathy may be the most common of the group to cause
respiratory problems in infancy and throughout life. Arthrogryposis congenita multiplex is the name given to a condition characterized by flexion contracture of the
limbs; as determined by EMG and muscle biopsy, the syndrome is sometimes neurogenic and sometimes a congenital myopathy of the nonspecific type. In the
Prader-Willi syndrome (MIM 176270), the findings include hypotonia, neonatal dysphagia, tented upper lip, depressed myotatic reflexes, and cryptorchidism; these
manifestations are prominent in infancy, but there is no permanent weakness. The syndrome is later recognized by mental retardation, obesity, short stature, skeletal
anomalies, and childhood diabetes.
Progress is being made in the molecular genetics of these disorders. The following have been mapped: myotubular myopathy, Xq28; central core disease, 19q13.1;
and nemaline myopathy, 1q21-q23 and 2q22. The Prader-Willi syndrome has been linked to deletions at 15q11-q13 and is a disease in which imprinting is involved;
the autosomal-dominant condition results if the paternal chromosome is affected. If the maternal chromosome is affected, a different clinical disorder called the
Angelman syndrome (MIM 234400) results; it is also manifested by mental retardation, but the other Prader-Willi manifestations are lacking. Instead, characteristics
are microcephaly, lack of speech, and inappropriate laughter, leading to the appellation of the happy puppet syndrome.
Although chromosome map positions have been established, only four gene products have been identified. In X-linked myotubular myopathy, the MTM1 gene
encodes myotubularin, which is a protein tyrosine phosphatase. The gene product for autosomal recessive, chromosome-1q21-linked nemaline disease is slow
tropomyosin. The affected protein in autosomal dominant nemaline disease is alpha-tropomyosin in some families, but others lack this mutation. The fourth known
gene product is that of central core disease, which maps to the ryanodine receptor at 19q13.1. This is also the map position noted for malignant hyperthermia (MIM
145600). Patients with central core disease are at increased risk for malignant hyperthermia, and the two conditions may be found in different people in the same
family.
The diagnosis of these conditions rests on the muscle pathology. Other congenital syndromes include myasthenia gravis, congenital myotonic dystrophy, and spinal
muscular atrophy. In addition, the typical morphologic structures are sometimes found in adult-onset myopathies or other conditions. For instance, a late-onset
nemaline disease can cause a severe myopathy after age 50 years.
Treatment of the congenital myopathies is symptomatic.
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Myotonia Congenita
Becker PE. Myotonia congenita and syndromes associated with myotonia: clinical-genetic studies of the nondystrophic myotonias . Stuttgart: Thieme, 1977.
Deymeer F, Cakirkaya S, Serdaroglu P, et al. Transient weakness and compound muscle action potential decrement in recessive myotonia congenita. Muscle Nerve 1998;21:13341337.
Koch MC, Steinmeyer K, Lorenz C, et al. Skeletal muscle chloride channel in dominant and recessive human myotonia. Science 1992;257:797800.
Kubisch C, Schmidt-Rose T, Fontaine B, Bretag AH, Jentsch TJ. ClC-1 chloride channel mutations in myotonia congenita: variable penetrance of mutations shifting the voltage dependence. Hum Mol
Genet 1998;7:17531760.
Plassart-Schliess E, Garvais A, Eymard B, et al. Novel muscle chloride channel (CLCN1) mutations in myotonia congenita with various modes of inheritance including incomplete dominance and
penetrance. Neurology 1998;50:11761179.
Trudell RG, Kaiser KK, Griggs RC. Acetazolamide-responsive myotonia congenita. Neurology 1987;37:488491.
Wagner S, Deymeer F, Kurz LL, et al. The dominant chloride channel mutant G200R causing fluctuating myotonia: clinical findings, electrophysiology, and channel pathology. Muscle Nerve
1998;21:11221128.
Chondrodystrophic Myotonia (Schwartz-Jampel Syndrome)
Brown KA, Al-Gazali LI, Moynihan M, Lench NJ, Markham AF, Mueller RF. Genetic heterogeneity in Schwartz-Jampel syndrome: two families with neonatal Schwartz-Jampel syndrome do not map to
chromosome 1p34-p36.1. J Med Genet 1997;34:685687.
Farrell SA, Davidson RG, Thorp P. Neonatal manifestations of Schwartz-Jampel syndrome. Am J Med Genet 1987;27:799805.
Nicole S, Ben Hamida C, Beighton P, et al. Localization of the Schwartz-Jampel syndrome locus to chromosome 1p34-36.1 by homozygosity mapping. Hum Mol Genet 1995;4:16331636.
Schwartz O, Jampel RS. Congenital blepharophimosis associated with a unique generalized myopathy. Arch Ophthalmol 1962;68:5257.
Spaans F, Theunissn P, Reekerss AD, et al. Schwartz-Jampel syndrome. I. Clinical, electromyographic, and histologic studies. Muscle Nerve 1990;13:516527.
Taylor RG, Layzer RB, Davis HS, Fowler WM. Continuous muscle fiber activity in the Schwartz-Jampel syndrome. Electroencepahlogr Clin Neurophysiol 1972;33:497502.
Congenital Myopathies
Baeta AM, Figarella-Branger D, Bille-Ture F, Lepidi H, Pellissier JF. Familial desmin myopathies and cytoplasmic body myopathies. Acta Neuropathol 1996;92:499510.
De Angelis MS, Palmucci L, Leone M, Doriguzzi C. Centronucleolar myopathy: clinical, morphological, and genetics characters: a review of 288 cases. J Neurol Sci 1991;103:29.
Glenn CC, Nicholls RD, Robinson WP, et al. Modification of 15q11-q13 DNA methylation imprints in unique Angelman and Prader-Willi patients. Hum Mol Genet 1993;2:13771382.
Goebel HH, Anderson JR. Structural congenital myopathies (excluding nemaline myopathy, myotubular myopathy and desminopathies). 56th European Neuromuscular Centre (ENMC) sponsored
international workshop, December 1214, 1997, Naarden, The Netherlands. Neuromuscul Disord 1999;9:5057.
Goebel HH, Lenard HG. Congenital myopathies. In: Vinken PJ, Bruyn GW, Klawans HL, Rowland LP, DiMauro S, eds. Myopathies. Handbook of clinical neurology, rev ser, vol 62(18). New York:
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Griggs RC, Mendell JR, Miller RG. Evaluation and treatment of myopathies. Philadelphia: FA Davis Co, 1995.
Gyure KA, Prayson RA, Estes ML. Adult-onset nemaline myopathy: case report and review of the literature. Arch Pathol Lab Med 1997;121:12101213.
Howard RS, Wiles CM, Hirsch NP, Spencer GT. Respiratory involvement in primary muscle disorders: assessment and management. Q J Med 1993;86:175189.
Laing NG, Wilton SD, Akkari PA, et al. A mutation of the alpha tropomyosin gene TPM3 associated with autosomal dominant nemaline myopathy. Nat Genet 1995;9:7579. Erratum: Nat Genet
1995;10:249.
Romero NB, Nivoche Y, Lunardi J, et al. Malignant hyperthermia and central core disease: analysis of two families with heterogeneous clinical expression. Neuromuscul Disord 1993;3:547551.
Shuaib A, Martin JME, Mitchell LB, Brownell AKW. Multicore myopathy: not always a benign entity. Can J Neurol Sci 1988;15:1014.
Shuaib A, Paasuke RT, Brownell AKW. Central core disease: clinical features in 13 patients. Medicine 1987;66:389396.
Shy GM, Engel WK, Somers JE, Wanko T. Nemaline myopathy: a new congenital myopathy. Brain 1963;86:793810.
Spargo E, Doshi B, Whitwell HL. Fatal myopathy with cytoplasmic inclusions. Neuropathol Appl Neurobiol 1988;14:516.
Spiro AJ, Shy GM, Gonatas NK. Myotubular myopathy. Arch Neurol 1966;14:114.
Tanner SM, Schneider V, Thomas NST. Characterization of 34 novel and six known MTM1 gene mutations in 47 unrelated X-linked myotubular myopathy patients. Neuromuscul Disord 1999;9:4149.
Tein I, Haslam RHA, Rhead WJ, Bennett MJ, Becker LE , Vockley J. Short-chain acyl-coA dehydrogenase deficiency: a cause of ophthalmoplegia and multicore myopathy. Neurology
1999;52:366372.
Tome FMS, Guicheney P, Fardeau M. Congenital muscular dystrophies. In Emery AEH, ed. Neuromuscular disorders: clinical and molecular genetics. New York: John Wiley and Sons, 1998:2158.
Vajsar J, Becker LE, Freedom RM, Murphy EG. Familial desminopathy: myopathy with accumulation of desmin-type intermediate filaments. J Neurol Neurosurg Psychiatry 1993;56:644648.
Wallgren-Petterson C. Genetics of the nemaline myopathies and the myotubular myopathies. Neuromuscul Disord 1998;8:401404.
CHAPTER 128. MYOGLOBINURIA
MERRITTS NEUROLOGY
CHAPTER 128. MYOGLOBINURIA

LEWIS P. ROWLAND
Suggested Readings
When necrosis of muscle is acute, myoglobin escapes into the blood and then into the urine. In the past, the term myoglobinuria was reserved for grossly pigmented
urine, but modern techniques can detect amounts of this protein so minute that discoloration may not be evident. (Determination of serum myoglobin content by
radioimmunoassay has the same diagnostic significance as measurement of serum creatine kinase [CK] activity.) The clinically important syndromes, however, are
associated with gross pigmenturia. Sometimes, the disorder can be recognized without direct demonstration of myoglobin in the urine, for instance, in cases of acute
renal failure with very high levels of serum CK activity. Inexplicably, rhabdomyolysis has become the official (Index Medicus) term for these syndromes, although it is
really a synonym for myoglobinuria.
No classification of the myoglobinurias is completely satisfactory, but Table 128.1 lists the most important causes. Many cases of inherited recurrent myoglobinuria
are due to unidentified abnormalities. In six forms, however, the genetic defect has been recognized: lack of phosphorylase (McArdle), phosphofructokinase (Tarui),
carnitine palmityltransferase (CPT) (DiMauro-Bank), phosphoglyceraldehyde kinase (DiMauro), phosphoglycerate mutase (DiMauro), and lactate dehydrogenase
(Kanno). CPT is important in lipid metabolism; the others are involved in glycogenolysis or glycolysis, and are reviewed in Chapter 84. In all these conditions, there is
a disorder in the metabolism of a fuel necessary for muscular work; in all six, exercise is limited by painful cramps after exertion, and myoglobinuria occurs after
especially strenuous activity. There may be a subtle difference in the kinds of activity that provoke attacks, which are more prolonged in CPT deficiency than in the
glycogen disorders. The glycogen disorders can be identified by a simple clinical test: A cramp is induced by ischemic exercise of forearm muscles for less than 1
minute, and venous lactate fails to rise as it does in normal individuals or those with CPT deficiency. Specific diagnosis requires histochemical or biochemical analysis
of muscle homogenates. Five of the conditions are inherited in autosomal-recessive pattern; phosphoglycerate kinase deficiency is X-linked.
TABLE 128.1. CLASSIFICATION OF HUMAN MYOGLOBINURIA
The relative frequency of the causes of recurrent myoglobinuria differed in two studies. In the United States, samples were sent to an active referral laboratory, and
almost 50% had an identifiable cause; phosphorylase, phosphorylase kinase, phosphofructokinase, CPT, and myoadenylate deaminase deficiencies accounted for
almost all in the report of Tonin and colleagues (1990). In Finland, however, only 23% of 22 patients with recurrent myoglobinuria had an identifiable cause, and none
had CPT deficiency or myoadenylate deaminase deficiency. Lofberg and associates (1998) gave two explanations of recurrent myoglobinuria without an enzyme
defect: disappearance of some genes from the genetically isolated population in Finland and an increase in recreational distance running or body building.
Another important form of inherited myoglobinuria occurs in malignant hyperthermia (MIM 180901, 145600), which is attributed to succinylcholine, halothane, or both
together. The characteristic syndrome includes widespread muscular rigidity, a rapid rise in body temperature, myoglobinuria, arrhythmia, and metabolic acidosis. In
some cases, muscular rigidity is lacking. The pathogenesis is uncertain, but the offending drugs may interact with a defective protein in the muscle sarcoplasmic
reticulum that fails to bind calcium. The muscle, flooded with calcium, shortens to create the stiff muscles and attendant muscle necrosis. The syndrome is often
familial in an autosomal dominant pattern, but many cases are sporadic. In some families, the gene mapped to chromosome 19q12-13.2, the site of the gene for the
ryanodine receptor, which is the calcium release channel and also the locus for central core disease, a congenital myopathy that seems to increase the risk of
malignant hyperthermia. A similar syndrome in pigs maps to the same gene product. However, there is evidence of locus heterogeneity because only 50% of all
families map to that locus. Another calcium-binding protein of the sarcoplasmic reticulum is the dihydropyridine receptor, but the disease does not map to the locus for
that candidate gene product. Yet another sign of heterogeneity is the occurrence of the syndrome in children with Duchenne muscular dystrophy or myotonia
congenita. A closely related disorder is the neuroleptic malignant syndrome, which is similar in clinical manifestations, although the offending drugs are different and
the disorder has not yet appeared in a family with malignant hyperthermia.
Most attacks of acquired myoglobinuria occur in nonathletic individuals who are subjected to extremely vigorous exercise, a hazard faced primarily by military recruits.
These individuals are otherwise normal. Even trained runners may experience myoglobinuria in marathon races. If muscle is compressed, as occurs in the crush
syndrome of individuals pinned by fallen timber after bombing raids, or after prolonged coma in one position, myoglobinuria may ensue. Ischemia after occlusion of
large arteries may also lead to necrosis of large amounts of muscle. Depression of muscle metabolism, especially after drug ingestion, may also be responsible in
some cases. Hypokalemia from any cause may predispose to myoglobinuria, but especially after chronic licorice ingestion or abuse of thiazide diuretics. Alcoholics
seem especially prone to acute attacks of myoglobinuria, which may punctuate or initiate a syndrome of chronic limb weakness (alcoholic myopathy). In children, as in
adults, the attacks may be precipitated by exercise (often with an identifiable enzymatic defect); in contrast to adults, however, myoglobinuria in children seems more
often associated with a nonspecific viral infection and fever.
Whatever the cause, the clinical syndrome is similar: widespread myalgia, weakness, malaise, renal pain, and fever. Pigmenturia usually ceases within a few days,
but the weakness may persist for weeks, and high concentrations of serum enzymes may not return to normal for even longer. The main hazard of the syndrome is
heme-induced nephropathy with anuria, azotemia, and hyperkalemia. Hypercalcemia occurs in a few patients after anuria. Occasionally, respiratory muscles are
symptomatically weakened.
Treatment of an acute episode of myoglobinuria is directed primarily toward the kidneys. Promotion of diuresis with mannitol seems desirable whenever there is
oliguria. Dialysis and measures to combat hyperkalemia may be necessary. In recurrent cases due to defects of glycolytic enzymes or to unknown cause, various
therapeutic regimens have been tried, but patients usually learn the limits of exercise tolerance.
The treatment of malignant hyperthermia is unsatisfactory because the rigidity is not abolished by curare. Intravenous infusions of dantrolene sodium (Dantrium) are
given because this drug inhibits the release of calcium from the sarcoplasmic reticulum, relaxing the hypercontracted muscle. The average dose in successfully
treated patients is 2.5 mg/kg body weight.
Once a person has been identified with malignant hyperthermia, the clinician must determine whether other family members are at risk. With the mapping of the gene
to chromosome 19, it was hoped that a DNA test would be available. Locus heterogeneity, however, means that other, still unidentified genes are sometimes
responsible. An alternative test to identify susceptibility is the caffeine contracture test, during which bundles of fibers from a muscle biopsy are exposed to the drug
and tension is measured. Individuals are deemed susceptible if the response is significantly greater than normal. Unfortunately, the test is not completely reliable.
Nevertheless, the condition is now so well known to anesthesiologists that offending volatile and neuromuscular blocking agents are avoided in people who may be at
risk, and the frequency of attacks has fallen.
For the malignant neuropletptic syndrome, bromocriptine mesylate (Parlodel) and carbamazepine (Tegretol) have reportedly been beneficial (see Chapter 116).
SUGGESTED READINGS
Ball SP, Johnson KJ. The genetics of malignant hyperthermia. J Med Genet 1993;30:8993.
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Bristow MF, Kohen D. How malignant is the neuroleptic malignant syndrome? BMJ 1993;307:12231224.
Britt BA, Kalow W. Malignant hyperthermia: a statistical review. Can Anaesth Soc J 1970;17:293315.
Corpier CL, Jones PH, Suki WN, et al. Rhabdomyolysis and renal injury with lovastatin use: report of two cases in cardiac transplant patients. JAMA 1988;260:239241.
Denborough M. Malignant hypethermia. Lancet 1998;352:11311136.
DiMauro S, Dalakas M, Miranda AF. Phosphoglycerate kinase deficiency: another cause of recurrent myoglobinuria. Ann Neurol 1983;13:1119.
DiMauro S, DiMauro PMM. Muscle carnitine palmityl transferase deficiency and myoglobinuria. Science 1973;182:929931.
Duthie DJR. Heat-related illness. Lancet 1998;352:13291330.
Ebadi M, Pfeiffer RF, Murrin LC. Pathogenesis and treatment of neuroleptic malignant syndrome. Gen Pharmacol 1990;21:367386.
Gabow PA, Kaehny WD, Kelleher SP. The spectrum of rhabdomyolysis. Medicine 1982;61:141152.
Hogan K. The anesthetic myopathies and malignant hyperthermias. Curr Opin Neurol 1998;11:469476.
Knochel JP. Rhabdomyolysis and myoglobinuria. Annu Rev Med 1982;33:435443.
Kolb ME, Horne ML, Matz R. Dantrolene in human malignant hyperthermia: a multicenter study. Anaesthesiology 1982;56:254262.
Lofberg M, Jankala H, Paetau A, Harkonen M, Somer H. Metabolic causes of recurrent rhabdomyolysis. Acta Neurol Scand 1998;98:268275.
Manning BM, Quane KA, Ording H, et al. Identification of novel mutations in the ryanodine-receptor gene (RYR1) in malignant hyperthermia: genotype-phenotype correlation. Am J Hum Genet
1998;62:599609.
Melamed I, Romen Y, Keren G, et al. March myoglobinuria: a hazard to renal function. Arch Intern Med 1982;142:12771279.
Nelson TE, Butler IJ. Malignant hyperthermia: skeletal muscle defects predisposing to labile Ca 2+ regulation? J Child Neurol 1992;7:329331.
Penn AS, Rowland LP, Fraser DW. Drugs, coma, and myoglobinuria. Arch Neurol 1972;26:336343.
Perkoff GT. Alcoholic myopathy. Annu Rev Med 1971;22:125132.
Quane KA, Healy JMS, Keating KE, et al. Mutations in the ryanodine receptor gene in central core disease and malignant hyperthermia. Nat Genet 1993;5:5155.
Romero NB, Nivoche Y, Lunardi J, et al. Malignant hyperthermia and central core disease: analysis of two families with heterogeneous clinical expression. Neuromuscul Disord 1993;3:547551.
Rowland LP. Myoglobinuria. Can J Neurol Sci 1984;11:113.
Tein I, DiMauro S, Rowland LP. Myoglobinuria. In: Vinken PJ, Bruyn GW, Klawans HL, Rowland LP, DiMauro S, eds. Myopathies. Handbook of clinical neurology, rev ser, vol 62(18). New York:
Tonin P, Lewis P, Servidei S, DiMauro S. Metabolic causes of myoglobinuria. Ann Neurol 1990;27:181185.
Ueda M, Hamamoto M, Nagayama H, et al. Susceptibility to neuroleptic malignant syndrome in Parkinson's disease. Neurology 1999;52:777781.
Wedel DJ. Malignant hyperthermia and neuromuscular disease. Neuromuscul Disord 1993;3:157164.
Yaqub B, Al Deeb S. Heat strokes: aetiopathogenesis, neurological characteristics, treatment and outcome. J Neurol Sci 1998;156:144151.
CHAPTER 129. MUSCLE CRAMPS AND STIFFNESS
MERRITTS NEUROLOGY
CHAPTER 129. MUSCLE CRAMPS AND STIFFNESS

ROBERT B. LAYZER AND LEWIS P. ROWLAND
Ordinary Muscle Cramps

Neuromyotonia (Isaacs Syndrome)
Tetany
Stiff-Man Syndrome (Moersch-Woltman Syndrome)
Suggested Readings
The term muscle stiffness implies a state of continuous muscle contraction at rest; cramps or spasms are transient, involuntary contractions of a muscle or group of
muscles. Table 129.1 lists some of the many disorders that cause muscle stiffness or cramps.
TABLE 129.1. MOTOR UNIT DISORDERS CAUSING CRAMPS AND STIFFNESS
ORDINARY MUSCLE CRAMPS
The common muscle cramp is a sudden, forceful, often painful muscle contraction that lasts from a few seconds to several minutes. Cramps are provoked by a trivial
movement or by contracting a shortened muscle. They may occur during vigorous exercise but are more likely to occur after exercise ceases. Unusually frequent
cramps tend to accompany pregnancy, hypothyroidism, uremia, profuse sweating or diarrhea, hemodialysis, and lower motor neuron disorders, especially anterior
horn cell diseases. Benign fasciculations or myokymia may be associated with frequent muscle cramps in apparently healthy people.
Nocturnal cramps typically cause forceful flexion of the ankle and toes, but cramps can affect almost any voluntary muscle. A cramp often starts with fasciculations,
after which the muscle becomes intermittently hard and knotlike as the involuntary contraction waxes and wanes, passing from one part of the muscle to another.
Electromyography (EMG) shows brief, periodic bursts of motor unit potentials discharging at a frequency of 200 to 300 Hz, appearing irregularly and intermingling with
similar discharges from adjacent motor units. Several foci within the same muscle may discharge independently. This electrical activity clearly arises within the lower
motor neuron; whether it occurs in the soma, in the peripheral nerve, or in the intramuscular nerve terminals is still debated. The chemical mechanisms are not
understood.
Stretching the affected muscle usually terminates a cramp. Information about prophylactic therapy is largely anecdotal, and no single agent appears to be uniformly
effective. For nocturnal leg cramps, a bedtime dose of quinine, phenytoin sodium (Dilantin), carbamazepine (Tegretol), or diazepam may be used. The beneficial
effects of quinine have been demonstrated by controlled trials. Serious adverse effects are uncommon; tinnitus is relieved by interrupting treatment. The conventional
dosage is 300 or 600 mg at bedtime. Frequent daytime cramps sometimes respond to maintenance therapy with carbamazepine or phenytoin.
Most people have cramps at some time, but a few people have inordinately frequent cramps, often accompanied by fasciculations. The syndrome of benign
fasciculation with cramps is disproportionately more frequent among physicians and other medical workers because they are more likely to know the ominous
implications of fasciculations for the diagnosis of motor neuron disease. In fact, however, motor neuron disease almost never starts with fasciculations alone. If neither
weakness nor wasting exists, motor neuron disease is essentially excluded. The syndrome of benign fasciculation has been reported many times with variations on
the name. Because the syndrome and the physiologic analysis were completely described by Denny-Brown and Foley, a reasonable eponym is the Denny-Brown,
Foley syndrome.
True cramps must be distinguished from cramplike muscle pain unaccompanied by spasm. The cramps of McArdle disease occur only during intense or ischemic
exercise. Because no electrical activity is evident in the EMG during the painful shortening of muscle affected by McArdle disease, the term contracture is used. The
origin of the contracture is not known; depletion of adenosine triphosphate has long been suspected (because of the block of glycogen metabolism) but has not been
proved, even by magnetic resonance spectroscopy.
Mild dystrophinopathies, with little or no clinical weakness, may be manifested by exertional muscle pain and even myoglobinuria. These symptoms have been
referred to as muscle cramps, but actual muscle spasm has not been described in such cases; the pain may simply be a measure of muscle injury.
Myalgia and cramps are believed to be especially common in myoadenylate deaminase deficiency (MIM 102770), but that state is common in asymptomatic people
(found in 1% to 3% of all muscle biopsies). Therefore, the association is difficult to confirm. Moreover, in affected families, a poor correlation exists between the
muscle enzyme deficiency and clinical symptoms. An autosomal-dominant cramp syndrome is seen without known biochemical abnormality (MIM 158400).
NEUROMYOTONIA (ISAACS SYNDROME)
Isaacs first described this disorder as a state of continuous muscle fiber activity. The invariable clinical manifestation is myokymia (clinically visible and continuous
muscle twitching that may be difficult to distinguish from vigorous fasciculation). The word has two meanings, one clinical and the other electromyographic.
Physiologically, spontaneous activity is seen at rest in the form of fasciculations, doublets, and multiplets that may lead to prolonged trains of discharges at a rate up
to 60 Hz. In Isaacs syndrome, both the clinical and the EMG features are present, but myokymia may be found in the EMG of some individuals without any clinically
visible twitching. Neuromyotonic discharges start and stop abruptly, and the discharge rate of 150 to 300 Hz is higher than that in myokymia.
As a result of the continuous activity, a second characteristic of the syndrome is the finding of abnormal postures of the limbs, which may be persistent or intermittent
and are identical to carpal or pedal spasm. A third characteristic is pseudomyotonia, which resembles the difficulty in relaxing in true myotonia; here, however, the
characteristic EMG patternwaxing and waning of myotonic burstsis not seen. Instead, continuous motor unit activity interferes with relaxation. In addition, there is
no percussion myotonia. The fourth characteristic is liability to cramps. Hyperhidrosis, or increased sweating, is variable.
The syndrome affects children, adolescents, or young adults and begins insidiously, progressing slowly for months or a few years. Slow movement, clawing of the
fingers, and toe-walking are later joined by stiffness of proximal and axial muscles; occasionally, oropharyngeal or respiratory muscles are affected. The stiffness and
myokymia are seen at rest and persist in sleep. Voluntary contraction may induce a spasm that persists during attempted relaxation.
The EMG recorded from stiff muscles reveals prolonged, irregular discharges of action potentials that vary in amplitude and configuration; some of them resemble
fibrillations. Voluntary effort triggers more intense discharges that persist during relaxation, accounting for the myotonia-like after-contraction. The condition is often
attributed to a peripheral neuropathy because acral sensory loss is noted in some patients, nerve conduction may be slow, or abnormality may appear on sural nerve
biopsy. Perhaps, most important, the EMG activity may persist after nerve block by injection of local anesthetic but is abolished by botulinum toxin, implying that the
activity arises distal to the nerve block and proximal to the neuromuscular junction; the generator must be in the nerve terminals. In an analysis of 28 reported cases,
however, only four patients had definite evidence of peripheral neuropathy ( Table 129.2), and some of the features suggested a disorder of the nerve cell itself.
TABLE 129.2. MANIFESTATIONS OF ISAACS SYNDROME IN 28 PATIENTS
Sometimes, neuromyotonia is seen in association with a tumor; that is, it may be a paraneoplastic syndrome. Several patients have had thymoma with or without
myasthenia gravis. Newsom-Davis, Vincent, and their associates have demonstrated antibodies to neural potassium channels in most patients.
Treatment with carbamazepine or phenytoin usually controls the symptoms and signs. Plasmapheresis and intravenous immunoglobulin therapy have been effective
in some patients.
TETANY
Tetany is a clinical syndrome characterized by convulsions, paresthesia, prolonged spasms of limb muscles, or laryngospasm; it is accompanied by signs of
hyperexcitability of peripheral nerves. It occurs in patients with hypocalcemia, hypomagnesemia, or alkalosis; it occasionally represents a primary neural abnormality.
Hyperventilation may unmask latent hypocalcemic tetany, but respiratory alkalosis itself only rarely causes outright tetany.
Intense circumoral and digital paresthesia generally precedes the typical carpopedal spasms, which consist of adduction and extension of the fingers, flexion of the
metacarpophalangeal joints, and equinovarus postures of the feet. In severe cases, the spasms spread to the proximal and axial muscles, eventually causing
opisthotonus. In all forms of tetany, the nerves are hyperexcitable, as manifested by the reactions to ischemia (Trousseau sign) and percussion (Chvostek sign). The
spasms are due to spontaneous firing of peripheral nerves, starting in the proximal portions of the longest nerves. EMG shows individual motor units discharging
independently at a rate of 5 to 25 Hz; each discharge consists of a group of two or more identical potentials.
The treatment of tetany consists of correcting the underlying metabolic disorder. In hypomagnesemia, tetany does not respond to correction of the accompanying
hypocalcemia unless the magnesium deficit is also corrected.
STIFF-MAN SYNDROME (MOERSCH-WOLTMAN SYNDROME)
The catchy name for this syndrome was coined by two senior clinicians at the Mayo Clinic in 1956. The name has been perpetuated since, but the titles have
sometimes been awkward (e.g., stiff-man syndrome in a woman, stiff-man syndrome in a boy, stiff-baby syndrome, or stiff-person syndrome). We now strive for
gender-neutral language; the masculine version is especially inappropriate for a syndrome that occurs equally often in women and men. The eponym seems apropos.
Clinical Manifestations
The Moersch-Woltman syndrome is defined clinically, with progressive muscular rigidity and painful spasms that resemble a chronic form of tetanus. The symptoms
develop over several months or years and may either increase slowly or become stable. Aching discomfort and stiffness tend to predominate in the axial and proximal
limb muscles, causing awkwardness of gait and slowness of movement. Trismus does not occur, but facial and oropharyngeal muscles may be affected. The stiffness
diminishes during sleep and under general anesthesia. Later, painful reflex spasms occur in response to movement, sensory stimulation, or emotion. The spasms may
lead to joint deformities and are powerful enough to rupture muscles, rip surgical sutures, or fracture bones. Passive muscle stretch provokes an exaggerated reflex
contraction that lasts several seconds. Whether any of the findings in Table 129.3 must be present to make the diagnosis is not clear. For instance, the response to
diazepam may not be complete, or the spinal deformity may not be present. And some investigators have noted that findings on examination and EMG activity are
compatible with those of voluntary behavior. A psychogenic cause has been mentioned, however, only to be derided because the tin-soldier appearance of the patient
is so dramatic and because the spasms may cause physical injury.
TABLE 129.3. DEFINING CHARACTERISTICS OF THE MOERSCH-WOLTMAN SYNDROME
Laboratory Data
EMG recordings from stiff muscles show a continuous discharge of motor unit potentials resembling normal voluntary contraction. As in tetanus, the activity is not
inhibited by voluntary contraction of the antagonist muscles; however, a normal silent period is present during the stretch reflex, indicating that there is no impairment
of recurrent spinal inhibition. The rigidity is abolished by spinal anesthesia, by peripheral nerve block, or by selective block of gamma motor nerve fibers. Some
authors have postulated that both alpha and gamma motor neurons are rendered hyperactive by excitatory influences descending from the brainstem. The
electroencephalogram is normal. Routine cerebrospinal fluid (CSF) analysis is also normal, but immunoglobulin (Ig) G concentration may be increased and oligoclonal
IgG bands may be present.
Administration of diazepam is the most effective symptomatic treatment; high doses may be required. Additional benefit can be obtained in some cases from
administration of baclofen, phenytoin, clonidine hydrochloride (Catapres), or tizanidine (Zanaflex). Intrathecal baclofen (Lioresal) has been used. The long-term
prognosis is still uncertain.
The pathogenesis may involve autoimmunity. Antibodies to glutamate decarboxylase have been found in both serum and CSF in this syndrome and in diabetes
mellitus; the frequency of the association of the two diseases seems to be inordinately high. Plasmapheresis may be beneficial. Other autoimmune diseases may be
present, and the Moersch-Woltman syndrome is sometimes paraneoplastic.
Evidence of corticospinal tract disease or abnormality of the CSF implies an anatomic disorder of the central nervous system (CNS), but in postmortem examination of
typical cases, no CNS histopathology is revealed. Patients with similar physical findings may show CSF pleocytosis or Babinski signs. In autopsies of those patients,
however, inflammation has been sufficient to warrant the term encephalomyelitis. Stiffness of the arms in some patients with cervical lesions is attributed to
spontaneous activity of alpha motor neurons isolated from synaptic influences. That combination is best regarded as stiff encephalomyelitis, because the
pathogenesis ought to differ in the two categories with or without clear evidence of CNS disease. However, antibodies to glutamate decarboxylase have also been
found in patients with myelitis. A related disorder has been called the stiff limb syndrome.
The main distinction between Moersch-Woltman and Isaacs syndromes is the distribution of the symptoms, which affect the distal arms and legs in Isaacs and the
trunk in Moersch-Woltman. Myokymia is seen only in Isaacs. Many of the features of Isaacs syndrome are similar to those of tetany, as are the painful tonic spasms of
multiple sclerosis (MS). MS, however, is identified by other signs of disseminated CNS lesions. These tonic spasms, like other paroxysmal symptoms in MS, are
thought to originate as ectopic activity in demyelinated CNS nerve tracts. They usually last less than 1 minute but occur many times a day. The attacks usually
respond promptly to treatment with carbamazepine or phenytoin. The startle reactions of Moersch-Woltman syndrome are similar to those in the autosomal-dominant
condition hyperekplexia or startle disease (MIM 149400). Hyperekplexia, however, lacks axial rigidity and has been mapped to a subunit of an inhibitory glycine
receptor on chromosome 5. It is relieved by the t-aminobutyric acid agonist clonidine. The Moersch-Woltman syndrome itself is rarely autosomal-dominant (MIM
184850). The fixed postures of the limbs in Isaacs syndrome can be simulated by the Schwartz-Jampel syndrome (SJS) (see Chapter 127). However, SJS is
characterized by a unique facial appearance (blepharophimosis), short stature, and bony abnormalities. In SJS, the more frequent EMG pattern is that of myotonia,
but there may be continuous motor activity with both myokymic and neuromyotonic discharges.
SUGGESTED READINGS
Cramps and Related Disorders
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Neuromyotonia
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Stiff-man Syndrome (Moersch-Woltman Syndrome)
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CHAPTER 130. DERMATOMYOSITIS
MERRITTS NEUROLOGY
CHAPTER 130. DERMATOMYOSITIS

LEWIS P. ROWLAND
Pathology and Pathogenesis

Incidence
Symptoms and Signs
Diagnosis
Prognosis
Treatment
Suggested Readings
Dermatomyositis, a disease of unknown etiology, is characterized by inflammatory changes in skin and muscle.
PATHOLOGY AND PATHOGENESIS
Dermatomyositis is thought to be an autoimmune disease, but there has been no consistent evidence of either antibodies or lymphocytes directed against specific
muscle antigens. However, there has been growing agreement among muscle histologists that dermatomyositis is humorally mediated, characterized by more B cells
than T cells in the muscle infiltrates, as well as a vasculopathy with deposits of immunoglobulins in intramuscular blood vessels. This contrasts with the predominance
of T cells in polymyositis, which is attributed to a disorder of lymphocyte regulation. Some authorities believe that the pathogenesis of the disease differs in adults and
children.
The acute changes of both skin and muscle are marked by signs of degeneration, regeneration, edema, and infiltration by lymphocytes. The inflammatory cells are
found around small vessels or in the perimysium rather than within the muscle fiber itself. In muscle biopsies, however, lymphocytic infiltration may be lacking in 25%
of patients; this probably depends on the time of sampling, as well as on the distribution and severity of the process. The lymphocytes are predominantly B cells, with
some CD4 (T-helper) cells. Capillaries often show endothelial hyperplasia; deposits of immunoglobulin (Ig) G, IgM, and complement (the membrane attack complex)
may be found within and occluding these vessels. Evidence of muscle degeneration and regeneration is multifocal and may be most marked at the periphery of
muscle bundles (perifascicular atrophy), where the capillaries are occluded. Increasingly, investigators have come to believe that the primary attack is on blood
vessels. A similar myopathy without skin lesions can be induced in animals by immunization with muscle extracts. Viruslike particles have been seen in some cases,
but no virus has been cultured from muscle.
INCIDENCE
Dermatomyositis is rare. Together with polymyositis, the incidence has been estimated to be about seven cases each year for a population of 1 million. That figure
may be too low; in our 1,200-bed hospital, we see five new cases of dermatomyositis and 15 to 20 cases of polymyositis each year.
Dermatomyositis occurs in all decades of life, with peaks of incidence before puberty and at about age 40 years. In young adults, women are more likely to be
affected. Familial cases are rare. It is generally believed that about 10% of cases starting after age 40 are associated with malignant neoplasms, most often
carcinoma of lung or breast. Typical findings, including the rash, have also been seen in patients with agammaglobulinemia, graft-versus-host disease, toxoplasmosis,
hypothyroidism, sarcoidosis, ipecac abuse, hepatitis B virus infection, penicillamine reactions, or vaccine reactions. Cases have even been ascribed to azathioprine
(Imuran).
SYMPTOMS AND SIGNS
The first manifestations usually involve both skin and muscle at about the same time. The rash may precede weakness by several weeks, but weakness alone is
almost never the first symptom. Sometimes, the rash is so typical that the diagnosis can be made even without evidence of myopathy (amyopathic dermatomyositis),
and sometimes weakness is not evident but there is electromyographic (EMG), biopsy, or serum creatine kinase (CK) evidence of myopathy.
The rash may be confined to the face in a butterfly distribution around the nose and cheeks, but the edema and erythema are especially likely to affect the eyelids,
periungual skin, and extensor surfaces of the knuckles, elbows, and knees. The upper chest is another common site. The initial redness may be replaced later by
brownish pigmentation. The Gottron sign is denoted by red-purple scaly macules on the extensor surfaces of finger joints. Fibrosis of subcutaneous tissue and
thickening of the skin may lead to the appearance of scleroderma. Later, especially in children, calcinosis may involve subcutaneous tissues and fascial planes within
muscle. The calcium deposits may extrude through the skin.
Affected muscles may ache and are often tender. Weakness of proximal limb muscles causes difficulty in lifting, raising the arms overhead, rising from low seats,
climbing stairs, or even walking on level ground. The interval from onset of weakness to most severe disability is measured in weeks. Cranial muscles are spared,
except that difficulty in swallowing is noted by about one-third of patients. Some patients have difficulty in holding the head up because neck muscles are weak.
Sensation is preserved, tendon reflexes may or may not be lost, and there is no fasciculation.
Systemic symptoms are uncommon. Fever and malaise may characterize the acute stage in a minority of patients. Pulmonary fibrosis has been encountered, and
rarely there are cardiac symptoms. Arthralgia may be prominent, but deforming arthritis and renal failure have never been documented.
In about 10% of patients, the cutaneous manifestations have features of both scleroderma and dermatomyositis, warranting the name sclerodermatomyositis. These
cases have sometimes been designated as mixed connective tissue disease, with a high incidence of antibody to extractable nuclear antigen; however, it now seems
unlikely that the mixed syndrome is unique in any way.
DIAGNOSIS
The characteristic rash and myopathy usually make the diagnosis clear at a glance. Problems may arise if the rash is inconspicuous; in those cases the differential
diagnosis is that of polymyositis (see Chapter 131). Other collagen-vascular diseases may cause both rash and myopathy at the same time, but systemic lupus
erythematosus is likely to affect kidneys, synovia, and the CNS in patterns that are never seen in dermatomyositis. Similarly, there has never been a documented
case of typical rheumatoid arthritis with typical dermatomyositis. The diagnosis of dermatomyositis is therefore clinical, based on the rash and myopathy. There is no
pathognomonic laboratory test.
Except for the presence of lymphocytes and perifascicular atrophy in the muscle biopsy and increased serum CK (and other sarcoplasmic enzymes), there are no
characteristic laboratory abnormalities. The EMG shows myopathic abnormalities and, often, evidence of increased irritability of muscle. Computed tomography (CT)
and magnetic resonance imaging (MRI) of muscle have not been widely adopted but are useful in evaluating pulmonary fibrosis. Nonspecific serologic abnormalities
include rheumatoid factor and several different kinds of antinuclear antibodies, none consistently present in patients with dermatomyositis. For instance, anti-Jo
antibodies (against histidyl transfer RNA synthetase) are present in about 50% of patients with pulmonary fibrosis, but only 20% of all patients with inflammatory
myopathy.
Once the diagnosis is made, many clinicians set off on a search for occult neoplasm. In preimaging days, Callen (1982) showed that in most cases a tumor was
already evident or that there was an abnormality in some simple routine test (blood count, erythrocyte sedimentation rate, test for heme pigment in stool, chest film) or
in findings on physical examination including pelvis and rectum. However, investigations have not yet evaluated the impact of CT or MRI of the chest, abdomen, and
pelvis on the discovery of tumors in patients with dermatomyositis. Sometimes, no matter how exhaustive the search, the tumor is not discovered until an autopsy is
performed.
PROGNOSIS
The natural history of dermatomyositis is now unknown because patients are automatically treated with steroids. The disease may become inactive after 5 to 10 years.
Although the mortality rate 50 years ago was given as 33% to 50%, it is not appropriate to use those ancient figures for current comparison; antibiotics and respirators
affect outcome as much as any presumably specific immunotherapy. Even so, in reviews published after 1982, mortality rates were 23% to 44%. Because few
fatalities have occurred in children, many of the deaths are caused by the associated malignancy. Other causes of death are myocarditis, pulmonary fibrosis, or
steroid-induced complications. The myopathy may also be severe. In an analysis of survivors of childhood dermatomyositis, 83% were capable of self-care, almost all
were working, and 50% were married; 33% had persistent rash or weakness, and a similar number had calcinosis.
TREATMENT
The standard therapy for dermatomyositis is administration of prednisone. The recommended dose for adults is at least 60 mg daily; higher dosages are often given
for severe cases. For children, the recommended dose is higher: 2 mg/kg body weight. The basic dosage is continued for at least 1 month, perhaps longer. If the
patient has improved by then, the dosage can be reduced slowly. If there has been no improvement, choices include prolonging the trial of prednisone in the same or
a higher dosage with or without the addition of an immunosuppressive drug chosen according to local usage.
In the past decade, improvement was reported in 80% of all steroid-treated patients in one series, but only 50% or fewer patients benefited in other studies. Apparent
response to treatment of individual patients with apparent relapses on withdrawal of medication has been reported anecdotally many times. In one retrospective
analysis, favorable outcome of childhood dermatomyositis seemed to be linked to early treatment (less than 4 months after onset) and use of high doses of
prednisone. Dubowitz (1984), however, reported just the reverse: better outcome and fewer steroid complications with low doses of prednisone (1 mg/kg body weight).
The value of steroid treatment is still unproved, however, because there has never been a prospectively controlled study. In one retrospective analysis, untreated
patients were seen many years before treated patients. In another study, there was no difference in outcome of patients treated with prednisone alone or with both
prednisone and azathioprine. Moreover, it is not clear whether immunosuppressive drugs are more or less dangerous than steroids, and there is no evidence that any
single immunosuppressive drug is superior to others. Azathioprine, methotrexate, cyclophosphamide, and cyclosporine have all been championed.
Plasmapheresis was of no value in a controlled trial, but intravenous immunoglobulin (IVIG) therapy was uniformly beneficial in eight patients with steroid-resistant
dermatomyositis, in contrast to no improvement in seven blinded, control patients who were given placebo. IVIG therapy may therefore be the procedure of choice for
acute therapy of seriously ill patients. Some long-term immunosuppressive therapy, however, would have to be added. IVIG therapy is also useful in adults or children
who do not respond to other agents.
Some clinicians worry that exercising a weak muscle may be harmful, but formal tests in dermatomyositis and polymyositis have shown benefit.
SUGGESTED READINGS
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Banker BQ, Victor M. Dermatomyositis (systemic angiopathy) in childhood. Medicine 1966;45:261289.
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Bowyer SL, Blane CE, Sullivan DB, Cassidy JT. Childhood dermatomyositis: factors predicting functional outcome and development of dystrophic calcification. J Pediatr 1983;103:882888.
Callen JP. The value of malignancy evaluation in patients with dermatomyositis. J Am Acad Dermatol 1982;6:253259.
Chalmers A, Sayson R, Walters K. Juvenile dermatomyositis: medical, social and economic status in adulthood. Can Med Assoc J 1982;126:3133.
Chou SM, Mike T. Ultrastructural abnormalities and perifascicular atrophy in childhood dermatomyositis. Arch Pathol Lab Med 1981;105:7685.
Dalakas MC. Molecular immunology and genetics of inflammatory muscle diseases. Arch Neurol 1998;55:15091512.
Dalakas MC, Illa I, Dambrosia JM, et al. A controlled trial of high-dose intravenous immune globulin infusions as treatment for dermatomyositis. N Engl J Med 1993;329:19932000.
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Esmie-Smith AM, Engel AG. Microvascular changes in early and advanced dermatomyositis: a quantitative study. Ann Neurol 1990;27:343356.
Euwer RL, Sontheimer RD. Amyopathic dermatomyositis (dermatomyositis sine myositis): six new cases. J Am Acad Dermatol 1991;24:959966.
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Maugars YM, Berthelot JMM, Aabbas AA, et al. Long-term prognosis of 69 patients with dermatomyositis or polymyositis. Clin Exp Rheumatol 1996;14:263274.
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CHAPTER 131. POLYMYOSITIS, INCLUSION BODY MYOSITIS, AND RELATED MYOPATHIES
MERRITTS NEUROLOGY
CHAPTER 131. POLYMYOSITIS, INCLUSION BODY MYOSITIS, AND RELATED MYOPATHIES

LEWIS P. ROWLAND
Definition Of Polymyositis
Laboratory Data
Pathogenesis
Diagnosis
Relation Of Polymyositis To Dermatomyositis
Relation Of Polymyositis To Inclusion Body Myositis
Relation Of Polymyositis To Eosinophilic Myositis
Myopathy In Acquired Immunodeficiency Syndrome
Relation of Polymyositis to Polymyalgia Rheumatica
Therapy
Suggested Readings
DEFINITION OF POLYMYOSITIS
Polymyositis is a disorder of skeletal muscle of diverse causes characterized by acute or subacute onset, possible intervals of improvement of symptoms, and typically
infiltration of muscle by lymphocytes. It is one of the three major categories of inflammatory myopathy; each differs from the others clinically and in muscle pathology.
The other two conditions are dermatomyositis and inclusion body myositis (IBM).
This definition is insufficiently precise, however, because there is no pathognomonic clinical syndrome, laboratory test, or combination of the two. The problem arises
because lymphocytic infiltration of muscle may be lacking in an individual case or the typical pattern may not be seen; also, lymphocytic infiltration may be seen in
other conditions. Additionally, polymyositis may occur alone or as part of a systemic disease, especially a collagen-vascular disease.
CLINICAL MANIFESTATIONS
The symptoms are those of a myopathy that primarily affects proximal limb muscles: difficulty climbing stairs or rising from low seats, lifting packages or dishes, or
working with the arms overhead. Weakness of neck muscles may result in difficulty holding the head erect. Distal muscles are usually affected later, so difficulty using
the hands is not encountered at first. Eyelids and ocular movements are spared; the only cranial symptom is dysphagia, usually without dysarthria. Respiration is only
rarely affected.
Symptoms of systemic disease, malaise, or even weight loss are not evident. In many cases, arthralgia is symptomatic without objective change in the joints. Raynaud
symptoms may be prominent, but by definition, there is no rash of dermatomyositis. No visceral lesions appear, other than interstitial lung disease and pulmonary
fibrosis in some patients. Myocarditis may also occur. The syndrome is usually subacute in onset, reaching a nadir in months rather than weeks or years, but both
acute and chronic forms are seen. Symptoms may persist for years and then the condition seems to become quiescent.
LABORATORY DATA
The findings are those of a myopathy, with characteristic electromyographic (EMG) findings of small-amplitude short-duration potentials and full recruitment. Signs of
muscle irritability may be noted, with fibrillations and positive waves but no fasciculations. Nerve conduction studies give normal values. Serum levels of creatine
kinase (CK) and other sarcoplasmic enzymes are usually increased to values 10 times normal or even more. Serum enzyme levels may be normal, however, probably
depending on the stage of the disease.
A definite diagnosis requires characteristic changes in the muscle biopsy, especially infiltration around healthy muscle fibers by cells that have the
immunocytochemical characteristics of CD8+ T lymphocytes. Signs of muscle necrosis and regeneration are apparent, but the pattern differs from that of
dermatomyositis because neither vascular lesions nor perifascicular atrophy are seen. The pattern differs from IBM because vacuoles or the defining inclusions are
not evident.
PATHOGENESIS
Polymyositis is considered an autoimmune disease of disordered cellular immunity (in contrast to the presumed humoral abnormalities of dermatomyositis). The
nature of the antigen is not known, however, and the nature of the immunologic aberration is not known. The association with collagen-vascular disease increases the
likelihood of autoimmune disorder, as does the association of polymyositis with other autoimmune diseases, including Crohn disease, biliary cirrhosis, sarcoidosis,
myasthenia gravis with thymoma and candidiasis, or graft versus host disease. Human immunodeficiency virus and human T-cell lymphotropic virus type I are viral
diseases associated with polymyositis; it is not known whether polymyositis is a viral infection of muscle or an autoimmune reaction. In contrast to dermatomyositis,
myopathy without rash is uncommon in patients with concomitant malignant neoplasms.
Fibers adjacent to the T cells express the class 1 major histocompatibility complex, an antigen that is lacking in normal fibers and is a recognition factor for the
activation of T cells. Circulating T cells may be cytotoxic to cultures of the patient's cultured myotubes.
In the past decade, interest has been directed to antibodies to cytoplasmic ribonucleoproteins. Because they are not disease specific, however, they neither help to
explain pathogenesis nor provide a major diagnostic tool. Anti-Jo antibodies are found in about half of all patients with both polymyositis and pulmonary fibrosis.
DIAGNOSIS
In the past, polymyositis was regarded as dermatomyositis without a rash. The histologic differences are now recognized, but the clinical problem remains: How can
we identify the qualities of polymyositis that are similar to those of dermatomyositis while distinguishing polymyositis from other myopathies with which it might be
confused, such as muscular dystrophies, metabolic myopathies, or disorders of the neuromuscular junction? The following criteria are suggested:
1. There is no family history of similar disease and onset is usually after age 35. No familial limb-girdle dystrophy starts so late. Cases of younger onset are few,
unless there is some associated collagen-vascular or other systemic disease. If there is no family history, it may be necessary to test for sarcoglycanopathies.
2. Progression from onset to peak weakness is measured in weeks or months, not years as in the muscular dystrophies.
3. Symptoms may improve spontaneously or concomitantly with the administration of drugs, unlike any muscular dystrophy.
4. In addition to proximal limb weakness, there may be dysphagia or weakness of neck flexors, but other cranial muscles are not affected. (If eyelids or ocular
muscles were involved, it would be difficult or impossible to distinguish the disorder from myasthenia gravis.)
5. Arthralgia, myalgia, and Raynaud symptoms help to make the diagnosis, but lack of these symptoms does not exclude the diagnosis.
6. Muscle biopsy usually shows the abnormalities described above, especially early in the course. As in patients with dermatomyositis, however, lymphocytic
infiltration may be lacking in muscle biopsies in polymyositis. Typical histologic changes help to make the diagnosis; lack of these changes does not exclude the
diagnosis because the changes may be focal in the muscle or transient and not present in the muscle at the site and time of the biopsy. In histochemical stains,
there must be no evidence of excess lipid or glycogen storage and there should be no signs of denervation.
7. In addition to conventional EMG signs of myopathy, increased irritability of muscle may be evident.
The problem of diagnosis is exemplified by a patient with limb weakness at age 40 when EMG and muscle biopsy indicate that the disorder is a myopathy. Search
must then be made for known causes of myopathy (Table 131.1). If none is found, the diagnosis of exclusion is idiopathic polymyositis.
TABLE 131.1. DIFFERENTIAL DIAGNOSIS OF POLYMYOSITIS
It seems unlikely that this residual group is all due to one disease because there is clinical heterogeneity, such as differences in rapidity of progression, distribution of
weakness, or severity of disorder. In addition, if there are so many known causes of similar syndromes, it is likely that still more remain to be identified. A restricted
concept of idiopathic polymyositis will emerge only when more is known about the disordered immunology of dermatomyositis itself.
If there is no family history of similar disease and, especially if there are no inflammatory cells in the muscle biopsy, a form of limb-girdle muscular dystrophy must be
considered. Sometimes polymyositis is the suspected diagnosis, but muscle biopsy shows glycogen or lipid accumulation or mitochondrial disease.
RELATION OF POLYMYOSITIS TO DERMATOMYOSITIS
These conditions are usually considered together because of the similarities in course and muscle disease. There are, however, important differences, as follows:
1. Dermatomyositis is a homogeneous condition, only rarely associated with a known cause other than carcinoma. Polymyositis is associated with some other
systemic disease in about half the cases.
2. Polymyositis is often a manifestation of a specific collagen-vascular disease, such as systemic lupus erythematosus, systemic sclerosis, or different forms of
vasculitis. Dermatomyositis, however, is rarely if ever associated with evidence of collagen-vascular disease other than scleroderma. When polymyositis occurs
in a patient with lupus erythematosus, for instance, it can be regarded as a manifestation of lupus, not a combination of two different disorders (or an overlap
syndrome).
3. Dermatomyositis occurs at all ages, including childhood. Polymyositis is rare before puberty.
4. As assessed by inability to walk, the myopathy of dermatomyositis is severe more often than the myopathy of polymyositis.
5. Dermatomyositis is far more likely to be associated with malignant neoplasm than is myopathy without rash.
RELATION OF POLYMYOSITIS TO INCLUSION BODY MYOSITIS
The attempt to link polymyositis to a viral infection led Chou (1986) to find tubular filaments in nuclear and cytoplasmic vacuoles in some patients with other pathologic
features of polymyositis. Yunis and Samaha coined the name in 1971. These histologic findings were then related to a characteristic clinical syndrome ( Table 131.2).
TABLE 131.2. DEFINITION OF INCLUSION BODY MYOSITIS IN ANALYSIS OF 48 PATIENTS
Polymyositis and IBM are similar in that they are inflammatory myopathies, lack a rash, and rarely affect children. IBM is slower in progression. Dysphagia is common
in both. Neither IBM nor polymyositis, in contrast to dermatomyositis, is often a paraneoplastic disorder. The two conditions differ clinically and histologically.
Clinically, IBM affects proximal limb muscles but, in contrast to polymyositis, is much more likely to affect distal muscles of the legs, and IBM is one of the few
myopathies that causes weakness of the long finger flexors, an early symptom and sign in most IBM patients. IBM characteristically affects men after age 50;
polymyositis affects younger adults as well and women more often than men. IBM more often shows mixed neurogenic and myopathic features in conventional EMG.
In contrast to polymyositis, IBM is less often seen with collagen-vascular or other autoimmune disorders. Serum CK values are normal or only slightly increased in
IBM. A major distinction is the failure of IBM to respond to steroid therapy.
IBM and polymyositis differ pathologically because IBM is characterized by rimmed vacuoles, with the defining cellular inclusions and vacuoles. The pathogenesis of
IBM is not known. Originally, IBM was thought to be a variant of polymyositis because, in addition to the inclusions, muscle is often infiltrated by lymphocytes in
distribution, number, and T-cell characteristics similar to those of polymyositis. However, the vacuoles give immunochemical stains for proteins seen in the brain of
patients with Alzheimer disease (beta-amyloid precursor protein and others), which leads some investigators to regard IBM as a degenerative disease rather than an
autoimmune disorder.
Yet another peculiar facet of IBM is the presence of ragged fibers and cytochrome c oxidase negative fibers, findings that imply abnormalities of mitochondria, which
prove to be multiple deletions of mitochondrial DNA. How this arises or what it means in the pathogenesis of the disorder is still uncertain.
IBM may be familial with little inflammation and vacuolar histologic characteristics similar to those of autosomal dominant Welander distal muscular dystrophy or
oculopharyngeal muscular dystrophy; these syndromes differ clinically, but the similarities may cause problems in classification.
RELATION OF POLYMYOSITIS TO EOSINOPHILIC MYOSITIS
Rarely, a myopathy is associated with infiltration of muscle by eosinophils in addition to or instead of lymphocytes. One is the eosinophilic myositis of trichinosis or
other parasitic infestation. Another form was seen in an epidemic in Spain of the toxic oil syndrome that was attributed to ingestion of denatured rapeseed oil. In
addition to rash, fever, adenopathy, and other symptoms, some patients had prominent myalgia, but serum CK values were normal. In 1989, an epidemic in the United
States of similar symptoms was finally attributed to ingestion of a contaminated preparation of L-tryptophan as a sedative. As many as 10,000 cases of that
eosinophilia-myalgia syndrome may have occurred. Arthralgia, limb swelling, and evidence of myopathy or sensorimotor peripheral neuropathy were prominent.
Muscle biopsy showed fascitis, perimyositis, and inflammatory microangiopathy. Eosinophilic myositis was found in some cases. The neuropathy had physiologic
features of axonal damage in most patients, but some had conduction block.
MYOPATHY IN ACQUIRED IMMUNODEFICIENCY SYNDROME
Myopathy may appear in patients with AIDS. Intense debate has ensued about the pathogenesis of the disorder. Some believe it is an autoimmune polymyositis or the
result of viral invasion of muscle. Others believe it is virtually restricted to those taking zidovudine; in those cases most show ragged-red fibers, and depletion of
mitochondrial DNA has been documented. DNA levels return to normal when the drug therapy is interrupted.
RELATION OF POLYMYOSITIS TO POLYMYALGIA RHEUMATICA
In polymyalgia rheumatica, no symptomatic weakness or elevation of serum CK levels occurs. If overt weakness or high CK levels were evident, the syndrome would
be impossible to distinguish from polymyositis. Polymyalgia can be defined as a syndrome in which a person older than age 65 has joint pains, myalgia, malaise, and
a high erythrocyte sedimentation rate as described in Chapter 155.
THERAPY
Polymyositis itself is treated with steroids and immunosuppressive drugs, as described for dermatomyositis in Chapter 130. The advantages and risks must be
balanced against the patient's disability. In controlled trials, plasmapheresis and leukapheresis had no effect, but intravenous immunoglobulin therapy has been
beneficial, at least temporarily.
IBM characteristically does not respond to steroid therapy; this feature has led to the diagnosis of IBM in patients originally thought to have polymyositis. IBM does not
respond to plasmapheresis but benefit was found in a few patients participating in a trial of intravenous immunoglobulin. Favorable results have been few.
The eosinophilia-myalgia syndrome has not responded to conventional immunosuppression, steroids, or plasmapheresis.
SUGGESTED READINGS
Polymyositis (also refer to Suggested Readings in Chapter 130)
1Amato AA, Barohn RJ. Idiopathic inflammatory myopathies. Neurol Clin 1997;15:615648.
Arahata K, Engel AG. Monoclonal antibody analysis of mononuclear cells in myopathies. V. T8+ cytotoxic and suppressor cells. Ann Neurol 1988;23:493499.
Bautista J, Gil-Necija E, Castilla J, et al. Dialysis myopathy: 13 cases. Acta Neuropathol (Berl) 1983;61:7175.
Benbassat J, Gefel D, Larholt K, et al. Prognostic factors in polymyositis. A computer-assisted analysis of 92 cases. Arthritis Rheum 1985;28:249255.
Cohen O, Steiner I, Argov Z, et al. Mitochondrial myopathy with atypical subacute presentation. J Neurol Neurosurg Psychiatry 1998;410411.
Crennan JM, Van Scoy RE, McKenna CH, Smith TF. Echovirus polymyositis in patients with hypogammaglobulinemia: failure of high-dose intravenous gamma globulin therapy. Am J Med
1986;81:3542.
Cumming WJK, Weiser R, Teoh R, et al. Localized nodular myositis: a clinical and pathological variant of polymyositis. Q J Med 1977;184:531546.
Dalakas MC. Inflammatory myopathies. Handb Clin Neurol 1992;18:369390.
Dewberry RG, Schneider BF, Cale WF, Phillips LH II. Sarcoid myopathy presenting with diaphragm weakness. Muscle Nerve 1993;16:832835.
Gheradi RK, Coquet M, Cherin P, et al. Macrophagic myofasciitis: an emerging entity. Lancet 1998;352:347352.
Hart FD. Polymyalgia rheumatica. Correct diagnosis and treatment. Drugs 1987;33:280287.
Hopkinson ND, Shawe DJ, Gumpel JM. Polymyositis, not polymyalgia rheumatica. Ann Rheum Dis 1991;50:321322.
Kaufman LD, Kephart GM, Seidman RJ, et al. The spectrum of eosinophilic myositis. Arthritis Rheum 1993;36:10141024.
Lampe J, Kitzler H, Walter MC, Lochmuller H, Reichmann H. Methionine homozygosity at prion gene codon 129 may predispose to sporadic inclusion-body myositis. Lancet 1999;353:465466.
Lange DJ. Neuromuscular diseases associated with HIV infection. Muscle Nerve 1994;7:1630.
Layzer RB. The hypereosinophilic syndromes. In: Serratrice G, Pellissier J, Desnuelle C, Pouget J, eds. Myelopathies, neuropathies et myopathies: acquisitions recentes (advances in neuromuscular
diseases). Paris: Expansion Scientifique Francaise, 1989.
Layzer RB, Shearn MA, Satya-Murti S. Eosinophilic polymyositis. Ann Neurol 1977;1:6571.
Miller FW. Myositis-specific autoantibodies. Touchstones for understanding inflammatory myopathies. JAMA 1993;270:18461849.
Moskovic E, Fisher C, Wetbury G, Parsons C. Focal myositis: a benign inflammatory pseudotumor: CT appearance. Br J Radiol 1991;64:489493.
Navarro C, Bragado FG, Lima J, Fernandez JM. Muscle biopsy findings in systemic capillary leak syndrome. Hum Pathol 1990;21:297301.
Persellin ST. Polymyositis associated with jejunoileal bypass. J Rheumatol 1983;10:637639.
Phillips BA, Zilko P, Garlepp MJ, Mastaglia FL. Frequency of relapses in patients with polymyositis and dermatomyositis. Muscle Nerve 1998;21:16681672.
Pickering MC, Walport MJ. Eosinophilic myopathic syndromes. Curr Opin Rheumatol 1998;10:504510.
Ringel SP, Thorne EG, Phanuphak P, et al. Immune complex vasculitis, polymyositis, and hyperglobulinemic purpura. Neurology 1979;29:682689.
Rowland LP, Clark C, Olarte M. Therapy for dermatomyositis and polymyositis. In: Griggs RC, Moxley RT, eds. Treatment of neuromuscular disease. New York: Raven Press, 1977.
Spuler S, Emslie-Smith A, Emgel AG. Amyloid myopathy: an underdiagnosed entity. Ann Neurol 1998;43:719728.
Symmans WA, Beresford CH, Bruton D, et al. Cyclic eosinophilic myositis and hyperimmunoglobulin-E. Ann Intern Med 1986;104:2632.
Tsokos GC, Moutsopoulos M, Steinberg AD. Muscle involvement in systemic lupus erythematosus. JAMA 1981;246:766768.
Vaish AK, Mehrotra S, Kushwaha MRS. Proximal muscle weakness due to amyloid deposition. J Neurol Neurosurg Psychiatry 1998;409410.
Drug-induced Myopathies
Arnaudo E, Dalakas M, Shanske S, et al. Depletion of muscle mitochondrial DNA in AIDS patients with zidovudine-induced myopathy. Lancet 1991;337:508510.
Batchelor TT, Taylor LP, Thaler HT et al. Steroid myopathy in cancer patients. Neurology 1997;48:12341238.
Choucair AK, Ziter FA. Pentazocine abuse masquerading as familial myopathy. Neurology 1984;34:524527.
Doyle DR, McCurley TL, Sergent JS. Fatal polymyositis in D-penicillamine-induced nephropathy and polymyositis. N Engl J Med 1983;308:142145.
Giordano N, Senesesi M, Mattii G, et al. Polymyositis associated with simvastatin. Lancet 1997;349:16001601.
Haller RG, Knochel JP. Skeletal muscle disease in alcoholism. Med Clin North Am 1984;68:91103.
Kalkner KM, Ronnblom L, Karlsson Parra AK, et al. Antibodies against double-stranded DNA and development of polymyositis during treatment with interferon. Q J Med 1998;91:393399.
Mastaglia FL. Adverse effects of drugs on muscle. Drugs 1982;24:304321.
Ojeda VJ. Necrotizing myopathy associated with steroid therapy. Report of two cases. Pathology 1982;14:435438.
Schultz CE, Kincaid JC. Drug-induced myopathies. In: Biller J, ed. Iatrogenic neurology. Boston: Butterworth-Heinemann, 1998:305318.
Simpson DM, Citak KA, Godfrey E, et al. Myopathies associated with HIV and zidovudine. Can their effects be distinguished? Neurology 1993;43:971976.
Simpson DM, Slasor P, Dafni U, et al. Analysis of myopathy in a placebo-controlled zidovudine trial. Muscle Nerve 1997;20:382385.
Takahasi K, Ogita T, Okudaira H, et al. Penicillamine-induced polymyositis in patients with rheumatoid arthritis. Arthritis Rheum 1986;29:560564.
Inclusion Body Myositis
Amato AA, Gronseth GS, Jackson CE, et al. Inclusion body myositis: clinical and pathological boundaries. Ann Neurol 1996;40:581586.
Askanas V. New developments in hereditary inclusion body myositis. Ann Neurol 1997;41:421422.
Askanas V, Serratrice G, Engel WK, eds. Inclusion-body myositis. Cambridge: Cambridge University Press, 1998.
Barohn RJ. The therapeutic dilemma of inclusion body myositis. Neurology 1997;48:567568.
Brannagan TH, Hays AP, Lange DJ, Trojaborg W. The role of quantitative electromyography in inclusion body myositis. J Neurol Neurosurg Psychiatry 1997;63:776779.
Chou SM. Inclusion body myositis: a chronic persistent mumps myositis? Hum Pathol 1986;17:765777.
Garlepp MJ, Mastaglia F. Inclusion body myositis. J Neurol Neurosurg Psychiatry 1996;60:251255.
Griggs RC, Askansas V, DiMauro S, et al. Inclusion body myositis and myopathies. Ann Neurol 1995;38:705713.
Lindberg C, Borg K, Edstrom L, et al. Inclusion body myositis and Welander distal myopathy: a clinical, neurophysiological, and morphological comparison. J Neurol Sci 1991;103:7681.
Lotz BP, Engel AG, Nishino H, et al. Inclusion body myositis. Observations in 40 patients. Brain 1989;112:727747.
Moslemi A-R, Lindberg C, Oldfors A. Analysis of multiple mitochondrial DNA deletions in inclusion body myositis. Hum Mutat 1997;10: 381386.
Sadeh M, Gadoth N, Hadar H, Ben-David E. Vacuolar myopathy sparing the quadriceps. Brain 1993;116:217232.
Sivakumar K, Dalakas MC. Inclusion body myositis and myopathies. Curr Opin Neurol 1997;10:413420.
CHAPTER 132. MYOSITIS OSSIFICANS
MERRITTS NEUROLOGY
CHAPTER 132. MYOSITIS OSSIFICANS

LEWIS P. ROWLAND
Suggested Readings
The identifying characteristic of myositis ossificans (MIM 135100), a rare disorder, is the deposition of true bone in subcutaneous tissue and along fascial planes in
muscle. McKusick (1974) believed that the primary disorder is in connective tissue and preferred the term fibrodysplasia ossificans rather than its traditional name,
which implies a disease of muscle. Nevertheless, in some cases myopathic changes occur in muscle biopsy or electromyogram, and occasionally serum creatine
kinase levels are increased.
Symptoms usually start in the first or second year of life. Transient and localized swellings of the neck and trunk are the first abnormality. Later, minor bruises are
followed by deposition of solid material beneath the skin and within muscles. Plates and bars of material may be seen and felt in the limbs ( Fig. 132.1), paraspinal
tissues, and abdominal wall. These concretions are readily visible on radiographic examination, magnetic resonance imaging, or computed tomography; when they
cross joints, a deforming ankylosis results. The cranial muscles are spared, but the remainder of the body may be encased in bone. The extent of disability depends
on the extent of ossification, which varies considerably. No abnormality of calcium metabolism has been detected.
FIG. 132.1. Ossification of muscle biopsy scar in boy with myositis ossificans. The outer border of marks indicates extent of spontaneous ossification.
Almost all cases are sporadic, but it is suspected that the disease is inherited because minor skeletal abnormalities occur in almost all patients, and these
abnormalities seem to be transmitted in the family in an autosomal dominant pattern. The most common deformity is a short great toe ( microdactyly) and curved
fingers (clinodactyly), and other digital variations are also seen. Most cases are attributed to new mutations because reproductive fitness is much reduced. The gene
locus has not been mapped yet. Restricted ossification at the site of single severe injury may also occur in otherwise normal adults with no apparent genetic risk.
Treatment is symptomatic. Excision of ectopic bone is fruitless because local recurrence is invariable and disability may become worse. Surgery sometimes helps to
refix a joint in a functionally better position. Treatment with diphosphonates inhibits calcification of new ectopic matrix but does not block production of the fibrous
material and may have adverse effects on normal skeleton.
SUGGESTED READINGS
Amendola MA. Myositis ossificans circumscripta: computed tomography diagnosis. Radiology 1983;149:775779.
Cohen RB, Hahn CV, Tabas JA, et al. The natural history of heterotopic ossification in patients with fibrodysplasia ossificans progressiva: 44 patients. J Bone Joint Surg [Am] 1993;75:215219.
Connor JM. Fibrodysplasia ossificans progressiva. In: Royce PM, ed. Connective tissue and its heritable disorders. New York: Wiley Press, 1993.
Connor JM, Skirton H, Lunt PW. A three-generation family with fibrodysplasia ossificans progressiva. J Med Genet 1993;30:687689.
Debene-Bruyerre C, Chikhami L, Lockhart R, et al. Myositis ossificans progressiva: five generations where the disease was exclusively limited to the maxillofacial region. Int J Oral Maxillofac Surg
1998;27:299302.
DeSmet AA, Norris AA, Fisher DR. MRI of myositis ossificans: 7 cases. Skel Radiol 1992;21:503507.
Kaplan FS, Tabas JA, Gauman FH, et al. The histopathology of fibrodysplasia ossificans progressiva. J Bone Joint Surg [Am] 1993;75:220230.
McKusick VA. Heritable diseases of connective tissue, 4th ed. St Louis: CV Mosby, 1972.
Smith R. ENMC-sponsored international workshop: fibrodysplasia (myositis) ossificans progressiva (FOP). Neuromusc Disord 1997:7:407410.
CHAPTER 133 MULTIPLE SCLEROSIS
MERRITTS NEUROLOGY
SECTION XIX. DEMYELINATING DISEASES

CHAPTER 133. MULTIPLE SCLEROSIS
JAMES R. MILLER
Definition
Incidence and Epidemiology
Etiology and Pathogenesis
Pathology
Symptoms and Signs
Mode of Onset
Laboratory Data
Diagnosis
Course and Prognosis
Variants of Multiple Sclerosis
Management
Suggested Readings
DEFINITION
Multiple sclerosis (MS) is a chronic disease that begins most commonly in young adults and is characterized pathologically by multiple areas of central nervous
system (CNS) white matter inflammation, demyelination, and glial scarring (sclerosis). The lesions are therefore multiple in space.
The clinical course varies from a benign, largely symptom-free disease to one that is rapidly progressive and disabling. Most patients begin with relapsing and
remitting symptoms. At first, recovery from relapses is almost complete, but then neurologic disabilities accrue gradually. The lesions are therefore multiple in time
and space.
The cause is elusive, although autoimmune mechanisms, possibly triggered by environmental factors in genetically susceptible individuals, are thought to be
important.
INCIDENCE AND EPIDEMIOLOGY
Age at onset follows a unimodal distribution with a peak between ages 20 and 30 years; symptoms rarely begin before age 10 or after age 60. In a series of 660
patients, Bauer and Hanefeld (1993) found that almost 70% of patients had symptoms at ages 21 to 40, 12.4% at ages 16 to 20, and 12.8% at 41 to 50. The youngest
patient had symptoms at age 3 and the oldest at 67 years. Younger and older cases have been reported.
In women, the incidence of MS is 1.4 to 3.1 times higher than in men. Among patients with later onset, the sex ratio tends to be equal.
The geographic distribution is uneven. In general, the disease increases in frequency with latitude in both the northern and southern hemispheres, although the rates
tend to decrease above 65 degrees north or south.
Because of differences in methods of case finding and the need to rely on subjective clinical criteria in identifying cases of MS in large populations, the absolute
numbers in any given area are uncertain. The distribution of MS is best considered in terms of zones. High prevalence areas are those with cases equal to or more
than 30 per 100,000 population, medium prevalence areas have rates between 5 and 30 per 100,000, and low prevalence areas have rates less than 5 per 100,000.
Most of northern Europe, northern United States, southern Canada, and southern Australia and New Zealand are areas of high prevalence. Southern Europe,
southern United States, Asia Minor, the Middle East, India, parts of northern Africa, and South Africa have medium prevalence rates. Low prevalence areas are
Japan, China, and Latin and South America. MS is virtually unknown among native Inuit in Alaska and among the indigenous people of equatorial Africa.
Although latitude may be an independent variable affecting MS prevalence rates, racial differences may explain some of the geographic distribution. This is illustrated
by comparing the prevalence rate for MS in Britain (85 per 100,000) and Japan (1.4 per 100,000), although both countries lie at the same latitude. When racial
differences are correlated with prevalence rates for MS worldwide, white populations are at greatest risk and both Asian and black populations have a low risk.
Studies of migrant populations provide evidence of environmental changes on the risk of MS while keeping genetic factors constant. Children born in Israel of
immigrants from Asian and North African countries showed relatively higher incidence rates, like those of European immigrants, rather than the low rates
characteristic of their parents. This finding implies that an environmental factor is critically important in pathogenesis. Similar differences were noted among the
native-born South African whites, who had a relatively low incidence, as opposed to the high incidence among immigrants from Great Britain. Refinement of these
studies suggested that age at time of immigration played an important role; an immigrant leaving the country of origin before age 15 years had nearly the same risk of
acquiring MS as that of the native-born Israeli or South African. Individuals migrating after age 15 have the risk of the country of origin. These studies were confirmed
by studies of people migrating from the Indian subcontinent or the West Indies to Great Britain. The data suggest that an infectious agent of long latency is acquired
at the time of puberty.
Reports of epidemics of MS provide further evidence of an environmental factor. The most impressive epidemic occurred in the Faroe Islands where cases appeared
shortly after the islands were occupied by British troops in World War II. Similar epidemics of cases have been seen in Iceland, in the Orkney and Shetland Islands,
and in Sardinia. Rigorous epidemiologic scrutiny failed to prove, however, that these cases were true point-source epidemics. Therefore, other plausible explanations
cannot be excluded.
MS is reported to occur more frequently in higher socioeconomic classes and in urban areas, but these assertions are unproved.
ETIOLOGY AND PATHOGENESIS
The cause of MS is unknown. Genetic susceptibility, autoimmune mechanisms, and viral infections may play a pathogenic role in the demyelination.
Genetic Susceptibility
Compelling data indicate that susceptibility to MS is inherited. The epidemiologic studies just summarized reveal a racial susceptibility to the development of MS.
Whites appear most susceptible. Within this group are regional trends; the highest rates are associated with areas in which Nordic invasions took place. Alternatively,
genetic resistance to MS in Asians and descendants of black Africans helps to explain racial variations in prevalence rates of MS. Because racial prevalence of MS
changes with migration, however, definite conclusions of genetic predisposition cannot be drawn.
Studies of families and twins provide more support for genetic susceptibility. In high-prevalence regions, the lifetime risk of developing MS is about 0.00125% in the
general population. Siblings of MS patients have a risk of about 2.6%, parents a risk of about 1.8%, and children a risk of about 1.5%. First-, second-, and
third-degree relatives also have a higher risk. Overall, about 15% of patients with MS have an affected relative. Data from twin studies indicate a concordance rate of
about 25% in monozygotic twins and of only 2.4% for same-sex dizygotic twins. These studies suggest a substantial genetic component. Rather than a single
dominant gene, however, multiple genes probably confer susceptibility.
Pedigree data from families with more than one affected member are consistent with the hypothesis that multiple unlinked genes predispose to MS. The major
histocompatibility complex (MHC) on chromosome 6 has been identified as one genetic determinant for MS. The MHC encodes the genes for the histocompatibility
antigens (the human leukocyte antigen [HLA] system) involved in antigen presentation to T cells. Of the three classes of HLA genes, the strongest association is with
the class II alleles, particularly the DR and DQ regions. In whites, the class II haplotype DR15, DQ6, Dw2 is associated with increased risk of MS. Delineation of this
haplotype in patients with MS and in normal people, however, revealed no significant differences; genetic susceptibility to MS may therefore reside in functional
aspects of these genes. The roles of other genes in MS, including the T-cell receptor (TCR) andimmunoglobulin heavy chain genes, are reviewed later in the chapter.
Immunology
Substantial evidence from peripheral blood abnormalities, cerebrospinal fluid (CSF) findings, and CNS pathology in MS and animal models of demyelination suggests
that autoimmune mechanisms are involved.
In the peripheral blood, several nonspecific changes are seen, particularly in secondary progressive MS. These changes are similar to those encountered in other
autoimmune diseases, such as systemic lupus erythematosus (SLE). The activity of suppressor CD8+ T cells is reduced, as is the autologous mixed lymphocyte
reaction, which seems to be an indicator of autoreactive cell suppression. In MS, as in SLE, there are fewer CD4+CD45RA+ suppressor-inducer T cells in the
peripheral blood. An increase in activated T cells in MS is unlikely because cell surface molecules associated with T-cell activation are not abundant and lymphokine
levels are normal.
CSF pleocytosis is common, particularly in the acute phases of MS. T cells that are helper-inducers (CD4+CDw29+ cells) constitute most of these cells and are found
in higher ratios in CSF than in the peripheral circulation. By contrast, the number of CD4+CD45RA T cells, which induce suppressor cells, is decreased. Although
some T lymphocytes in the CSF of patients with MS are activated, the antigenic stimulus is unclear. T-cell reactivity is found against several epitopes of myelin basic
protein (MBP) and proteolipid protein. Analysis of the TCR gene, which is unique for each T-cell clone, suggests that the immune response is polyclonal and likely to
have multiple antigenic specificities. Sequencing the variable regions of these cells reveals a high degree of somatic hypermutation, as is seen in chronic stimulation
in vivo.
Antibody-secreting B cells are also activated in MS. The amount of IgG in the CSF and the rate of IgG synthesis are increased. Because only a few clones of CSF
cells are activated, the response is oligoclonal. This seems to be a restricted response to stimulation within the neuraxis because similar oligoclonal IgGs are not
found at all or are found in lower concentration in the serum than in CSF. Oligoclonal IgG is found in other inflammatory or infectious conditions, such as viral
encephalitis or CNS syphilis. In these situations, however, the oligoclonal IgGs are antibodies directed against the agents of the infecting agent. In MS, an antigen for
most of the oligoclonal IgG has not been identified. Therefore, the CSF IgG may be a secondary effect, possibly a result of the decrease in CD4+CD45RA+
suppressor-inducer cells, which allows a few clones of antibody-producing cells to escape suppression.
Perivascular lymphocyte and macrophage infiltration is characteristic of the CNS immunopathology. The predominant lymphocytes in MS lesions are helper-inducer
cells (CD4+CDw29+). Interleukin-2 receptors are demonstrable on many of the T cells, thereby indicating that these cells are secreting cytokines and are
immunologically activated. Also, astrocytes, which normally do not express MHC molecules, express class II molecules in active lesions. This pattern suggests that
astrocytes are involved in antigen presentation to T cells. In more chronic lesions, g/d T cells are present around the edges of the plaque. Oligoclonal IgG is also
present in MS plaques. Overall, the types of immunologically active cells and IgGs in the CNS lesions are similar to those found in CSF.
The cytokines produced by activated T cells and macrophages may play a role in some of the tissue damage. The cytokine called tissue necrosis factor is toxic to
oligodendroglial cells and myelin and can be found in MS plaques. Further, CSF levels of tissue necrosis factor may correlate with MS disease activity.
Further evidence that MS may have an immunologic basis comes from the animal model experimental allergic encephalomyelitis (EAE), which is induced in genetically
susceptible animals by immunization with normal CNS tissue and an adjuvant. The chronic relapsing-remitting form of EAE is pathologically similar to that of MS. EAE
can also be induced by immunization with MBP or immunodominant peptide regions of MBP, thus suggesting that MBP is the putative antigen in EAE. T cells reactive
against MBP and proteolipid protein mediate the CNS inflammation, as shown by adoptive transfer: Sensitized T cells from an animal with EAE can transfer disease
to a healthy syngeneic recipient. The T-cell response in EAE seems to be genetically restricted to a few families on the TCR gene, however, and removal or
suppression of these T-cell lines leads to immunity from EAE. This response contrasts with the findings in human MS where the TCR gene response is more
heterogeneous.
Although current understanding of MS pathogenesis derives mainly from consideration of the EAE and chronic EAE models, many features of the human disease are
not understood or explained by this animal model. We do not know the precipitant antigens or even if the immune process is the primary force. There are differences
in the pathology of the experimental and clinical disorders, the relative roles of cytokine activation, and antibody-mediated immunity; macrophage activity may differ.
Healthy skepticism is warranted in considering theories of pathogenesis.
Viruses
Epidemiologic data imply a role for environmental exposure. Viral encephalitis in children may be followed by demyelination. In animals, the most widely studied
model of viral-induced demyelinating disease is created by the Theiler virus, a murine picornavirus. Infection with some Theiler strains results in an infection of
oligodendrocytes with multifocal perivascular lymphocytic infiltration and demyelination. Genetic factors influence susceptibility to development of demyelination and
clinical disease; this susceptibility is linked to the immune response generated in the animals against viral determinants. Therefore, in MS, demyelination could be
precipitated by a viral infection. Measles, rubella, mumps, coronavirus, parainfluenza, herpes simplex, Epstein-Barr, vaccinia, and human T-cell lymphotropic virus
type I viruses all have been reported to be present in patients with MS. None of these agents, however, has been detected reproducibly. Human herpesvirus-6 has
been implicated in MS disease activity; it is a ubiquitous agent that causes roseola subitum in children. Over 90% of adults have antibodies to the agent, and
infection, mostly asymptomatic, probably occurs in early childhood. Human herpesvirus-6 then persists in a latent state in neural tissue. Results have not been
uniform, but some investigators found an increased incidence of viral activity in areas around acute MS plaques. Activity of the virus may precipitate a flareup of
symptoms. Studies are in progresss to determine if prophylactic treatment with an antiviral agent could reduce the frequency of episodes in MS. Perhaps no single
virus is the trigger for demyelination in all patients with MS. Instead, several different viruses may be involved.
Other Factors
Other mechanisms have been suggested as precipitating the onset of MS or relapses. Physical trauma has been invoked as precipitating or aggravating the disease.
In a population-based cohort study, however, Siva et al. (1993) found no association between MS and head injuries in 819 patients. Other studies also failed to show
any causal correlation between trauma and MS. The effect of pregnancy is difficult to evaluate because MS is most common in women of childbearing age. If the
pregnancy year is considered, however, exacerbations seem to cluster in the postpartum period rather than during pregnancy. Whether this clustering is related to
hormonal changes or other factors is unclear. In any event, no convincing evidence has revealed that MS is worsened by pregnancy. Therefore, interruption of
pregnancy in women with MS is not indicated on this basis alone.
Vaccination is also cited frequently as a precipitating event, although the evidence is anecdotal. One study with influenza vaccine found no relationship. In the
absence of definitive studies, patients with MS should be advised against routine casual vaccination, especially if previous exacerbations have been preceded by
vaccination. However, medically indicated inoculations should not be withheld. Surgery, anesthesia, and lumbar punctures also have been invoked in MS, but
controlled studies failed to show any relationship.
PATHOLOGY
The gross appearance of the external surface of the brain is usually normal. Frequently in long-standing cases there is evidence of atrophy and widening of cerebral
sulci with enlargement of the lateral and third ventricles. Brain sections reveal numerous small irregular grayish areas in older lesions and pink areas in acute lesions
in the cerebral hemispheres, particularly in the white matter and in periventricular regions ( Fig. 133.1). The white matter that forms the superior lateral angle of the
body of the lateral ventricles is frequently and characteristically affected. Similar areas of discoloration are also found in the brainstem and cerebellum. These are the
plaques of MS.
FIG. 133.1. Gross appearance, coronal section, occipital lobe. Note extensive periventricular lesions. Several small lesions are scattered elsewhere in the white
matter. (Courtesy of Dr. Daniel Perl.)
The external appearance of the spinal cord is usually normal. In a few cases, the cord is slightly shrunken and the pia arachnoid may be thickened. The cord
occasionally may be swollen over several segments if death follows soon after the onset of an acute lesion of the cord. Plaques similar to those seen in the cerebrum
are seen occasionally on the external surface of the cord, but they are recognized most easily on cross-section. The optic nerves may be shrunken, but the external
appearance of the other cranial nerves is usually normal.
Myelin sheath stains of CNS sections show areas of demyelination in the regions that were visibly discolored in the unstained specimen. In addition, many more
plaques are apparent. These plaques are sharply circumscribed and are diffusely scattered throughout all parts of the brain and spinal cord ( Fig. 133.2). The lesions
in the brain tend to be grouped around the lateral and third ventricles. Lesions in the cerebral hemispheres vary from the size of a pinhead to large areas that
encompass the major portion of one lobe of the hemisphere. Small lesions may be found in the gray matter and in the zone between the gray and white matter.
Plaques of varying size may be found in the optic nerves, chiasm, or tracts ( Fig. 133.3). Lesions in the corpus callosum are not uncommon (Fig. 133.4). The lesions in
the brainstem are usually numerous (Fig. 133.5), and sections from this area when stained by the Weigert method have a characteristic Holstein cow appearance
(Fig. 133.6).
FIG. 133.2. A: Normal contrast-enhanced computed tomography. B: The axial T2-weighted magnetic resonance image in the same patient during the same period
shows multiple white matter lesions, the largest designated by arrows.
FIG. 133.3. Multiple sclerosis. Demyelinization of optic nerves and chiasm. (Courtesy of Dr. Abner Wolf.)
FIG. 133.4. Myelin sheath stain of right cerebral hemisphere in multiple sclerosis (celloidin). Note lesions in corpus callosum and superior lateral angle of the ventricle
and several plaques in the subcortical white matter. (Courtesy of Dr. Charles Poser.)
FIG. 133.5. Multiple sclerosis. Myelin sheath stain. Lesions in pons, middle cerebellum peduncle, and cerebellar white matter, typically near the dentate nuclei.
(Courtesy of Dr. Charles Poser.)
FIG. 133.6. Myelin sheath stain of brainstem in multiple sclerosis. Note sharp demarcation of lesions.
In sections of the spinal cord, the areas of demyelination vary from small lesions involving a portion of the posterior or lateral funiculi to almost complete loss of myelin
in an entire cross-section of the cord ( Fig. 133.7 and Fig. 133.8).
FIG. 133.7. Myelin sheath stain: tenth thoracic segment of spinal cord. Almost complete demyelination of the entire section. The gray matter is severely involved, and
cystic degeneration causes obliteration of normal architecture.
FIG. 133.8. Multiple sclerosis. A: Almost complete loss of myelin in transverse section of cord. B: Symmetric lesions in the posterior and lateral funiculi simulating
distribution of lesions in combined system disease. (From Merritt HH, Mettler FA, Putnam TJ. Fundamentals of clinical neurology. Philadelphia: Blakiston, 1947.)
Lesions are usually characterized by sharp delimitation from the surrounding normal tissue. Within the lesion is variable destruction of the myelin and to a lesser
degree damage to the neurons, proliferation of the glial cells, changes in the blood vessels, and relatively good preservation of the ground structure. Only rarely is the
damage severe enough to affect the ground substance and produce a cyst ( Fig. 133.6).
Most myelin sheaths within a lesion are destroyed, and many of those that remain show swelling and fragmentation. The degree of damage to the neurons varies. In
the more severe lesions, axons may be entirely destroyed, but more commonly only a few are severely injured and the remainder appear normal or show only minor
changes. However, loss of axons is found in even the earliest MS plaques. Secondary degeneration of long tracts occurs when the axons have been significantly
destroyed. Recently, it has been appreciated that axonal loss and resulting brain atrophy are probably more closely correlated with irreversible clinical dysfunction
than the number or size of plaques. When the lesion involves gray matter, nerve cells are less affected than is myelin, but some cells may be destroyed and show
degenerative changes.
In the early or acute lesion there is marked hypercellularity, with macrophage infiltration and astrocytosis accompanied by perivenous inflammation with lymphocytes
and plasma cells. Myelin sheaths disintegrate, and chemical breakdown of myelin occurs. It is not yet established whether the cellular response leads to, or occurs as
a result of, the myelin breakdown. These acute lesions may remain active for several months with continued macrophage and astrocytic hyperactivity and breakdown
of myelin. Phagocytic cells are laden with lipid degradation products of myelin. In these active but nonacute plaques, the inflammatory cell response is minimal
centrally. At the edges, however, myelin disintegration is still active, and numbers of macrophages, lymphocytes, and plasma cells are increased. With time, the
plaques become inactive. Demyelination is prominent, almost total oligodendrocyte cell loss occurs, and gliosis is extensive. Inactive lesions are hypocellular and
devoid of myelin breakdown products.
Remyelination in MS plaques, particularly after the early acute phase, is thought to result from the differentiation of a precursor cell that is common to type II
astrocytes and oligodendrocytes. This remyelination, however, is usually aberrant and incomplete. Uniform areas of incomplete myelination (shadow plaques) are
evident in some chronic lesions; it is not known whether these regions result from partial demyelination or incomplete remyelination.
Electron microscopy reveals different aspects of myelin disorder in MS, including widening of the outer myelin lamellae, splitting and vacuolation of myelin sheaths,
vesicular dissolution of myelin, myelin sheath fragmentation, ball and ovoid formation, filamentous accumulations in sheath, thin myelin sheaths, and
macrophage-associated pinocytosis and actual peeling of layers of myelin by the processes of these microglial cells.
The peripheral nerves are usually normal. Subtle changes, however, in sural nerve biopsies include endothelial pinocytosis, expansion of the endoneurial space,
mononuclear cell infiltration, or demyelination. In addition, hypertrophic neuropathy and chronic inflammatory demyelinating polyneuropathy have been reported in
patients with MS.
Biochemical analysis of MS lesions reveals a decrease in both the protein and the lipid components of normal myelin. Thus, by immunocytochemistry, a decrease in
staining for the MBP and myelin-associated glycoprotein and a decrease in cholesterol, glycolipids, phosphoglycerides, and sphingomyelins result. Because of
phagocytosis and lysosomal activation, myelin breakdown products, including polypeptides, glycerol, fatty acids, and triglycerides, are abundant, particularly in active
lesions.
Based largely on immunohistologic analysis of cell types in lesions, some investigators believe that there are variants in the pathology of MS and that individual
patients tend to have one type of pathology. For example, lesions may vary in the prominence of T cells or macrophages and may vary in the extent of demyelination.
This has led to the suggestion that MS may not be a single disease but rather a group of disorders all characterized by the final common pathway of inflammatory
mediated demyelination. Others have found too much pathologic overlap in a single patient to warrant the view that these variants imply different forms of MS.
SYMPTOMS AND SIGNS
MS is characterized by dissemination of lesions in time and space. Exacerbations and remissions occur frequently. In addition, signs and symptoms usually indicate
more than one lesion. Clinical manifestations may be transient and some may seem bizarre. The patient may experience unusual sensations that are difficult to
describe and impossible to verify objectively.
The symptoms and signs (Table 133.1 and Table 133.2) are diverse and seem to include all the symptoms that can result from injury to any part of the neuraxis from
the spinal cord to the cerebral cortex. The chief characteristics are multiplicity and tendency to vary in nature and severity with time. Complete remission of the first
symptoms frequently occurs, but with subsequent attacks, remissions tend not to occur or are incomplete. The clinical course extends for one or many decades in
most cases, but a rare few are fatal within a few months of onset.
TABLE 133.1. COMMON SYMPTOMS AND SIGNS IN CHRONIC MULTIPLE SCLEROSIS
TABLE 133.2. SYMPTOMS AND SIGNS SEEN INFREQUENTLY IN MULTIPLE SCLEROSIS
The clinical manifestations depend on the particular areas of the CNS involved. Although no classic form of MS exists, for unknown reasons the disease frequently
involves some areas and systems more than others. The optic chiasm, brainstem, cerebellum, and spinal cord, especially the lateral and posterior columns, are
commonly involved (Table 133.1). Because of these predilections, some clinicians have classified MS into spinal, brainstem, cerebellar, and cerebral forms. These
forms are often combined, and such classification is of no clinical value. In fact, the combination of anatomically unrelated symptoms and signs forms the basis for
the clinical diagnosis of MS.
Visual symptoms include diplopia, blurred vision, diminution or loss of visual acuity on one or both sides, and visual field defects ranging from a unilateral scotoma or
field contraction (Fig. 133.9) to homonymous hemianopsia. These symptoms characteristically begin over hours or days. Patients may also complain of a curious and
quite distinctive problem in recognizing objects or faces, often stated as blurry vision. This symptom is caused by optic nerve lesions that result in loss of contrasts of
shade and colors. In early or mild optic or retrobulbar neuritis, color vision may be decreased, whereas black and white vision remains normal. Rarely, when color
vision is affected in both eyes, either transient or permanent color blindness, almost always of the red-green type, may result. Examination of the visual fields with a
red or green test object may uncover a central scotoma or field contraction that is not apparent with the usual white test object. Optic neuritis must be differentiated
from papilledema because the fundoscopic appearance of both may be similar if the plaque is near the nerve head. Optic neuritis, however, is characterized by early
impairment of visual acuity, which is a late manifestation of papilledema. A central or cecocentral scotoma is the most characteristic field loss. Retrobulbar neuritis, a
common manifestation of MS, may not be associated with any fundoscopic abnormality but is revealed only by loss of visual acuity.
FIG. 133.9. Cecocentral scotoma in patient with acute right optic neuropathy: multiple sclerosis of 3 years' duration.
Diplopia may be caused by lesions in the medial longitudinal fasciculus that produce internuclear ophthalmoplegia. In young adults, internuclear ophthalmoplegia is
uncommon in any other condition and is therefore an important sign in the diagnosis of MS. It is characterized by paresis of one medial rectus with failure of the eye to
adduct on the side of the lesion and by nystagmus and weakness of the lateral rectus on the other side. This impairment of gaze may be present on attempts to look
to one or both sides. In uncomplicated lesions of the medial longitudinal fasciculus, action of the medial rectus is preserved in reflex convergence, thus implying a
supranuclear lesion. Mild diplopia may be reported as blurred vision. The true nature of the complaint is discovered only if the patient shuts one eye and vision
improves.
The sudden onset of optic neuritis, without any other CNS signs or symptoms, is often interpreted as the first symptom of MS. Optic neuritis may also result, however,
from a postinfectious or postvaccinal reaction or other conditions. The frequency by which MS follows a single isolated episode of optic neuritis is difficult to
determine; published figures range from 15% to 85%. This spread is probably the result of differences of follow-up periods or of diagnostic and assessment measures.
A critical review of published figures suggests that 35% to 40% of patients with optic neuritis ultimately develop MS.
The most common pupillary abnormalities are irregularities in the outline of the pupil, partial constriction, and partial loss of the light reflex.
Involvement of the descending root of the fifth cranial nerve occurs in some patients. Pain sensation in the face may be impaired and the corneal reflex may be
diminished or lost. Paroxysmal pain indistinguishable from cryptogenic trigeminal neuralgia may occur. This symptom often responds to carbamazepine. MS should be
considered whenever a young adult develops trigeminal neuralgia.
Weakness of the facial muscles of the lower half of one side of the face is common, but complete peripheral facial palsy is rare. On the other hand, hemifacial spasm
(consisting of spasmodic contractions of facial muscles) is a rare but characteristic paroxysmal disorder of MS. True vertigo, which often lasts several days and may
be severe, is seen with new lesions of the floor of the fourth ventricle but is seldom a chronic symptom. Dysarthria and, rarely, dysphagia are seen in advanced MS
because of cerebellar lesions or bilateral demyelination of corticobulbar tracts that cause pseudobulbar palsy, which is also characterized by emotional lability and
forced laughing or crying without the accompanying affect.
Limb weakness is the most common sign, almost always present in advanced cases. Monoparesis, hemiparesis, or tetraparesis may be present; an asymmetric
paraparesis is most common. Fatigability out of proportion to demonstrable muscular weakness is common. Direct testing of muscle strength alone often does not
correlate with the degree of difficulty in walking. Concomitant spasticity and ataxia augment the gait disturbance. Gait ataxia is caused by a combination of lesions in
the cerebellar pathways and loss of proprioception resulting from lesions in the posterior columns of the spinal cord.
In some patients, particularly those with late onset, the disease may appear as a slowly progressive spastic paraparesis, with no abnormality except corticospinal
signs (spasticity, hyperreflexia, bilateral Babinski signs) and slight impairment of proprioceptive sensation.
The cerebellum and its connections with the brainstem are usually involved, thereby causing dysarthria, gait ataxia, tremor, and incoordination of the trunk or limbs.
Tremor of the head and body is occasionally almost continuous when the patient is awake. The characteristic scanning speech of MS is a result of cerebellar
incoordination of the palatal and labial muscles combined with dysarthria of corticobulbar origin. (The so-called Charcot triad of dysarthria, tremor, and ataxic gait is a
combination of cerebellar symptoms.)
Urinary symptoms are also common, including incontinence and frequency or urgency of urination, and must be differentiated from manifestations of urinary tract
infections or local conditions. Fecal incontinence or urgency is less common than urinary disturbances, but constipation is not unusual, especially in established
cases. Loss of libido and erectile impotence are common problems in men. Almost invariably these are associated sphincter disturbances or corticospinal tract
dysfunction, but psychologic problems may compound the problem. Sexual dysfunction in women is also frequent. Lack of lubrication and failure to reach orgasm are
the major problems, but sensory dysesthesias are also significant.
Paresthesias and sensory impairment are common. When they are symptoms of an acute relapse, they tend to resolve completely in 6 to 8 weeks. In advanced
disease, vibratory perception is commonly affected. Frequently, patients feel tingling or numbness in the limbs, trunk, or face. The Lhermitte symptom is a sensation
of electricity down the back after passive or active flexion of the neck. It indicates a lesion of the posterior columns in the cervical spinal cord and may be seen in
other diseases. The Lhermitte symptom is rarely elicited by flexion of the trunk. Pain is increasingly recognized as a frequent and disabling symptom. Pain may be
associated with the Lhermitte phenomenon, trigeminal neuralgia, or retrobulbar neuritis. Other types of pain include painful flexor-extensor spasms; painful tonic
spasms of the limbs (which can be evoked by hyperventilation); local pain such as constricting pain around a limb, burning pain, or pseudoradicular pain; foreign body
sensation; headache; pain with pressure sores; pain caused by joint contractures and osteoporosis; pseudorheumatic pain with myalgia and arthralgia; or neuralgic
pain shooting down the legs or around the abdomen, as in tabetic pain.
Psychiatric mood disorder symptoms are frequent. Depression is common. Whether it is directly related to MS lesions or a psychologic response to the disease is
unclear. Both mechanisms are likely. Euphoria was once considered characteristic of MS patients. Even when this symptom exists, it appears more likely to be a
frontal lobe dysinhibition syndrome, and underlying depression is often found. Some have found hypomanic behavior or bipolar disorders to be more common than
expected by chance. This does not appear to be part of the disease, because the lifestyle is apparent long before neurologic symptoms occur. A genetic linkage has
been suggested, but significant epidemiologic data have not been obtained.
Some have commented upon a tendency of patients to exaggerate and extend symptoms that have an obvious anatomic basis. Thus, diplopia may be transformed
into triplopia, quadriplopia, or monocular double vision. However, because even the most obvious sensory symptoms often lack distinct correlates in the neurologic
examination, it is dangerous to assume that unexplained sensory phenomenon are psychogenic.
Cognitive, judgment, and memory disorders are important features in MS and may be more important than physical disorders in causing disability. These changes
may range from the very obvious to subtle; even sophisticated psychometric studies may not detect early changes. Remedial training for memory problems may be
helpful. Awareness of these potential difficulties may help relatives, friends, and patients cope with otherwise difficult behavior. Aphasic disorders are occasionally the
major feature of an exacerbation.
Fatigue is another common symptom. It may appear as persistent fatigue, easy fatigability related to physical activity, or fatigue related to minor degrees of mental
exertion. It is often the prodromal symptom of an exacerbation. Fatigue is not related to age because it is noted with the same frequency by patients under 30 or over
50. Also, fatigue is not related to the amount of physical disability because it is noted in more than 50% of patients with early MS. It is important to analyze the
symptom; depression or lack of sleep due to nocturia may play a role. The fatigue of MS may respond to brief naps.
As may be seen from Table 133.1, most symptoms described occur in more than 50% of patients with MS at some time. The clinical features of MS, however, are
protean; almost any part of the CNS may be affected (Table 133.2).
One of the characteristics of MS symptoms is evanescence. Diplopia may last only a few seconds. Paresthesias may last for seconds or hours; diminution of visual
acuity may be equally short-lived. Transient loss of color vision may presage the onset of optic neuritis. Because of the transient and bizarre nature of these
symptoms, they are frequently deemed hysterical before clearer manifestations arise. There may also be paroxysmal limb spasms, incoordination syndromes, or
neuralgias. Trigeminal neuralgia in young people is most clearly associated with MS, but similar pains in other distributions may occur. Both the paroxysmal
movements and neuralgias often respond to carbamazepine.
Other transient disorders may be precipitated by exercise, exposure to heat, or other stimuli. Transient dysesthesias, visual blurring or diplopia, or weakness after hot
showers or exercise may occur. These episodes appear to represent derangements of the neurologic signal through previous damaged pathways and not an increase
in the inflammatory process. They invariably disappear soon after the provoking activity is stopped.
Remissions are also characteristic, but clinicians have difficulty agreeing on the nature or duration of some remissions. If a remission is defined only by the complete
or almost complete disappearance of a major symptom, such as loss of vision, marked weakness of a limb, or diplopia, clinical remissions occur in about 70% of all
patients early in the course of the disease.
MODE OF ONSET
The onset is usually acute or subacute within days and is only rarely apoplectic. There is no characteristic mode of onset, but some symptoms and signs are more
common (Table 133.3). Monosymptomatic onset is most common, but when onset is polysymptomatic, the clinical features often help to establish the diagnosis.
Frequently, however, the past history reveals remote or recent episodes of other manifestations that had been ignored or not considered significant by the patient or
physician. Dismissal is particularly true of transient paresthesias, mild urinary disturbances, or mild ocular manifestations, such as blurred vision or transient
diminution of monocular visual acuity.
TABLE 133.3. COMMON SYMPTOMS AND SIGNS AT THE ONSET OF DISEASE IN PATIENTS WITH CLINICALLY DEFINITE MULTIPLE SCLEROSIS
LABORATORY DATA
There is no pathognomonic test for MS, but magnetic resonance imaging (MRI), CSF examination, and evoked potential studies are of greatest diagnostic value
(Table 133.4).
TABLE 133.4. LABORATORY FINDINGS IN MULTIPLE SCLEROSIS (MS)
The most valuable laboratory aid is MRI, which shows multiple white matter lesions in 90% of patients ( Fig. 133.10) and is the imaging procedure of choice in the
diagnosis of MS. T2-weighted imaging has been the standard for demonstrating areas of involvement. Subsequently, proton density images and the fluid-attenuated
inversion recovery technique have enhanced the ability to detect lesions, particularly in periventricular distribution. The distribution and morphology of plaques on
T2-weighted MRI may be strongly suggestive of MS (Fig. 133.11) but occasionally it is difficult to distinguish from other lesions, particularly vascular disease. The MS
plaques are found in the white matter in a periventricular distribution; the posterior poles of the lateral ventricles and the area of the centrum semiovale are most
frequently involved. Corpus callosum lesions are characteristic and are brought out best with saggital proton density or fluid-attenuated inversion recovery. The most
common appearance is of homogeneously hyperintense lesions; less commonly, ring or cystic lesions may occur. T1-imaging is not sensitive, but hypodense areas
(black holes) may be observed; these may be superimposed on active lesions or with frank tissue necrosis and glial scarring. Gadolinium enhancement is useful in
defining areas of active inflammation. Triple-dose gadolinium is more sensitive than the standard dose, and delay in scanning after injection also enhances detection
of inflammation. Because nonspecific white matter abnormalities are commonly seen, particularly in patients older than 50 years, a careful approach is still advisable
when interpreting MRI studies despite the improvement in techniques ( Table 133.4). Correlation of the MRI and the clinical history is of paramount importance.
FIG. 133.10. A: Proton-density axial magnetic resonance image shows multiple hyperintense lesions within the periventricular white matter and corona radiata that
are suggestive of demyelinating plaques. B: T1-weighted axial magnetic resonance image after gadolinium enhancement shows that some of these lesions exhibit
contrast enhancement. (Precontrast T1-weighted images showed no hyperintense lesions.) Contrast enhancement of demyelinating plaques suggests active
demyelination, and acute exacerbation of multiple sclerosis was evident clinically in this patient. (Courtesy of Dr. S. Chan.)
FIG. 133.11. A and B: Proton-density and T2-weighted axial magnetic resonance images demonstrate multiple periventricular hyperintense lesions, many of which
abut the ependymal lining of the lateral ventricles. C: T2-weighted axial magnetic resonance image shows single hyperintense lesion within inferior left pons. D:
T2-weighted sagittal magnetic resonance image shows two hyperintense lesions within cervical cord. This distribution of lesions is highly suggestive of multiple
sclerosis. (Courtesy of Dr. S. Chan and Dr. A. G. Khandji.)
Although MRI has been most useful diagnostically, correlation with clinical findings and disability has been disappointing. First, MRI abnormality is only an indirect
measure of the actual lesions, and histologic damage may be far less than the size on the scan. This amplification factor is useful diagnostically but reduces the
correlation with function. Also, much of observed motor dysfunction is based on spinal cord lesions, which are difficult to image and are unobserved if only the brain is
imaged. Volumetric MRI studies demonstrate cerebral atrophy even early in MS when obvious lesions are relatively sparse. This atrophy reflects axonal and neuronal
loss and correlates better with disability than other scanning techniques, particularly with cognitive and memory dysfunction. Unfortunately, these techniques are
largely clinically unavailable.
MR spectroscopy is useful for analyzing the parenchyma involved in MS lesions. Changes in tissue components may antedate by 1 week even the earliest observable
MRI finding of gadolinium enhancement. Some have speculated that this may indicate the inflammatory process is only secondary to some other neuropil involvement.
Further studies are required to resolve the issue.
Examination of the CSF frequently provides supportive information for the diagnosis ( Table 133.4). The characteristic changes in CSF gamma globulins (IgG) are the
most useful findings. The presence of oligoclonal IgG bands by electrophoretic analysis of CSF is the most frequent abnormality. A few antibody-producing plasma
cell clones are thought to proliferate within the neuraxis in MS. The IgG production of these clones stands out in the electrophoretic analysis of the CSF as distinct
oligoclonal bands (OCBs). This pattern is not seen in normal people, in whom the CSF IgGs are passively derived from the serum and appear as diffuse broad bands
in electrophoretic gels. For OCBs to be diagnostically useful, two or more bands must be seen, and these bands should be either absent from the serum or present in
lower concentrations than in CSF, implying primary intrathecal synthesis of the IgG. More than 90% of patients with clinically definite MS have CSF OCBs, but they
are also detected in patients with other CNS inflammatory or infectious diseases. The other conditions, however, often reveal serum bands of at least equal intensity,
thus indicating the systemic nature of the illness. For reasons unknown, OCBs are found in about 5% of patients with other (noninflammatory) neurologic problems.
The first abnormality of CSF IgG reported in MS was a relative increase in concentration of IgG compared with CSF total protein. This increase is found in only 70% of
patients with clinically definite MS. Refinements of technique now compare the concentration of CSF IgG to serum IgG and take into account the relative
concentrations of serum and CSF albumin, thereby increasing the sensitivity. By accounting for the relative albumin concentrations, the method can be used when the
CSF total protein content is elevated, indicating breakdown of the bloodbrain barrier and passive diffusion of antibody into the CSF from the serum. Formulas have
been derived to estimate intrathecal IgG synthetic rate, which is elevated in MS. The sensitivity of these measurements now approaches the frequency of detection of
CSF OCBs by electrophoresis.
The recording of cortical-evoked responses from visual, auditory, and somatosensory stimulation is also of great value in demonstrating clinically unsuspected lesions
(Table 133.4). Visual-evoked responses to both flash and pattern reversal stimuli demonstrate abnormalities in many patients without symptoms or signs of visual
impairment. Somatosensory-evoked potentials may help but are usually normal unless there are distinct clinical symptoms or findings. Brainstem auditory-evoked
responses are even less sensitive in detecting abnormalities in asymptomatic patients but may be useful in confirming abnormalities in patients with brainstem
symptoms or signs. These procedures are simple, noninvasive, harmless, and may be useful in providing evidence of anatomic abnormalities when clinical data are
not clear. Magnetically evoked motor potentials detect lesions of the motor pathways from the cortex to spinal cord. This technique is not yet widely available.
DIAGNOSIS
Because no specific test for MS is available, the diagnosis rests on the multiple signs and symptoms with characteristic remissions and exacerbations ( Table 133.5).
The diagnosis can rarely be made with assurance at the time of the first attack. The diagnosis of MS is based on the ability to demonstrate, on the basis of the history,
neurologic examination, and laboratory tests, the existence of lesions involving different parts of the CNS. The history should bring out mild and transient past events,
and the examination should be detailed (e.g., testing for monocular color vision).
TABLE 133.5. CRITERIA FOR CLINICAL DIAGNOSIS OF MULTIPLE SCLEROSIS (MS)
The advent of technologically based laboratory tests ( Table 133.4) has added a new dimension to the documentation of multiple lesions. Even in patients who have
had a single attack of optic neuritis or transverse myelitis, these tests may indicate more than one lesion, thereby changing the diagnosis from probable to
laboratory-supported definite MS. At present, the following guidelines combine the clinical criteria of 1976 ( Table 133.5) and those of 1983 (Table 133.6) with a few
modifications:
TABLE 133.6. CRITERIA FOR THE DIAGNOSIS OF MULTIPLE SCLEROSIS
1. Clinically definite MS requires either evidence from both history and neurologic examination of more than one lesion or evidence from history of two episodes,
signs of one lesion on examination, and evidence from evoked responses or MRI of other lesions.
2. Laboratory-supported definite MS requires evidence of two lesions in either history or examination. If only one lesion is evident in either of those categories, at
least one more lesion must be evident in evoked response or MRI. In addition, CSF IgG content and pattern should be abnormal.
3. In clinically probable MS, either history or examination, but not both, provides evidence of more than one lesion. If only one lesion is evident by history and only
one by neurologic examination, evoked potentials or MRI may provide evidence of one or more lesions in addition. In this category, CSF IgG studies are normal.
In practice, these criteria are overly conservative because the diagnosis can certainly be made in patients even if symptoms begin after age 50. Finally, when the
diagnosis of MS cannot be made with certainty, the clinician should reevaluate the patient rather than make a hasty diagnostic decision. In some cases, however, MS
may remain asymptomatic, and a firm diagnosis may be made only at autopsy.
DIFFERENTIAL DIAGNOSIS
In young adults with characteristic manifestations ( Table 133.3) and laboratory abnormalities (Table 133.4), the diagnosis is easily made. Although the complete list of
diagnostic possibilities may seem endless, only a few disorders have similar clinical or laboratory features that lead to diagnostic difficulties ( Table 133.7).
TABLE 133.7. DIFFERENTIAL DIAGNOSIS OF MULTIPLE SCLEROSIS
It is difficult, if not impossible, to differentiate between the first attack of MS and acute disseminated encephalomyelitis (ADEM). ADEM follows infection or vaccination
and occurs most commonly in children. A clear distinction between the two conditions may not be possible because about 25% of patients diagnosed as having ADEM
later develop MS. Furthermore, the pathologic lesions of MS and ADEM are difficult to distinguish.
In endemic areas, Lyme disease is an important consideration because chronic CNS infection with Borrelia burgdorferi can cause spastic paraparesis, cerebellar
signs, and cranial nerve palsies. The MRI and CSF abnormalities of MS can also be seen in Lyme disease, so the diagnosis of Lyme disease must rest on a history of
characteristic acute symptoms and rash of Lyme disease, with demonstration of antibodies to Borrelia antigens in high titer and in both CSF and serum.
Because other infections may mimic MS, serologic tests for human immunodeficiency virus, human T-cell lymphotropic virus type I, and syphilis are required.
Progressive multifocal leukoencephalopathy should be considered in immunosuppressed individuals.
Several autoimmune diseases have CNS manifestations and particularly MRI changes that can resemble MS. SLE, polyarteritis nodosa, Sjgren syndrome, Behet
disease, and sarcoidosis are the most notable. The non-CNS features of these diseases usually distinguish them from MS, but if diagnostic difficulties are
encountered, specific serum antibody tests, such as anti-DNA antibodies in SLE, or a biopsy of an appropriate site, such as in sarcoidosis, are sufficient to clinch the
diagnosis.
Paraneoplastic syndromes with cerebellar signs may cause diagnostic problems, particularly in older patients. Serum antibodies to Purkinje cells are useful in making
the diagnosis.
Subacute combined degeneration should be excluded in all cases of spinal MS by measuring serum vitamin B 12 levels. Similarly, women with progressive spastic
paraparesis should have a test for the plasma content of very-long-chain fatty acids to exclude the heterozygous carrier state of adrenomyeloneuropathy. Subacute
myelooptic neuritis is an adverse reaction to chlorhydroxyquinoline; relapses of sensory symptoms, limb weakness, and optic neuritis may occur. Subacute myelooptic
neuritis is restricted almost exclusively to Japanese people, and no further cases should be seen because the drug has been withdrawn.
Hereditary spinocerebellar ataxia syndromes can cause diagnostic dilemmas. If the syndrome is Friedreich ataxia, differentiation is easily made on clinical grounds,
but if only cerebellar and pyramidal signs develop, diagnosis may be difficult. The most vexing problem is to separate slowly progressive spastic paraparesis of MS
from hereditary spastic paraplegia or primary lateral sclerosis, especially if CSF studies and MRI are normal.
Vascular disease, arteriovenous malformations, tumors of brain or spinal cord, and arachnoid cysts can have relapsing-remitting signs. MRI is usually defining. The
effects of an Arnold-Chiari malformation can simulate MS clinically, but MRI findings are usually diagnostic. Cervical spondylotic myelopathy may simulate spinal MS;
MRI of the brain and CSF changes may indicate MS.
Common neurologic conditions, including cerebrovascular disease or cervical spondylosis, may be found in a patient who also has MS. Determination of whether new
symptoms are caused by relapse of MS or by the coexisting condition may be challenging. History, examination, and MRI are of greatest use in determining the
cause.
COURSE AND PROGNOSIS
The clinical course of MS varies. Exceptional cases are clinically silent for a lifetime; the typical pathologic findings are discovered only at autopsy. At the other
extreme, some cases are so rapidly progressive or malignant that only a few months elapse between onset and death.
Clinical observation of the course of MS led to the description of types. Relapsing-remitting MS is one type. This pattern is usually present at the outset and is
characterized by exacerbations followed by a variable extent of improvement, ranging from complete resolution of neurologic deficit to symptomatic residual
dysfunction. About 10% of patients have relatively few attacks throughout their life and accrue minimal disability. This is referred to as benign MS. Relapsing-remitting
MS frequently (approximately 85% of the time) evolves into a situation in which the course progresses slowly in between or in lieu of discrete attacks. This is referred
to as secondary-progressive MS.
Subsets have also been described. These descriptions have limitations because a relapsing-remitting course may occur for several years followed by a
chronic-progressive illness. Also, no universal agreement has been reached about the definition of relapse or remission. Determining if a patient is having a relapse
may be difficult, especially in mild cases, and the assessment is often made in retrospect.
There is no discernible difference in MRI activity between relapsing-remitting and secondary-progressive MS, and the change of course does not indicate a change in
the inflammatory process. This is supported by newer information that the b-interferons appear to be beneficial in the treatment of both these phases of MS.
Primary-progressive MS has some different characteristics from the other types of MS and is discussed more fully below as a variant.
The diagnostic use of evoked potentials, CSF OCBs, and MRI has changed concepts about the course of MS. People once thought to have a mild neurologic disorder
of undetermined cause are now included as having probable or definite MS, altering the incidence and prevalence data of clinical subtypes.
The question most frequently asked by patients is that of prognosis. Unfortunately, no reliable prognostic indicators are available, and the generalizations that follow
may not be applicable in individual cases. The characteristics of a good prognosis in order of usefulness are minimal disability 5 years after onset, complete and rapid
remission of initial symptoms, age 35 years or less at onset, only one symptom in the first year, acute onset of first symptoms, and brief duration of the most recent
exacerbation. In general, onset with sensory symptoms or mild optic neuritis is also associated with a good prognosis. Poor prognostic indicators include
polysymptomatic onset, cerebellar signs of ataxia or tremor, vertigo, or corticospinal tract signs.
Disability and work capacity are important concerns in any chronic disease with onset from 15 to 55 years ( Table 133.8). Overall, MS has only a modest effect on life
expectancy, but disability is a major issue. After 10 years, 70% of MS patients are not working full-time because of cognitive and memory disorders, spastic
paraparesis, poor coordination, and sphincter dysfunction.
TABLE 133.8. WORKING CAPACITY AND SURVIVAL IN 800 PATIENTS WITH MULTIPLE SCLEROSIS
Death from MS itself is rare. Bronchopneumonia after aspiration or respiratory insufficiency is the most common cause of death. Other causes include cardiac failure,
malignancies (as would be expected in older patients regardless of MS), septicemia (decubitus ulcers, urinary infections), and suicide.
In the last few decades, average survival has increased from 25 years to 35 years after onset, probably as a result of better management of infection and decubitus
ulcers.
VARIANTS OF MULTIPLE SCLEROSIS
Several variants of MS are recognized. The typical form of relapsing-remitting disease, which often evolves into more progressive disease, is called the Charcot
variant. Primary-progressive MS differs from the more common form because it is progressive from the outset and distinct exacerbations do not occur. It accounts for
about 10% of MS cases and is more common in older men. Brain MRI lesions tend to be sparse or absent, and this seems to be mainly a spinal cord syndrome. Not
infrequently, optic neuropathy is present as demonstrated by visual evoked responses (VERs). The pathology tends to show a less exuberant immune inflammatory
component than in more typical disease. OCBs are, however, found in the CSF in over 50% of patients. The course is more relentless than that of typical MS.
A more rapidly progressive disease with severe disability and frequently death in the first year is the Marburg variant. The pathology usually shows more exuberant
inflammation and axonal loss than in the Charcot variant. Some patients have a fulminant myelitis with optic neuritis, which is frequently bilateral; this combination is
called the Devic syndrome. Some consider it a separate disease because of the severely necrotic lesions and a relative paucity of immune active cells. However,
many cases with typical pathology of Devic syndrome have had a previous course consistent with the Charcot variant and many cases have lesions that elsewhere
are indistinguishable from classic MS.
Schilder disease appears to be fulminant MS in children. The pathology is similar to that of MS, but confluent lesions involving both hemispheres are typical. The
concentric sclerosis of Balo also occurs primarily in children. The course is similar to typical MS but the pathology is strikingly different and characterized by
concentric rings of inflammation and demyelination. It is not known how this pattern comes about.
Although these variants are unusual, without clear knowledge of etiology and pathogenesis it is impossible to state authoritatively whether they are separate diseases
or forms of MS.
Finally, some paroxysmal inflammatory CNS disorders in adults are equivocally related to MS. Cases of recurrent optic neuritis without any evidence of other neuraxis
involvement are well known. Similarly, recurrent episodes of myelitis may occur without other CNS lesions. The CSF may be inflammatory, but OCBs are often absent.
ADEM may be clinically indistinguishable from an attack of MS. Lesions tend to be more inflammatory and less demyelinating than MS plaques. ADEM is
characteristically a monophasic illness and may be more of a cognate for EAE than MS. Recurrences have been reported, but unless there is a distinct immune
stimulant, it is hard to understand why these cases should not be classified as MS.
MANAGEMENT
MS presents a major challenge for the physician. The fact that no known cure exists is often interpreted as meaning that no treatment is effective. This error leads to
neglect of symptoms and complications that are amenable to prevention and treatment. The skepticism and pessimism pervasive among physicians are based in large
part on the long list of ineffective therapeutic regimens that have been tried. Although no cure is in sight, the results of controlled therapeutic trials with b-interferons
suggest that the natural history of MS can be favorably altered.
Before making specific recommendations about treatment, some general guidelines are appropriate:
1. The patient and family should be informed of the diagnosis by specific name when it is firmly established, so they can begin to accept the diagnosis and can
avail themselves of all accessible services.
2. The disease should be explained in understandable terms, with a realistic but best possible prognosis.
3. At first, the patient should be reevaluated at short intervals for counseling and support and then at regular intervals to monitor possible complications and to
evaluate progress.
4. The patient should be given realistic information about the goals of therapy and should participate in decisions (e.g., adjustment of antispastic medication).
5. Patients with MS have complex problems, and many benefit from care at MS centers, where a team approach provides comprehensive service.
6. The patient should be informed about local and national MS societies that provide educational material, support groups, and other services.
Therapeutic regimens are either disease specific (immunosuppressive or immunomodulatory) or symptomatic. If the symptoms of an acute attack are severe enough
to warrant treatment, methylprednisolone is given in a dose of 1 g by intravenous infusion daily for 7 to 10 days. This is followed by oral prednisone in a tapering
schedule. A typical tapering regimen follows: prednisone 80 mg daily for 4 days; followed by 60, 40, 20, 10, and 5 mg each for 4 days; and then four doses of 5 mg on
alternate days. Tapering schedules are arbitrary and are often empiric or based on speculative theoretic considerations. They may be considerably longer or shorter
than the one described.
Alternatively, corticotropin may be given, but it has lost favor because it seems to give less rapid improvement. In controlled trials, steroid therapy hastens recovery
from acute attacks, but it is not clear whether it affects the eventual outcome. Both CSF pleocytosis and MRI findings are reduced in patients who receive intravenous
high-dose steroid therapy. A shorter (3-day) high-dose intravenous methylprednisolone treatment was compared with oral steroids and placebo over a 2-year period
in patients with a first episode of optic neuritis alone. The effect on speeding up recovery without influencing eventual outcome was confirmed. Retrospective data
analysis suggested that the development of MS was delayed in the intravenous methylprednisolone group. The 3-day course of intravenous high-dose cortico-steroids
is a matter of convenience and has never been demonstrated to be as effective as longer courses.
In the short term, adverse effects of corticosteroids are usually minimal or transitory. Psychologic agitation is perhaps most common and should be treated if it occurs.
Avascular necrosis of joints is rare but can occur regardless of the steroid dose. Patients who have frequent relapses and are treated repeatedly with steroids,
however, are at risk of serious adverse effects. To minimize these effects, the steroid dosage is tapered and calcium carbonate supplements (650 mg two times per
day) are given to forestall osteoporosis. Chronic oral steroid use has no merit, either daily or on alternate days, because this treatment does not alter the course of the
disease.
In 1993, the first practical treatments for use in early MS that affected the course of the disease became available in the United States and subsequently in other
countries. Two classes of medications are now in use. b-Interferon is available in two preparations with a third expected soon. The first released was b-interferon-1b
(Betaseron), a form chemically modified from naturally occurring human b-interferon. This medication is given on alternate days subcutaneously in a dose of 0.250
mg. b-Interferon-1a (Avonex) is chemically unaltered and is given intramuscularly once week in a dose of 30 g. Rebif is also classified as a b-interferon-1a but is not
yet commercially available. In initial trials it was given three times weekly in doses of 22 or 44 g subcutaneously. In placebo-controlled studies, all three forms of
b-interferon have given remarkably similar results. They all seem to reduce the frequency of attacks in the relapsing-remitting phase by about 30%. The severity of
attacks also seems to be reduced. Favorable effects on MRI changes have also been noted. Most important, a favorable effect on the development of disability is now
being established for these medications. Studies in progressive disease are also being concluded; one published study of Betaseron confirms its usefulness in
retarding progression. Similar results can be anticipated for the other b-interferons.
The b-interferons are well tolerated. Early in treatment a flulike syndrome may follow each injection but rarely lasts longer than 24 hours. It may include myalgia,
arthralgia, headache, and fever, which dissipate in about a month. Taking the medication in the evening and with acetaminophen or a nonsteroidal anti-inflammatory
drug often ameliorates the syndrome. Low doses of corticosteroids at the outset of treatment have also been advocated. Rarely, these symptoms persist and force
discontinuation of treatment. Some patients find that their function decreases the day after an injection, and this may also necessitate discontinuation. Hepatic
abnormalities and bone marrow depression may occur but rarely necessitate discontinuation. Periodic blood studies are advisable in the first 2 years of
administration. Although there is no known danger to the fetus, manufacturers have indicated pregnancy (including the period of conception and breastfeeding) as a
contraindication to the use of the b-interferons. Depression is commonly thought to be caused by the b-interferons, but there is no scientific support for this contention,
based solely on anecdote.
All these medications can be self-administered, if neurologic function permits. Neutralizing antibodies against b-interferon may appear and render treatment
ineffective. Development of antibodies seems to be more frequent with Betaseron (approximately 25%), intermediate with Rebif, and least frequent with Avonex (5% to
10%). The subcutaneous route for injection may be a factor in antibody development. If antibodies interfere, medication should probably be stopped and alternative
treatment considered.
There is now debate about the optimum route of administration and dosage, the intensity of which is matched only by the lack of directly comparable information.
Unfortunately, the information is unlikely to be forthcoming, because it would require a direct comparison of the medications, and the expense of such a study would
be staggering.
The other disease-specific therapy currently available is glatiramer acetate (Copaxone or copolymer I), a mixture of polymers of four amino acids. One of the
sequences is a nonencephalitogenic peptide fragment of MBP. It has been demonstrated to have effects similar to the b-interferons on exacerbation frequency and
attack severity. However, effects on MRI lesions or development of disability are less well established. Some consider this to be the drug of choice in early mild cases,
as suggested by controlled studies. Its effect on progressive problems is currently being studied. Glatiramer acetate is given subcutaneously on a daily basis. It is not
associated with systemic symptoms or abnormalities; some patients report chest pressure similar to angina, but there is no evidence of cardiac ischemia. The
injections can be associated with intense but brief pain. When disease-specific treatment first became available, fewer patients accepted treatment then was
anticipated. The reasons were diverse but included reluctance to take injections and disappointment because of the partial effect. As evidence accrued of a favorable
effect on progression, the importance of early treatment became more apparent. The current recommendation of the National Multiple Sclerosis Society is that all
patients with clinically definite exacerbating disease should be taking medication. In view of the information supporting the use of b-interferon in progressive illness,
many experts are treating MS patients as well. A study of Avonex is designed to determine the benefit of taking b-interferon before a second attack occurs.
Severe and frequent relapses or rapidly progressive MS pose a difficult therapeutic problem. This may occur at the outset of the disease or later even with treatment
with one of the prophylactic agents. Typically, these patients have no response to high-dose intravenous steroids or, more frequently, have a modest initial response
and minimal responses with subsequent cycles of therapy. If a b-interferon is being administered, it is appropriate to determine the neutralizing antibody level.
Alternative treatments that may be used are mainly the immunosupressants. Cyclophosphamide is used in monthly pulse doses of 800 to 1,000 mg/m 4 helper cells,
and some consider this a theoretic advantage.
Azathioprine taken orally in a dose of 1 to 2 mg/kg body weight merits mention. As with all other such agents, its use is limited by toxicity, and reliable controlled
studies are wanting. Mitoxantrone has been widely used in Europe. Methotrexate taken in doses similar to those used in rheumatoid arthritis (7.5 to 15 mg orally once
a week) is modestly effective in progressive disease. It should be considered in situations when prophylactic agents or more intensive chemotherapy is not indicated.
In a disease that cannot be prevented or cured, symptomatic therapy is important to minimize functional impairment and discomfort. Spasticity with stiffness, painful
flexor or extensor spasms, and clonus are major causes of disability. If untreated, contractures may develop and increase disability. Baclofen is the most commonly
used drug at a dose of 40 to 80 mg/day in divided doses. If tolerated, higher doses may be used in severe cases. Diazepam or dantrolene may be added or
substituted if necessary. Tizanidine in doses up to 24 mg daily may also be considered. It supposedly does not cause as much weakness as the other antispasticity
agents but sedation is a major problem with tizanidine, and very slow titration is required. For localized adductor spasms, injections of botulinum toxin may be useful.
However, the large muscle groups involved required large doses of medication and antibody production rapidly develops. In resistant cases, baclofen may be
administered intrathecally with an indwelling catheter and implantation of a reservoir pump. Only patients who have a beneficial effect with an intrathecal test bolus
dose of 50 to 100 g baclofen should have the pump implanted. Adverse effects are not common but include meningitis and seizures. Cracks in the tubing may
develop and should be considered if effect is rapidly lost. In addition to relief of spasticity, bladder symptoms frequently improve. The dosage of all antispastic agents
must be monitored and titrated with the clinical response; flaccidity and unmasked weakness changes in mentation may result in functional deterioration.
Bladder management is important to prevent debilitating and life-threatening infections or stone formation and to allow maximum functional independence. The basic
problem may be failure to retain urine, excessive urinary retention, or a combination of the two. In all these problems, the symptoms of urgency, frequency, and
incontinence are similar. The most important measures are postvoiding residuals, urine cultures, and, occasionally, urodynamic studies or renal ultrasound studies.
The atonic bladder with a residual volume over 100 mL is best managed by a program of clean intermittent self-catheterization. Cholinergic drugs, such as
bethanechol, carbachol, and pyridostigmine, are marginally and transiently effective in aiding bladder emptying. For acute urinary retention during a relapse of MS,
phenoxybenzamine is the drug of choice because it induces relaxation of the bladder neck. Patients with bladder atony are susceptible to urinary infections. Some
authorities routinely use urine acidifiers, such as vitamin C, and urinary antiseptics, such as methenamine mandelate, for all such patients.
Detrusor muscle hyperexcitability that causes the spastic bladder is the most common cause of urinary urgency and incontinence in patients with MS. Oxybutinin is
the most effective agent in relieving symptoms, but other anticholinergic medications include propantheline, hycosamine, and imipramine. Tolterodine (Detrol), a
long-acting anticholinergic, has been released and decreases the frequency of dosing. A sustained-release form of oxybutinin is currently under study. The synthetic
antidiuretic hormone (vasopressin), desmopressin acetate, has been used with success as an intranasal spray, particularly for patients with nocturia. The usual dose
is 10 to 40 g at night. Serum osmolality and electrolytes should be measured weekly for the first month and then monthly as a precaution in these patients. Some
patients find a morning-after rebound effect that is unacceptable.
In patients with long-standing bladder disease, indwelling catheters may have to be used even though the risk of infection increases. Disposable catheters, periodic
irrigation, weekly catheter renewal, and urine acidifiers minimize infections. Bladder augmentation with a section of bowel has been helpful when bladder size has
diminished because of spasticity. A continent port may be placed on the abdominal wall to facilitate catheterization in appropriate situations. In late stages, suprapubic
cystostomy or urinary diversion procedures may be appropriate. In all patients with urinary symptoms, a urine culture should be obtained because treatment of
infection alone may suffice to relieve new symptoms.
Cerebellar symptoms are generally resistant to therapy. An occasional patient with disabling intention tremor may respond to propranolol or clonazepam.
Cryothalamotomy may be effective but is reserved for severe cases.
Painful radiculopathy or neuralgia and painful parasthesias may respond to carbamazepine or, if not tolerated, to phenytoin or amitriptyline. Less specific pain
syndromes may respond to nonsteroidal anti-inflammatory agents.
Fatigue may respond to amantadine or pemoline and to a change in work schedule. Methylphenidate is also used to control fatigue. Depression may contribute to
fatigue and usually responds to selective serotonin reuptake inhibitor antidepressants. Whether these drugs affect fatigue independent of depression is conjectural.
Constipation responds best to changes in diet, bulk-providing substances, and stool softeners. Laxatives are reserved for resistant cases. Bowel incontinence is less
common and is generally unresponsive to medication. Regularization of bowel habits seems the most useful approach. Anticholinergic drugs may be useful adjuncts.
Sexual dysfunction should be treated with counseling for both partners, but treatments exist to alleviate the problems. In the past, erectile dysfunction had been
treated with papaverine injections, alprostadil intracavernosal injections, or intraurethral suppositories or less effectively with vacuum devices designed to increase
penile blood flow. Although often successful, few patients continue to use these treatments. However, sildenafil citrate (Viagra) is successful in treating erectile
dysfunction in MS patients. Ease of use makes it likely to be of continuing benefit. In women, lubricating agents may help. The usefulness of sildenafil in restoring
orgasmic capability and lubrication is currently being studied in women with MS.
When paraparesis is severe, skin care is essential to prevent decubitus ulcers. Physical therapy and nursing care with adequate nutrition and hydration are valuable
in preventing painful disabling complications, such as decubitus ulcers, renal and bladder calculi, contractures, and intercurrent infections. When these complications
occur, aggressive attempts to relieve them often give gratifying results.
Diet therapy and vitamin supplements are frequently advocated, but no special supplementation or elimination diet has proved to be more beneficial than a
well-balanced diet that maintains correct body weight and provides sufficient roughage for bowel management. Other therapies, such as hyperbaric oxygen,
plasmapheresis, intravenous immunoglobulin, neurostimulation, cobra or bee sting venom, and acupuncture, are unproven, and any response to these treatments is
usually a result of coincidental spontaneous remission so often seen early in the disease.
Physical therapy should be applied judiciously with the goals of maintaining mobility in ambulatory patients or avoiding contractures in bedridden patients. Excessive
active exercise may exhaust the patient, and the increase in body temperature may cause transient symptoms. Swimming in cool water is the best active physical
therapy. Occupational therapy is important to assist patients in activities of daily living.
MS is one of the few diseases for which a cure is unavailable, yet a comprehensive therapeutic regimen supervised by an experienced and sympathetic physician can
give rewarding results.
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Rudick RA, Goodkin DE, Jacobs LD, et al. Impact of interferon beta-1a on neurologic disability in relapsing multiple sclerosis. The Multiple Sclerosis Collaborative Research Group (MSCRG).
Neurology 1997;49:358363.
Rudick RA, Simonian NA, Alam JA, et al. Incidence and significance of neutralizing antibodies to interferon beta-1a in multiple sclerosis. Multiple Sclerosis Collaborative Research Group (MSCRG)
[see comments]. Neurology 1998;50:12661272.
Sadovnick AD, Ebers GC, Wilson RW, Paty DW. Life expectancy in patients attending multiple sclerosis. Neurology 1992;42:991994.
Sibley WA. Therapeutic claims in multiple sclerosis. New York: Demos, 1992.
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Sorensen TL, Ransohoff RM. Etiology and pathogenesis of multiple sclerosis. Semin Neurol 1998;18:287294.
Staugaitis S, Roberts JK, Sacco RL, Miller JR, Dwork AJ. Devic type multiple sclerosis in an 81 year old woman. J Neurol Neurosurg Psychiatry 1998;64:417418.
Trapp BD, Peterson J, Ransohoff RM, Rudick R, Mork S, Bo L. Axonal transection in the lesions of multiple sclerosis. N Engl J Med 1998;338:278285.
Weiner HL, Mackin GA, Orav EJ, et al. Intermittent cyclophosphamide pulse therapy in progressive multiple sclerosis: final report of the Northeast Cooperative Multiple Sclerosis Treatment Group.
Neurology 1993;43:910918.
Weinshenker BG. The natural history of multiple sclerosis. Neurol Clin 1995;13:119146.
Weinshenker BG. The natural history of multiple sclerosis: update 1998. Semin Neurol 1998;18:301307.
Weinshenker BG, Issa M, Baskerville J. Long-term and short-term outcome of multiple sclerosis: a 3-year follow- up study. Arch Neurol 1996;53:353358.
CHAPTER 134. MARCHIAFAVA-BIGNAMI DISASE
MERRITTS NEUROLOGY
CHAPTER 134. MARCHIAFAVA-BIGNAMI DISASE

JAMES R. MILLER
Etiology
Pathology
Incidence
Symptoms and Signs
Diagnosis
Course
Treatment
Suggested Readings
Primary degeneration of the corpus callosum is clinically characterized by altered mental status, seizures, and multifocal neurologic signs. Demyelination of the
corpus callosum without inflammation is the primary pathologic feature, but other areas of the central nervous system may be involved. The disease was first
described by Marchiafava and Bignami in 1903.
ETIOLOGY
The cause is not known. The disease was first noted in middle-aged and elderly Italian men who consumed red wine. It has been described worldwide, however, and
is not confined only to drinkers of red wine. In some cases, alcohol consumption was not a factor. Nutritional deficiencies also have been implicated. The syndrome is
rare, however, even in severe malnutrition. Toxic factors have been suggested, but no agent has been implicated.
PATHOLOGY
The sine qua non is necrosis of the medial zone of the corpus callosum. The dorsal and ventral rims are spared. The necrosis varies from softening and discoloration
(Fig. 134.1) to cavitation and cyst formation. Usually, all stages of degeneration are found. In most cases, the rostral position of the corpus callosum is affected first.
The lesions arise as small symmetric foci that extend and become confluent. Although medial necrosis of the corpus callosum is the principal finding, there also may
be degeneration of the anterior commissure ( Fig. 134.2), the posterior commissure, centrum semiovale, subcortical white matter, long association bundles, and middle
cerebellar peduncles. All these lesions have a constant bilateral symmetry. Usually spared are the internal capsule, corona radiata, and subgyral arcuate fibers. The
gray matter is not grossly affected.
FIG. 134.1. Marchiafava-Bignami disease. Acute necrosis of corpus callosum and neighboring white matter of the frontal lobes. (From Merritt HH, Weisman AD. J
Neuropathol Exp Neurol 1945;4:155163.)
FIG. 134.2. Marchiafava-Bignami disease. Medial necrosis of the corpus callosum and anterior commissure with sparing of the margins. (Courtesy of Dr. P.I.
Yakovlev.)
Few diseases have such a well-defined pathologic picture. The corpus callosum may be infarcted as a result of occlusion of the anterior cerebral artery, but the
symmetry of the lesions, sparing of the gray matter, and occurrence of similar lesions in the anterior commissure, long association bundles, and cerebellar peduncles
are found only in Marchiafava-Bignami disease.
The microscopic alterations are the result of a sharply defined necrotic process with loss of myelin but relative preservation of axis cylinders in the periphery of the
lesions. There is usually no evidence of inflammation aside from a few perivascular lymphocytes. In most cases, fat-filled phagocytes are common. Gliosis is usually
not well advanced. Capillary endothelial proliferation may be present in the affected area, but no thrombi are seen.
The disease has been reported with central pontine myelinolysis or Wernicke encephalopathy in alcoholics and in nonalcoholic persons, thus suggesting a possible
common pathogenesis.
INCIDENCE
More than 100 cases have been reported, but the disease is probably more common. Before the advent of modern imaging, however, the diagnosis was rarely made
before death because the symptoms and findings are nonspecific. Genetic predisposition has been suspected because of the frequent reports in Italian men. The
onset is usually in middle age or late life.
SYMPTOMS AND SIGNS
The onset is usually insidious, and the first symptoms are so nonspecific that an accurate estimate of the exact time of onset is difficult. There is a mixture of focal and
diffuse signs of cerebral disease, especially dementia. In addition to memory loss and confusion, manic, paranoid, or delusional states may occur. Depression and
extreme apathy are typical.
DIAGNOSIS
Marchiafava-Bignami disease may be suspected when insidiously developing dementia, multifocal neurologic signs, and seizures occur in elderly, particularly
alcoholic, men. Computed tomography and especially magnetic resonance imaging have enhanced the ability to diagnose the disease before death. Either form of
imaging can show the typical callosal lesions and symmetric demyelinating lesions in other areas. Brain single-photon emission computed tomographies may also
prove useful in analysis of cases.
COURSE
The disease is usually slowly progressive and results in death within 3 to 6 years. There is a rare acute fever lasting days or weeks. In an occasional patient there is a
temporary remission. Some reports of reversibility exist, but the diagnosis has only been by imaging studies.
TREATMENT
There is no known therapy.
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CHAPTER 135. CENTRAL PONTINE MYELINOLYSIS
MERRITTS NEUROLOGY
CHAPTER 135. CENTRAL PONTINE MYELINOLYSIS

GARY L. BERNARDINI AND ELLIOTT L. MANCALL
Suggested Readings
In 1959, Adams, Victor, and Mancall described a distinctive, previously unrecognized disease characterized primarily by the symmetric destruction of myelin sheaths
in the basis pontis. They called it central pontine myelinolysis and numerous reports followed. The general term myelinolysis may be more appropriate because the
condition affects extrapontine brain areas as well.
Most patients who develop pontine myelinolysis have had documented hyponatremia, and serum sodium levels were corrected rapidly to normal or supranormal
levels. Chronic alcoholism and undernutrition are frequently associated with this condition. Pontine myelinolysis has been seen, however, in hyponatremic
nonalcoholic patients, including some with dehydration resulting from vomiting, diarrhea, or diuretic therapy; with postoperative overhydration; or with compulsive
water drinking. Severe malnutrition, including that resulting from extensive burn injuries, may be a predisposing condition. The main underlying factor to the
development of pontine myelinolysis in these cases seems to be too rapid the correction of serum sodium levels. Correction after hypernatremia rather than
hyponatremia has also been encountered. The condition has been described with increasing frequency in patients undergoing orthotopic liver transplantation. Pontine
myelinolysis is found in 0.28% to 9.8% of these cases.
The clinical manifestations vary from asymptomatic to comatose, although there may be signs of a generalized encephalopathy associated with low levels of serum
sodium. Neurologic signs and symptoms of myelinolysis usually appear within 2 to 3 days after rapid correction of sodium levels. Findings include dysarthria or
mutism, behavioral abnormalities, ophthalmoparesis, bulbar and pseudobulbar palsy, hyperreflexia, quadriplegia, seizures, and coma. Typically, a rapidly progressive
corticobulbar and corticospinal syndrome may be noted in a debilitated patient, often during an acute illness with associated electrolyte imbalance. Although the
patients are mute, coma is unusual. The patients may be locked-in; communication by eye blinking can sometimes be established. The course is rapid, and death
generally ensues within days or weeks of the onset of symptoms.
Extrapontine myelinolysis is seen in about 10% of all cases of pontine myelinolysis. Clinically, extrapontine myelinolysis can present with ataxia, irregular behavior,
visual field deficits, or movement disorders such as Parkinson disease or parkinsonism, choreoathetosis, or dystonia. The movement disorders can appear with or
without radiographic evidence of extrapontine myelinolysis. Bilateral symmetric involvement outside the pons may affect the cerebellum, putamen, thalamus, corpus
callosum, subcortical white matter, claustrum, caudate, hypothalamus, lateral geniculate bodies, amygdala, subthalamic nuclei, substantia nigra, or medial lemnisci.
Although most cases have been diagnosed only at autopsy, the syndrome can be diagnosed in life. The clinical diagnosis is supported by radiologic studies.
Computed tomography may be normal, especially early in the course, but computed tomography abnormalities include symmetric areas of hypodensity in the basis
pontis and extrapontine regions without associated mass effect. Magnetic resonance imaging is more sensitive in diagnosing the condition; lesions appear
hyperintense on T2-weighted images and hypointense on T1-weighted images but typically do not enhance ( Fig. 135.1). The lesions may take 2 weeks to appear on
magnetic resonance imaging. Brainstem auditory-evoked responses may demonstrate prolonged III-V and I-V latencies consistent with bilateral pontine lesions. An
electroencephalogram may show slowing and low voltage. Cerebrospinal fluid levels of protein and myelin basic protein may be elevated.
FIG. 135.1. A: T1-weighted sagittal magnetic resonance (MR) image in a 21-year-old alcoholic woman after rapid correction of severe hyponatremia, showing a
hypointense area in the basis pons consistent with the lesion of pontine myelinolysis. B: T2-weighted axial MR image in the same patient demonstrating the
characteristic centrally located hyperintense areas consistent with demyelination within the pons. (Courtesy of Dr. L. A. Heier.)
The principal pathologic change is demyelination; within affected areas, nerve cells and axon sheaths are spared, blood vessels are unaffected, and there is no
inflammation. In animal studies, the initial event after administration of hypertonic saline in hypotonic rats seems to be opening of the bloodbrain barrier, followed
sequentially by swelling of the inner loop of the myelin sheath, oligodendrocyte degeneration, and release of macrophage-derived factors leading to the eventual
breakdown of myelin. Histologically, the lesion begins in the median raphe and may involve all or part of the base of the pons ( Fig. 135.2). The lesion may spread into
the pontine tegmentum or superiorly into the mesencephalon or involve bilateral extrapontine areas with or without concurrent basis pontis lesions. Microscopically,
the lesions resemble those of Marchiafava-Bignami disease.
FIG. 135.2. Central pontine myelinolysis. Histologic section through rostral pons showing characteristic lesion. (Courtesy of Dr. J. Kepes.)
The cause of pontine myelinolysis is uncertain. In those with hyponatremia that has been rapidly corrected to normal or supranormal levels, it is not clear whether the
low sodium, the rate of correction, or the absolute change in the serum sodium content is the causative factor. Symptoms are, however, more likely to develop with
rapid correction of chronic (more than 48 hours) rather than acute hyponatremia. In experimental animals, pontine myelinolysis develops in hyponatremic rats, rabbits,
or dogs treated rapidly with hypernatremic saline. Animals left with untreated hyponatremia did not develop neuropathologic changes. Therefore, attention has
focused on the rate of correction of the hyponatremia rather than on the hyponatremia itself as the mechanism of injury.
Prevention of myelinolysis includes judicious correction of hyponatremia with normal saline and free water restriction, discontinuation of diuretic therapy, and
correction of associated metabolic abnormalities and medical complications. Hyponatremic patients who are asymptomatic may not require saline infusion; those with
agitated confusion, seizures, or coma should be treated with normal saline until the symptoms improve. Based on clinical data and animal studies, there is a low
incidence of myelinolysis if the increase in serum sodium is less than or equal to 12 mmol/L in 24 hours. Late appearance of tremor and dystonia or cognitive and
behavioral changes have been reported in survivors. Full recovery has also been seen.
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Adams RD, Victor M, Mancall EL. Central pontine myelinolysis: a hitherto undescribed disease occurring in alcoholic and malnourished patients. Arch Neurol Psychiatry 1959;81:154172.
Ayus JC, Krothpalli RK, Arieff AI. Treatment of symptomatic hyponatremia and its relation to brain damage. N Engl J Med 1987;317:11901195.
Brunner JE, Redmond JM, Haggar AM, et al. Central pontine myelinolysis and pontine lesions after rapid correction of hyponatremia: a prospective magnetic resonance imaging study. Ann Neurol
1990;27:6166.
Donahue SP, Kardon RH, Thompson HS. Hourglass-shaped visual fields as a sign of bilateral lateral geniculate myelinolysis. Am J Ophthalmol 1995;119:378380.
Hadfield MG, Kubal WS. Extrapontine myelinolysis of the basal ganglia without central pontine myelinolysis. Clin Neuropathol 1996;15:96100.
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Kandt RS, Heldrich FJ, Moser HW. Recovery from probable central pontine myelinolysis associated with Addison's disease. Arch Neurol 1983;40:118119.
Kleinschmidt-Demasters BK, Norenberg MD. Rapid correction of hyponatremia causes demyelination: relation to central pontine myelinolysis. Science 1981;211:10681071.
Laureno R, Karp BI. Myelinolysis after correction of hyponatremia. Ann Intern Med 1997;126:5762.
Morlan L, Rodriguez E, Gonzales J, et al. Central pontine myelinolysis following correction of hyponatremia: MRI diagnosis. Eur Neurol 1990;30:149152.
Norenberg MD, Leslie KO, Robertson AS. Association between rise in serum sodium and central pontine myelinolysis. Ann Neurol 1982;11:128135.
Rojiani AM, Cho ES, Sharer L, et al. Electrolyte-induced demyelination in rats. 2. Ultrastructural evolution. Acta Neuropathol 1994;88:293299.
Salerno SM, Kurlan R, Joy SE, et al. Dystonia in central pontine myelinolysis without evidence of extrapontine myelinolysis. J Neurol Neurosurg Psychiatry 1993;56:12211223.
Schrier RW. Treatment of hyponatremia. N Engl J Med 1985;312:11211122.
Thompson DS, Hutton JT, Stears JC, et al. Computerized tomography in the diagnosis of central and extrapontine myelinolysis. Arch Neurol 1981;38:243246.
Wright DG, Laureno R, Victor M. Pontine and extrapontine myelinolysis. Brain 1979;102:361385.
CHAPTER 136. NEUROGENIC ORTHOSTATIC HYPOTENSION AND AUTONOMIC FAILURE
MERRITTS NEUROLOGY
SECTION XX. AUTONOMIC DISORDERS

CHAPTER 136. NEUROGENIC ORTHOSTATIC HYPOTENSION AND AUTONOMIC FAILURE
LOUIS H. WEIMER
Multiple System Atrophy

Pure Autonomic Failure
Suggested Readings
MULTIPLE SYSTEM ATROPHY
In 1960, Shy and Drager described two patients with generalized autonomic failure and additional findings in other central and peripheral systems. This combination
differed from the pure autonomic failure (PAF) described in 1925 by Bradbury and Eggleston. Currently, the Shy-Drager syndrome with initial or predominate
autonomic failure is considered a manifestation of multiple system atrophy (MSA). Distinguishing this form of MSA from PAF or idiopathic Parkinson disease (PD) is
still clinically challenging.
Autonomic failure is the hallmark of Shy-Drager syndrome, but demonstrable evidence of autonomic dysfunction is eventually found in 97% of patients clinically
diagnosed with any form of MSA (see Chapter 114). Orthostatic hypotension (OH) or syncope is often the first recognized and most disabling symptom. However,
other autonomic symptoms often predate OH, including impotence or ejaculatory dysfunction, decreased sweating, and urinary and less commonly fecal incontinence.
Postprandial hypotension starting 10 to 15 minutes after a meal can be disabling. Parkinsonism is common with rigidity and bradykinesia more prominent than rest
tremor but may be mild or not evident for several years after the onset of autonomic failure. Parkinsonian symptoms usually respond poorly to levodopa therapy, yet
some have initial symptomatic relief. Levodopa therapy may also exacerbate or unmask underlying OH. Cerebellar and corticospinal tract signs provide evidence of
multisystem involvement. Less commonly, fasciculations and amyotrophy are evident, as in one of the two original cases. Rarely, peripheral neuropathy or signs of a
mild frontal lobe dementia are seen. Inspiratory stridor is a frequent feature with laryngeal muscle denervation. A variety of sleep disturbances and altered respiratory
patterns are common and include apnea producing hypoxemia and paroxysmal sleep movements.
Laboratory Data
An autonomic screening battery (Table 136.1) in addition to bedside tests can aid in establishing the diagnosis, especially before the development of OH. Formal
testing is also beneficial in MSA and in other cases of dysautonomia to characterize the individual autonomic problems, monitor progression, and assess treatment
effects. To enhance reliability, before testing patients should be free of autonomically active medications such as caffeine or nicotine, recovered from any acute
illness, and in a relaxed euvolemic state.
TABLE 136.1. TESTS OF AUTONOMIC FUNCTION
The degenerative process in MSA has a special predilection for Onuf nucleus, spinal somatic motor neurons that serve voluntary urinary and anal sphincter function.
Concentric needle electromyography of striated sphincters may show chronic partial denervation, an important diagnostic sign in all forms of MSA, not simply
Shy-Drager syndrome. Paradoxically, these sphincter muscles are spared in amyotrophic lateral sclerosis. Formal sleep studies may document dangerous nocturnal
apneic episodes or other alterations of sleep or respiratory patterns. MSA patients have normal or mildly reduced supine resting levels of norepinephrine that fail to
show a normal increase on head-up tilt. PAF patients have low resting norepinephrine levels, which also fail to elevate with tilt.
Pathology
Demonstration of argyrophilic glial cytoplasmic inclusions in oligodendroglia (GCIs) has enhanced and refined the pathologic diagnosis of MSA over earlier
assessments based on patterns of neuronal loss and gliosis. However, the inclusions are occasionally seen in other disorders. GCIs are prominent in vital sites of
autonomic control such as the intermediolateral column of the spinal cord, dorsal vagal nucleus, solitary tract and nucleus, pontobulbar reticular formation, and
medullary tegmentum. GCIs correlate better with clinical findings than do areas of neuronal loss.
Diagnosis
Classification of MSA cases remains inexact before autopsy. The main difficulty is separating cases with initial autonomic failure from the rare PAF cases and, more
problematically, from idiopathic PD with autonomic features. Severe autonomic failure is rare in typical PD. However, autonomic symptoms and lesser degrees of
autonomic dysfunction are relatively common. When more marked autonomic failure occurs in PD, it tends to be later in the disease and in elderly patients.
Magalhes et al. (1995) retrospectively reviewed autonomic symptoms in 135 autopsy-proven cases of PD and MSA. One-third of the 33 MSA cases were
misdiagnosed as PD before autopsy. Autonomic symptoms at onset, stridor, and cerebellar signs were rare in PD patients in this series. The degree of
clonidine-induced growth hormone release has been proposed as an alternate test to separate MSA from PD.
Prognosis studies have divided MSA into parkinsonian (striatonigral degeneration) and cerebellar (sporadic OPCA) forms, without separate data on patients with
autonomic onset. In general, however, the prognosis is worse than for either PAF or PD with autonomic features or MSA without autonomic onset.
PURE AUTONOMIC FAILURE
Isolated PAF without involving other systems is rare but well described (idiopathic OH, Bradbury-Eggleston syndrome). Widespread autonomic failure is present with
prominent and often disabling OH. However, approximately 10% develop into MSA within 3 to 5 years. In contrast to MSA and idiopathic chronic pandysautonomia,
severe cholinergic impairment and gastrointestinal symptoms other than constipation are less apparent. Supine norepinephrine levels are reduced, and the response
to norepinephrine infusion is excessive because of denervation supersensitivity. Histopathology is predominantly that of degeneration of postganglionic sympathetic
neurons. Some loss of sympathetic neurons in the intermediolateral spinal cell column has been noted. Lewy bodies staining for ubiquitin may be seen in sympathetic
ganglia.
Other Causes of Autonomic Failure
A multitude of peripheral neuropathies show some degree of impairment in autonomic function on formal testing, especially in distal vasomotor and sudomotor
function. However, only some lead to frank clinically important autonomic failure with prominent OH. Particularly noteworthy causes include diabetes, amyloidosis,
paraneoplastic, selected hereditary neuropathies, and dopamine b-hydoxylase deficiency ( Table 136.2). Other disorders that disrupt central or peripheral autonomic
pathways may also lead to OH (Table 136.2) or less marked dysautonomia, especially lesions in the region of the third ventricle, posterior fossa, spinal cord,
autonomic ganglia, and small diameter nerve fibers. In addition, processes may be pathway specific such as predominantly cholinergic, regional, or organ specific.
TABLE 136.2. SELECTED DISORDERS OF AUTONOMIC FUNCTION
Treatment
Therapy of autonomic failure is aimed at symptomatic relief and improved quality of life. Treatment of OH, generally the most disabling symptom, depends on the
underlying mechanism. Asymptomatic hypotension on standing usually does not require treatment. Cerebral perfusion typically does not drop significantly until the
systolic pressure is reduced below 80 mm Hg due to compensatory effects of cerebrovascular autoregulation. Simple maneuvers are tried initially and may be
sufficient. Measures include maintaining the head and trunk at about 15 to 20 degrees higher than the legs in bed, which promotes the release of renin and stimulates
baroreceptors. This can be achieved with a hospital bed with head elevation or by placing blocks under the head of an ordinary bed. Counterpressure support
garments that provide abdominal and lower limb compression (such as Jobst half-body leotard) can reduce venous pooling, but patients often find these garments too
uncomfortable and cumbersome to put on, especially if they are hampered by other neurologic impairment. Physical countermaneuvers such as squatting and leg
crossing may provide some benefit. Particular care after situations that predictably lower blood pressure is prudent, including meals, vigorous exercise, hot
temperature, and motionless standing.
No single drug is ideal for the treatment of neurogenic OH. Common useful therapies include supplemental sodium chloride (2 to 4 g/day) to increase plasma volume
and, if necessary, fludrocortisone, starting at 0.1 mg/day to increase salt and water retention. The patient must be watched carefully to avoid excessive water
retention, rising blood pressure, or heart failure. Oral sympathomimetics, such as ephedrine, phenylephrine, and tyramine, are usually of limited benefit; however,
midodrine (a selective alpha-1 agonist now approved in the United States) is of proven benefit in OH. Anemia is a common exacerbating condition with autonomic
failure. Epoetin alpha (Epogen) increases hematocrit, reduces symptoms, and elevates systolic pressure an average of 10 to 15 mm Hg. Other drugs of potential but
less consistent benefit include indomethacin, somatostatin analogues, caffeine, ergot alkaloids, nocturnal desmopressin, and 3,4-dihydroxyphenylserine, which is
specifically indicated in the rare but distinctive hereditary dopamine b-hydoxylase deficiency. Concomitant treatment of urinary dysfunction, gastric and intestinal
dysmotility, impotence, and secretomotor dysfunction is often necessary. In MSA, inspiratory stridor may necessitate tracheostomy, and nocturnal positive pressure
ventilation may be needed for sleep apnea.
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CHAPTER 137. ACUTE AUTONOMIC NEUROPATHY
MERRITTS NEUROLOGY
CHAPTER 137. ACUTE AUTONOMIC NEUROPATHY

LOUIS H. WEIMER
Suggested Readings
Acute autonomic neuropathy (AAN) is rare, but there have been numerous reports since the initial description by Young et al. in 1975. Autonomic manifestations
include orthostatic hypotension, nausea and vomiting, constipation or diarrhea, bladder atony, impotence, anhidrosis, impaired lacrimation and salivation, and
pupillary abnormalities. Gastroparesis may be prominent. In pure dysautonomia, there is no somatic disturbance, but minor sensory findings are not uncommon, and
in severe cases cutaneous sensation may be markedly impaired. Motor involvement is less common. Roughly one-fourth of cases have a purely cholinergic form,
without orthostatic hypotension (OH), and rarely findings are restricted to gastrointestinal dysmotility. Although OH is the hallmark of the dysautonomia, exaggerated
orthostatic tachycardia may be evident without change in blood pressure. This has led to the proposal that a syndrome of orthostatic intolerance without OH (postural
orthostatic tachycardia syndrome) may be an attenuated form of AAN. This assertion is supported by abnormalities of sudomotor and other autonomic systems in
roughly one-half of cases and an antecedent viral infection at the same percentage, as seen in AAN. Symptoms include postural dizziness, palpitations, and
presyncope despite minimal changes in blood pressure. Possible etiologies are multiple, including distal loss of vasomotor control with excessive venous pooling,
volume depletion, and altered cerebrovascular autoregulation.
In pure dysautonomia, electromyography, nerve conduction velocities, sural nerve biopsy, and cerebrospinal fluid are normal. In complicated cases, these studies
may yield abnormalities blurring the distinction from Guillain-Barr syndrome. Additionally, autonomic involvement is common in typical Guillain-Barr syndrome and
may be a prominent cause of morbidity and mortality. Functional tests in AAN usually reveal widespread abnormalities of autonomic function ( Table 136.1).
The etiology of AAN is unknown, but many cases are presumed to be immune mediated and follow diverse viral infections. Sural nerve biopsies show epineural
mononuclear cell infiltrates. Symptoms may evolve for several weeks, plateau for many weeks, and then slowly improve. The differential diagnosis includes other
subacute neuropathies, such as paraneoplastic panautonomic neuropathy, Guillain-Barr syndrome, botulism, porphyria, and some drug or other toxic neuropathies.
Treatment is symptomatic based on the involved systems. Control of OH is typically most important. Anecdotal reports suggest that intravenous immune globulin
therapy may be effective. Recovery is slow and often incomplete.
SUGGESTED READINGS
Bennett JL, Mahalingam R, Wellish MC, et al. Epstein-Barr virus associated with acute autonomic neuropathy. Ann Neurol 1996;40:453455.
Fagius J, Westerburg CE, Olsson Y. Acute pandysautonomia and severe sensory deficit with poor recovery. A clinical, neurophysiological and pathological case study. J Neurol Neurosurg Psychiatry
1983;46:725733.
Hart RG, Kanter MC. Acute autonomic neuropathy: two cases and clinical review. Arch Intern Med 1990;150:23732376.
Heafield MTE, Gammage MD, Nightingale S, Williams AC. Idiopathic dysautonomia treated with intravenous gammaglobulin. Lancet 1996;347:2829.
Laiwah ACY, MacPhee GJA, Boyle MR, Goldberg A. Autonomic neuropathy in acute intermittent porphyria. J Neurol Neurosurg Psychiatry 1985;48:10251030.
Low PA, Dyck PJ, Lambert EH, et al. Acute panautonomic neuropathy. Ann Neurol 1983;13:412417.
McLeod JG, Tuck RR. Disorders of the autonomic nervous system. Ann Neurol 1987;21:419430, 519529.
Neville BG, Sladen OF. Acute autonomic neuropathy following primary herpes simplex infection. J Neurol Neurosurg Psychiatry 1984;47:648650.
Schondorf R, Low PA. Idiopathic postural orthostatic tachycardia syndrome. An attenuated form of acute pandysautonomia? Neurology 1993;43:132137.
Suarez GA, Fealey RD, Camilleri M, Low PA. Idiopathic autonomic neuropathy: clinical, neurophysiologic and follow-up studies on 27 patients. Neurology 1994;44:16751682.
Young RR, Asbury AK, Corbett JL, Adams RD. Pure pandysautonomia with recovery. Brain 1975;98:613636.
CHAPTER 138. FAMILIAL DYSAUTONOMIA
MERRITTS NEUROLOGY
CHAPTER 138. FAMILIAL DYSAUTONOMIA

ALAN M. ARON
Overview
Clinical Presentation
Diagnosis
Biochemical and Pathologic Data
Pathophysiology
Prognosis
Treatment
Suggested Readings
OVERVIEW
Familial dysautonomia was described by Riley et al. in 1949. The autonomic symptoms are prominent, but the condition also affects other parts of the nervous system
and general somatic growth. It is a rare autosomal recessive disease; more than 500 cases have been reported. Virtually all patients are of Eastern European
(Ashkenazi) Jewish descent where the carrier rate is 1 in 30. The causative gene has been mapped to chromosome 9q31-q33. There results a sensory and autonomic
neuropathy whose biochemical and genetic defects are yet to be defined. Linkage analyses using closely related markers have permitted reliable prenatal diagnosis
in families with a previously affected child.
The condition can be diagnosed in the perinatal period. Clinical manifestations tend to increase with age. Biochemical alterations point to decreased synthesis of
noradrenaline. Hypersensitivity to sympathomimetic drugs suggests a denervation type of supersensitivity. The exact pathophysiology has yet to be elucidated.
CLINICAL PRESENTATION
The dysautonomic infant frequently shows low birth weight and breech presentation. Neurologic abnormalities detected in the neonatal period include decreased
muscle tone, diminished or absent deep tendon reflexes, absent corneal responses, poor Moro response, and weak cry and suck. The tongue tip lacks fungiform
papillae and appears smooth. Uncoordinated swallowing with resultant regurgitation may cause aspiration and pneumonia. Some infants require tube feeding,
gastrostomy, and fundoplication because of gastroesophageal reflux. Absence of overflow tears, which may be normal for the first 3 months, persists thereafter and
becomes a consistent feature. Corneal ulceration can occur.
During the first 3 years of life, affected children show delayed physical and developmental milestones, episodic vomiting, excessive sweating, excessive drooling,
blotchy erythema, and breathholding spells. Dysautonomic crises occur after age 3, with irritability, self-mutilation, negativistic behavior, diaphoresis, tachycardia,
hypertension, and thermal instability. The most outstanding symptom is episodic vomiting, which may be cyclic and require hospitalization for stabilization with
parenteral hydration.
The school-aged dysautonomic child tends to have short stature, awkward gait, and nasal speech. School performance may be poor. As a group, patients score in the
average range on intelligence tests but they are frequently 20 or more points below unaffected siblings. Scoliosis is frequent and can begin in childhood and progress
rapidly during preadolescence. Some poorly developed patients show delayed puberty. Vomiting and vasomotor crises tend to decrease during adolescence when
more frequent symptoms center on decreased exercise tolerance, poor general coordination, emotional difficulties, and postural hypotension. Vasovagal responses
may occur after micturition or during laryngeal intubation for anesthesia. Up to one-third of patients have seizures during early life. These are usually associated with
fever, breathholding spells, or hypoxia. Less than 10% of patients have subsequent long-standing seizure disorders.
Patients show abnormal responses to altered atmospheric air. Hypercapnia and hypoxia do not produce expected increases in ventilatory effort. Drownings have
occurred, presumably because air hunger did not develop when submerged. Coma has occurred in patients at high altitudes.
DIAGNOSIS
The diagnosis should be made on the constellation of clinical symptoms and genetic background. The most distinctive sign is the absence or paucity of overflow
tearing. Low doses of methacholine may restore transient tearing. Other cardinal clinical features include hyporeflexia, absent corneal responses, and the absence of
the fungiform tongue papillae. This is associated with impaired taste sensation. There is relative indifference to pain, poor temperature control, and postural
hypotension.
Intradermal histamine phosphate in a dosage of 1:1,000 (0.03 to 0.05 mL) normally produces pain and erythema. Within minutes, a central wheal forms and is
surrounded by an axon flare that is a zone of erythema measuring 2 to 6 cm in diameter. The flare lasts for several minutes. In dysautonomic patients, pain is greatly
reduced and there is no axon flare. In infants, a saline solution of 1:10,000 histamine should be used. The methacholine test involves installation of one drop of 2.5%
methacholine into the eye. (One drop of dilute pilocarpine [0.0625%] is equivalent to 2.5% methacholine.) The other eye serves as control. The pupils are compared
at 5-minute intervals for 20 minutes. The normal pupil remains unchanged; the dysautonomic pupil develops miosis. The pupillary responses to light and
accommodation in familial dysautonomia appear normal.
The combination of axon flare response to intradermal histamine, miosis with methacholine or pilocarpine, and absent glossal fungiform pupillae are diagnostic.
Frequently, there is an elevated urinary homovanillic acidvanilylmandelic acid ratio. This assay is not required for diagnosis.
BIOCHEMICAL AND PATHOLOGIC DATA
The neuronal abnormality is probably present at birth, but subsequent degenerative changes seem to occur. The primary metabolic defect is unknown. Fibroblast
study has shown normal mitochondrial DNA and respiratory chain activity. Mitochondrial dysfunctions due to glycosphingolipid accumulation, changes in
mitochondrial DNA, or mutation of chromosome 9 genetic material in mitochrondial factions have not been demonstrated.
Serum levels of both norepinephrine and dopamine are markedly elevated during dysautonomic crises. Vomiting coincides with high dopamine levels; hypertension
correlates with increased norepinephrine levels. Pathologic data reveal hypoplastic cervical sympathetic ganglia with diminished volume and neuronal counts.
Sympathetic preganglionic spinal cord neurons seem to be reduced in number. Patients are deficient in type C fibers. The parasympathetic sphenopalatine ganglia
have shown the most depleted neuronal populations with only minimal reductions in the ciliary ganglia. The lingual submucosal neurons and sensory axons are
reduced. Tastebuds are scant; circumvallate papillae are hypoplastic.
PATHOPHYSIOLOGY
Gastroesophageal dysfunction, manifest by prolonged esophageal transit time, gastroesophageal reflux, and delayed gastric emptying, has been demonstrated by
scintigraphic analysis, cine radiography, PH monitoring, and endoscopy. There is severe oropharyngeal incoordination.
Cardiovascular instability is a prominent manifestation. Prolonged QT intervals greater than 440 mse without shortening during exercise demonstrate a defect in
autonomic regulation of cardiac conduction. Renal insufficiency, common in adult patients, can be assessed by noninvasive Doppler techniques to detect changes in
renal blood flow.
Sympathetic denervation may increase the responsiveness to regulators of cardiovascular integrity such as atrial natriuretic peptide. Medication can also influence
circulating atrial natriuretic peptide and cathecol amines.
Excessive drooling and swallowing difficulties are common and can be attributable to salivary gland denervation hypersensitivity. Hypersalivation may account for the
low caries rate and increased plaque formation.
Postural hypotension can be explained by peripheral sympathetic denervation. Skin blotching and hypertension are attributed to denervation supersensitivity at the
sympathetic effector sites. Lack of overflow tears correlates with the diminution of neurons in the sphenopalatine ganglia. Other symptoms can be explained as
manifestations of a diffuse sensory deficit and autonomic insufficiency with hypersensitivity to acetylcholine and possibly to catecholamines. In addition, there may be
decreased or dysfunctional adrenoceptors and decreased denervation.
PROGNOSIS
Long-term survival has been documented. Surviving patients include women whose pregnancies terminated in the birth of normal infants. Infant and childhood
fatalities may be due to aspiration pneumonia, gastric hemorrhage, or dehydration. A second cluster of fatalities between the ages of 14 and 24 showed pulmonary
complications, sleep deaths, and cardiopulmonary arrests. The oldest patients are now in their fifth decade.
TREATMENT
Laparoscopic surgery for performing a modified Nissen fundoplication and gastrostomy has modified gastroesophageal reflux and the resultant pulmonary
complications associated with aspiration. The use of epidural anesthesia has been advocated for surgical procedures such as Nissen fundoplication and cesarean
section. This is to avoid intubation and the sometimes fatal complications of general anesthesia. Midodrine, a peripheral a-adrenergic agonist, may be useful in the
management of orthostatic hypotension in a dose of 0.25 mg/kg/day. Symptomatic treatment is indicated for dysautonomic crises with parenteral fluids, diazepam,
sedation, and antiemetic therapy.
SUGGESTED READINGS
Alvarez E, Ferrer T, Perez-Conde C, et al. Evaluation of congenital dysautonomia other than Riley-Day syndrome. Neuropediatrics 1996;27:2631.
Axelrod FB. Familial dysautonomia: a 47-year perspective. How technology confirms clinical acumen. J Pediatr 1998;132[3 Pt 2]:S2S5.
Axelrod FB, Goldstein DS, Holmes C, et al. Genotype and phenotype in familial dysautonomia. Adv Pharmacol 1998;42:925928.
Axelrod FB, Krey L, Glickstein JS, et al. Atrial natriuretic peptide response to postural change and medication in familial dysautonomia. Clin Auton Res 1994;4:311318.
Axelrod FB, Porges RF, Seir ME. Neonatal recognition of familial dysautonomia. J Pediatr 1987;110:969948.
Blumenfeld A, Slaugenhaupt SA, Axelrod FB. Localization of the gene for familial dysautonomia on chromosome 9 and definition of DNA markers for genetic diagnosis. Nat Genet 1993;4:160164.
Eng-CM, Slaugenhaupt SA, Blumenfeld A, et al. Prenatal diagnosis of familial dysautonomia by analysis of linked CA-repeat polymorphisms on chromosome 9q31-q33. Am J Med Genet
1995;59:349355.
Glickstein JS, Schwartzman D, Friedman D, et al. Abnormalities of the corrected QT interval in familial dysautonomia: an indicator of autonomic dysfunction. J Pediatr 1993;122:925928.
Korczyn AD, Rubenstein AE, Yahr MD, Axelrod FB. The pupil in familial dysautonomia. Neurology 1981;31:628629.
Pearson J, Pytel B. Quantitative studies of sympathetic ganglia and spinal cord intermediolateral gray columns in familial dysautonomia. J Neurol Sci 1978;39:4759.
Pearson J, Pytel B. Quantitative studies of ciliary and sphenopalatine ganglia in familial dysautonomia. J Neurol Sci 1978;39:123130.
Riley CM, Day RL, Greely DM, Langford NS. Central autonomic dysfunction with defective lacrimation. I. Report of five cases. Pediatrics 1949;3:468478.
Smith AA, Dancis J. Responses to intradermal histamine in familial dysautonomiaa diagnostic test. J Pediatr 1963;63:889894.
Strasberg P, Bridge P, Merante F, Yeger H, Pereira J. Normal mitochondrial DNA and respiratory chain activity in familial dysautonomia fibroblasts. Biochem Mol Med 1996;59:2027.
Szald A, Udassin R, Maayan C, et al. Laparoscopic modified Nissen fundoplication in children with familial dysautonomia. J Pediatr Surg 1996;31:15601562.
Udassin R, Seror D, Vinograd I, et al. Nissen fundoplication in the treatment of children with familial dysautonomia. Am J Surg 1992;164:332336.
Weiser M, Helz MJ, Bronfin L, Axelrod FB. Assessing microcirculation in familial dysautonomia by laser Doppler flowmeter. Clin Auton Res 1998;8:1323.
CHAPTER 139. MIGRAINE AND OTHER HEADACHES
MERRITTS NEUROLOGY
SECTION XXI.PAROXYSMAL DISORDERS

CHAPTER 139. MIGRAINE AND OTHER HEADACHES
NEIL H. RASKIN
Migraine
Cluster Headache
Cough Headache
Coital Headache
Postconcussion Headaches
Giant Cell Arteritis
Lumbar Puncture Headache
Brain Tumor Headache
Suggested Readings
When headache is chronic, recurrent, and unattended by signs of disease, the physician confronts a challenging but ultimately gratifying problem. Previously, head
pain was thought to originate from either contracted scalp and neck muscles or vascular dilatation. Neither of these mechanisms achieved scientific support; central
mechanisms of head pain are of current interest. In migraine, the neurologic symptoms are attributed to neuronal dysfunction similar to that of spreading depression; a
phase of vasoconstriction and vasodilatation also undoubtedly occurs, as does a final phase that results in the secretion of vasoactive peptides. Most recurring
headaches are probably caused by impaired central inhibitory mechanisms at varying loci within the brain.
MIGRAINE
The term migraine derives from Galen's usage of hemicrania to describe a periodic disorder that comprises paroxysmal and blinding hemicranial pain, vomiting,
photophobia, recurrence at regular intervals, and relief by darkness and sleep. Hemicrania was later corrupted into low Latin as hemigranea and migranea; eventually
the French translation, migraine, gained acceptance in the 18th century and has prevailed ever since. This designation is misleading, however, because head pain is
lateralized in less than 60% of those affected. Furthermore, undue emphasis on the dramatic features of migraine has often led to the illogical conclusion that a
periodic headache lacking such characteristics is not migrainous in mechanism. Severe headache attacks, regardless of causation, are more likely to be throbbing
and associated with vomiting and scalp tenderness. Milder headaches tend to be nondescripttight bandlike discomfort often involving the entire head, the profile of
tension headache. These differing clinical patterns of headaches that are not caused by an intracranial structural anomaly or systemic disease are probably different
points on a continuum rather than disparate clinical entities. Whether a common mechanism underlies the different headaches remains to be determined.
A working descriptive definition follows. Migraine is a benign recurring headache, recurring neurologic dysfunction, or both; it is usually attended by pain-free
interludes and is almost always provoked by stereotyped stimuli. It is far more common in women; those affected have a hereditary predisposition toward attacks; and
the cranial circulatory phenomena that attend attacks seem to be due to a primary brainstem disorder.
Clinical Subtypes
The designation classic migraine (migraine with aura) denotes the syndrome of headache associated with characteristic premonitory sensory, motor, or visual
symptoms; common migraine (migraine without aura) denotes the syndrome in which no focal neurologic symptoms precede the headache. Focal symptoms, however,
occur in only a small proportion of attacks and are more common during headache attacks than as prodromal symptoms. Focal neurologic symptoms without
headache or vomiting are called migraine equivalents or accompaniments and seem to be more common in patients between the ages of 40 and 70 years. The term
complicated migraine is generally used to describe migraine with dramatic focal neurologic features, thus overlapping with classic migraine; it has also been used to
connote a persisting neurologic disorder after a migraine attack.
Common Migraine
Benign periodic headache lasting several hours and often attributed to tension by its sufferers is the most liberal way of describing common migraine. The fallacy
intrinsic to most of the traditionally acceptable definitions is that they define severe attacks but do not include patients with more modest degrees of head pain; thus,
unilateral pain, attendant nausea or vomiting, positive family history, responsiveness to ergotamine, and scalp tenderness in varying combinations have been alleged
to establish a diagnosis of migraine. Each of these occurs in 60% to 80% of patients as dependent variables, however, and the validity of using these clinical features
to diagnose migraine has never been established. Common migraine is the most frequent type of headache and includes the now anachronistic concept of periodic
tension headache.
Classic Migraine
The most common premonitory symptoms are visual, arising from dysfunction of occipital lobe neurons. Scotomas or hallucinations occur in about one-third of
migraineurs and usually appear in the central portion of the visual fields. A highly characteristic syndrome occurs in about 10% of patients; it usually begins as a small
paracentral scotoma that slowly expands into a C shape. Luminous angles appear at the enlarging outer edge and become colored as the scintillating scotoma
expands and moves toward the periphery of the involved half of the visual field. It eventually disappears over the horizon of peripheral vision; the entire process
consumes 20 to 25 minutes. This phenomenon never occurs during the headache phase of an attack and is pathognomonic of migraine; it has never been described
with a cerebral structural anomaly. It is commonly called a fortification spectrum because the serrated edges of the hallucinated C seemed to Dr. Hubert Airy to
resemble a fortified town with bastions all round it; spectrum is used in the sense of an apparition or specter.
Basilar Migraine
Symptoms implying altered brainstem function include vertigo, dysarthria, and diplopia; they occur as the only neurologic symptoms of migraine in about 25% of
patients. Bickerstaff called attention to a stereotyped sequence of dramatic neurologic events, often comprising total blindness and sensorial clouding; this is most
commonly seen in adolescent women but also occurs in others. The episodes begin with total blindness accompanied or followed by admixtures of vertigo, ataxia,
dysarthria, tinnitus, and distal and perioral paresthesia. In about 25% of patients, a confusional state supervenes. The symptoms usually persist for about 30 minutes
and are usually followed by a throbbing occipital headache. The basilar migraine syndrome also occurs in children or adults over age 50. Sensorial alterations,
including confusional states that may be mistaken for psychotic reactions, may last as long as 5 days.
Carotidynia
The carotidynia syndrome, sometimes called lower-half headache or facial migraine, is more prominent among older patients, with peak incidence at ages 30 to 69.
Pain is usually located at the jaw or neck and is sometimes periorbital or maxillary. It is often continuous, deep, dull, and aching and becomes pounding or throbbing
episodically. Sharp ice picklike jabs are commonly superimposed. Attacks occur one to several times a week, each lasting minutes to hours. Tenderness and
prominent pulsations of the cervical carotid artery and swelling of soft tissues over the carotid are usually present homolateral to the pain; many patients report
throbbing ipsilateral headache concurrent with carotidynia and interictally. Dental trauma is a common precipitant of this syndrome. Carotid artery involvement in the
more traditional forms of migraine is also common; more than 50% of patients with frequent migraine attacks show carotid tenderness at several points homolateral to
the cranial side involved in most of their attacks.
Hemiplegic Migraine
Hemiparesis occasionally occurs during the prodromal phase of migraine; like the fortification spectrum, it often resolves in 20 to 30 minutes, and contralateral head
pain then commences. The affected side may vary from attack to attack. A more profound form appears as hemiplegia, often affecting the same side, that persists for
days to weeks after headache subsides. A clear autosomal dominant pattern of attacks may appear within a family. The gene for familial hemiplegic migraine maps to
chromosome 19 in half the families; a mutation in a P/Q-type calcium channel (1-subunit gene has been identified. Dysarthria and aphasia occur in more than 50% of
patients; hemihypesthesia attends hemiparesis in nearly every case. There may be cerebrospinal fluid (CSF) pleocytosis as high as 350 cells/mm 3 or transient CSF
protein elevations to 200 mg/dL.
Ophthalmoplegic Migraine
Rarely, patients report infrequent attacks of periorbital pain accompanied by vomiting for 1 to 4 days. As the pain subsides, ipsilateral ptosis appears, and within
hours, a complete third nerve palsy occurs, often including pupillary dilatation. The ophthalmoplegia may persist for several days to as long as 2 months. After many
attacks, some ophthalmoparesis may remain. This syndrome usually begins in childhood, whereas the Tolosa Hunt syndrome, another painful ophthalmoplegia, is a
condition of adults.
Pathogenesis
Modern orientations toward migraine began with Liveing's 1873 publication, A Contribution to the Pathology of Nerve Storms, the first major treatise devoted to the
subject of migraine. He believed that the analogy of migraine to epilepsy was obvious and that the clinically apparent circulatory phenomena of migrainous attacks
were caused by cerebral discharges or nerve storms. In the 1930s, attention was focused on the vascular features of migraine by Graham and Wolff, who found that
the administration of ergotamine reduced the amplitude of temporal artery pulsations in patients and that this effect was often, but not consistently, associated with a
decrease in head pain. Therefore, many authorities believed for many years that the headache phase of migrainous attacks was caused by extracranial vasodilatation
and that neurologic symptoms were produced by intracranial vasoconstriction, the vascular hypothesis of migraine. A barrage of publications by Wolff and coworkers
supported the hypothesis, and observations made during the 1940s nonresonant with their hypothesis were ignored.
In 1941, K. S. Lashley, a neuropsychologist, was among the first to chart his own migrainous fortification spectrum. He estimated that the evolution of his own scotoma
proceeded across the occipital cortex at a rate of 3 mm/min. He speculated that a wave front of intense excitation was followed by a wave of complete inhibition of
activity across the visual cortex. Uncannily, in 1944, the phenomenon of spreading depression was described in the cerebral cortex of laboratory animals by the
Brazilian physiologist Leo. A slowly moving (2 to 3 mm/min) potassium-liberating depression of cortical activity is preceded by a wave front of increased metabolic
activity. Spreading depression can be produced by a variety of experimental stimuli, including hypoxia, mechanical trauma, and the topical application of potassium.
These observations, striking in retrospect, could not be incorporated into the vascular model of migraine. Cerebral blood flow studies, however, have rendered
untenable a primary vascular mechanism and support the possibility that spreading depression, or more likely a neuronal phenomenon with similar characteristics, is
important in the pathogenesis of migraine.
The mechanism of migraine can be partitioned into three phases. The first is brainstem generation; the second may be considered vasomotor activation in which
arteries within and outside the brain may contract or dilate. In the third phase, cells of the trigeminal nucleus caudalis become active and release vasoactive
neuropeptides at terminations of the trigeminal nerve on blood vessels, possibly explaining the soft tissue swelling and tenderness of blood vessels during migraine
attacks. Activation of any of the three phases is sufficient for headache production; one phase may dominate in an individual's migrainous syndrome. For example, the
fortification spectrum is probably entirely neurogenic, requiring only the first phase.
During attacks of classic migraine, studies of regional cerebral blood flow have shown a modest cortical hypoperfusion that begins in visual cortex and spreads
forward at a rate of 2 to 3 mm/min. The decrease in blood flow averages 25% to 30% (too little to explain symptoms) and progresses anteriorly in a wavelike fashion
that is independent of the topography of cerebral arteries. The wave of hypoperfusion persists for 4 to 6 hours, follows the convolutions of the cortex, and does not
cross the central or lateral sulcus but progresses to the frontal lobe via the insula. Subcortical perfusion is normal. Contralateral neurologic symptoms appear during
the period of temporoparietal hypoperfusion; at times, hypoperfusion persists in these regions after symptoms cease. More often, frontal spread continues as the
headache phase begins. A few patients with classic migraine show no abnormalities of blood flow; rarely, focal ischemia is sufficient to cause symptoms. Focal
ischemia, however, does not appear necessary for focal symptoms to occur. In attacks of common migraine, no abnormalities of blood flow have been seen. The
changes in cerebral blood flow are attributed to alterations of cerebral neuronal function. The cortical events require a generator, which has been identified within
the brainstem.
Pharmacologic data converge on serotonin receptors. About 35 years ago, methysergide was found to antagonize peripheral actions of serotonin
(5-hydroxytryptamine) and was introduced as the first drug capable of preventing migraine attacks by stabilizing the basic fault. Platelet levels of serotonin fall at the
onset of headache, and migrainous episodes can be triggered by drugs that release serotonin. These changes in circulating levels proved to be pharmacologically
trivial, however, and interest in the role of serotonin declined, only to be revived by the introduction of sumatriptan, which is remarkably effective for migraine attacks.
Sumatriptan is a designer drug synthesized to activate selectively a particular subpopulation of serotonin receptors.
The main families of serotonin receptors are types 1, 2, 3, and 4; within each family are receptor subtypes. Sumatriptan interacts as an agonist with 1A receptors and
especially with 1D and 1B receptors. By contrast, dihydroergotamine, another drug effective in aborting migraine attacks, is most potent as an agonist of 1A receptors
but is an order of magnitude less potent at 1D and 1B receptors. After systemic administration, dihydroergotamine in the brain is found in highest concentrations in the
midbrain dorsal raphe. The dorsal raphe contains the highest concentration of serotonin receptors in the brain and could be the generator of migraine and the main
site of drug action. Raphe receptors are mainly of 1A, but 1D receptors are also present.
Electrical stimulation near dorsal raphe neurons can result in migrainelike headaches. Projections from the dorsal raphe terminate on cerebral arteries and alter
cerebral blood flow. The dorsal raphe also projects to visual processing neurons in the lateral geniculate body, superior colliculus, retina, and visual cortex. These
projections could provide the anatomic and physiologic bases for the circulatory and visual characteristics of migraine. The dorsal raphe cells stop firing during deep
sleep, and sleep ameliorates migraine; antimigraine drugs also stop the firing of the dorsal raphe cells through a direct or indirect agonist effect ( Fig. 139.1). The
shutdown of an inhibitory system may enhance or stabilize neurotransmission.
FIG. 139.1. The actions of the antimigraine drugs at brainstem and forebrain synapses. The solid arrows indicate agonist properties; the segmented arrows indicate
inhibitory properties. (From Raskin NH. Headache, 2nd ed. New York: Churchill Livingstone, 1988.)
Migraine may therefore be considered a hereditary perturbation of central inhibitory mechanisms. Similar perturbations may underlie many types of head pain;
ordinary periodic headaches may be the noise of the normally functioning system.
Treatment
Nonpharmacologic treatments have been advocated, but rigorously controlled trials have shown no benefit without concomitant drug treatment. The mainstay of
therapy is the judicious use of one or more of the many drugs that are relatively specific for migraine.
Acute Treatment
In general, an adequate dose of whichever agent is chosen should be used at the onset of an attack. If additional medication is requested in 30 to 60 minutes
because symptoms have returned or have not abated, the initial dosage should be increased for subsequent attacks. Drug absorption is impaired during attacks
because of reduced gastrointestinal motility. Absorption may be delayed in the absence of nausea, and the delay is related to the severity of the attack but not to the
duration. Therefore, when oral agents fail, the major considerations revolve about rectal administration of ergotamine, subcutaneous sumatriptan, parenteral
dihydroergotamine, and intravenous chlorpromazine or prochlorperazine.
For patients with a prolonged buildup of headache, oral agents may suffice. When aspirin and acetaminophen fail, the addition of butalbital and caffeine to these
analgesics is highly effective; ibuprofen (600 to 800 mg) and naproxen (375 to 750 mg) are often useful. One or two capsules of isometheptene compound are
effective for mild to moderate stress headaches. When these measures fail, more aggressive therapy is considered.
A subnauseating dose of ergotamine, if possible, should be determined for the individual patient; a dose that provokes nauseaprobably a centrally mediated
effectis too high for therapy and may intensify head pain. The average oral dose of ergotamine is 3 mg (three 1-mg ergotamine-caffeine tablets); the average dose
of the 2-mg suppository is one-half (1 mg). Many patients use one-fourth of a suppository (0.5 mg) with an optimal result. Sumatriptan may be given as an oral 50-mg
dose, a 20-mg intranasal dose, or a 6-mg subcutaneous dose; the recurrence rate is high because of the short half-life of this drug (2 hours), and a second dose may
be necessary. Rizatriptan and zolmitriptan have similar success rates, and peak blood levels are achieved more quickly. Naratriptan has the best side-effect profile of
this group of drugs and the lowest recurrence rate; it is less effective than the other triptans.
Dihydroergotamine is available as a parenteral preparation and as a nasal spray. Peak plasma levels of dihydroergotamine are achieved 45 to 60 minutes after nasal
administration, 45 minutes after subcutaneous administration, 30 minutes after intramuscular administration, and 3 minutes after intravenous administration. If an
attack has not already peaked, subcutaneous or intramuscular administration of 1 mg suffices for about 90% of patients. A common intravenous protocol is the mixture
of prochlorperazine 5 mg and dihydroergotamine 0.5 mg given over 2 minutes (they are miscible).
When a patient's headache profile transforms into a chronic daily headache syndrome, opiate-type analgesics should be restricted to 2 days out of 7. The mainstay of
therapy for these patients is daily amitriptyline (30 to 100 mg) or nortriptyline (40 to 120 mg). For recalcitrant individuals, valproate (500 to 2,000 mg) or phenelzine
(45 to 90 mg) may be necessary. Drugs that have antidepressant effects act independent of such effects in migraine.
Prophylaxis
Several drugs can stabilize migraine and prevent attacks; for this purpose, the drugs must be taken daily ( Table 139.1). When to implement this approach depends on
the frequency of attacks and how effective the acute treatment is. At least two or three attacks a month could signal this approach. Usually a lag of about 2 weeks
must pass before an effect is seen; this may be the time needed to downregulate serotonin receptors. The major drugs and their daily dose are propranolol (60 to 240
mg), amitriptyline (30 to 100 mg), valproate (500 to 2,000 mg), verapamil (120 to 480 mg), phenelzine (45 to 90 mg), and methysergide (4 to 12 mg).
TABLE 139.1. DRUG STABILIZATION OF MIGRAINE
Phenelzine and methysergide are usually reserved for more recalcitrant headaches because of serious adverse effects. Because phenelzine is a monoamine oxidase
inhibitor, concomitant use of tyramine-containing foods, decongestants, or meperidine is contraindicated. Methysergide may cause retroperitoneal or cardiac valvular
fibrosis when it is used for more than 8 months; thus, monitoring is requisite for patients using this drug. Imaging of the pelvis and abdomen and cardiac auscultation
should be carried out at least yearly. The risk of the fibrotic complications is about 1 in 1,500 and is likely to reverse after the drug is stopped.
The probability of success with any one of the antimigraine drugs is about 60% to 75%. If one drug is assessed each month, the likelihood is high that stabilization will
be achieved within a few months. Most patients are managed successfully with propranolol or amitriptyline; for more urgent resolution, valproate, methysergide, or
phenelzine can be implemented. Once effective, the drug is continued for about 6 months, and the dose is then tapered slowly to assess continued need. Many
patients can discontinue medication and experience fewer and less severe attacks for a long time, thus suggesting that the drugs may alter the natural history of
migraine.
CLUSTER HEADACHE
Recognition of this disorder has been retarded by confusing names, including Raeder syndrome, histamine cephalalgia, and sphenopalatine neuralgia. Cluster
headache is firmly established as a distinct syndrome that is likely to respond to treatment. The episodic type, the most common, is characterized by one to three
short-lived attacks of periorbital pain each day for 4 to 8 weeks, followed by a pain-free interval for a mean of 1 year. The chronic form may begin de novo or may
appear several years after an episodic pattern has been established. The attacks are similar, but there are no sustained periods of remission. Either type may
transform into the other.
Men are affected more often than women in a proportion of about 8:1. Hereditary factors are usually absent. The prevalence is 69 cases per 100,000 people. Although
most patients begin experiencing headache between the ages of 20 and 50 years, the syndrome may begin as early as the first decade and as late as the eighth
decade. The cluster syndrome differs from migraine genetically, biochemically, and clinically. Propranolol and amitriptyline are largely ineffective in cluster headache.
However, lithium is beneficial for the cluster syndrome and ineffective in migraine. Nevertheless, the two disorders may blend into one in occasional patients,
suggesting that the mechanisms include some features in common.
Clinical Features
Periorbital or, less commonly, temporal pain begins without warning and reaches a crescendo within 5 minutes. It is often excruciating in intensity and is deep,
nonfluctuating, and explosive in quality; only rarely is it pulsatile. Pain is strictly unilateral and usually affects the same side in subsequent months. Attacks last from
30 minutes to 2 hours; the associated symptoms of homolateral lacrimation, reddening of the eye, nasal stuffiness, lid ptosis, and nausea often appear. Alcohol
provokes attacks in about 70% of patients but has no effect when the bout remits; this onoff vulnerability to alcohol is pathognomonic of cluster headache. Only
rarely do foods or emotional factors activate the mechanism, in contradistinction to migraine.
Periodicity of attacks is evident in at least 85% of patients. At least one of the daily attacks of pain recurs at about the same hour each day for the duration of a bout.
This clock mechanism is set for nocturnal hours in about 50% of patients; in these circumstances, the pain usually wakens patients within 2 hours of falling asleep.
Pathogenesis
No consistent changes in cerebral blood flow attend attacks of pain. Perhaps the strongest evidence pointing to a central mechanism is the periodicity; reinforcing
this conclusion are the bilateral autonomic symptoms that accompany the pain and are more severe on the painful side. The hypothalamus may be the site of
activation. The posterior hypothalamus contains cells that regulate autonomic functions, and the anterior hypothalamus contains cells (the suprachiasmatic nuclei)
that serve as the principal circadian pacemaker in mammals. Activation of both is necessary to explain the symptoms of cluster headache. The pacemaker is
modulated serotonergically through projections of the dorsal raphe. Therefore, both migraine and cluster headache may result from abnormal serotonergic
neurotransmission, albeit at different loci.
Treatment
The most satisfactory treatment is the administration of drugs to prevent cluster attacks until the bout is over. The major prophylactic drugs are prednisone, lithium,
methysergide, ergotamine, and verapamil. Lithium (600 to 900 mg daily) appears to be particularly effective for the chronic form. A 10-day course of prednisone,
beginning at 60 mg daily for 7 days and rapidly tapering, seems to curtail the bout for many patients. Ergotamine is most effective when given 1 or 2 hours before an
expected attack; for patients with a single nocturnal episode, 1 mg ergotamine in suppository formulation taken at bedtime may be all that is necessary. Patients must
be educated regarding the early symptoms of ergotism (limb claudication) when ergotamine is used daily; a weekly limit of 14 mg should be followed.
For the attacks themselves, oxygen inhalation (9 L/min given with a loose mask) is effective; 15 minutes of inhalation of 100% oxygen is often necessary. The
self-administration of intranasal lidocaine, either 4% topical or 2% viscous, to the most caudal aspect of the inferior nasal turbinate can deliver a sphenopalatine
ganglion block that is often remarkably effective for the termination of an attack. Sumatriptan, 6 mg subcutaneously, usually shortens an attack to 10 to 15 minutes.
COUGH HEADACHE
A male-dominated (4:1) syndrome, cough headache is characterized by transient severe head pain upon coughing, bending, lifting, sneezing, or stooping. Head pain
persists for seconds to a few minutes. Many patients date the origin of the syndrome to a lower respiratory infection accompanied by severe coughing or to strenuous
weight-lifting programs. Headache is usually diffuse but is lateralized in about one-third of patients. The incidence of serious intracranial structural anomalies causing
this condition is about 25%; the Arnold-Chiari malformation is a common cause. Magnetic resonance imaging is indicated for these patients. The benign disorder may
persist for a few years; it is inexplicably and remarkably ameliorated by indomethacin at doses of 50 to 200 mg daily. A large-volume (40 mL) lumbar puncture
dramatically terminates the syndrome for 50% of patients so treated.
Many patients with migraine note that attacks of headache may be provoked by sustained physical exertion, such as during the third mile of a 5-mile run. Such
headaches build up over hours and thus are distinctly different from the cough headache syndrome. The term effort migraine has been used for this syndrome to
avoid the ambiguous term exertional headache.
COITAL HEADACHE
In another male-dominated (4:1) syndrome, headaches occur during coitus, usually close to orgasm. They are abrupt in onset and subside in a few minutes if coitus is
interrupted. These headaches are nearly always benign and usually occur sporadically; if coital headaches persist for hours or are accompanied by vomiting,
subarachnoid hemorrhage must be evaluated by computed tomography or CSF examination. An unruptured aneurysm may result in a headache during coitus and can
be indistinguishable from benign coital headache; therefore, angiography should be considered for the first attack of coital headache. If attacks occur frequently and
are brief, however, the disorder is benign.
POSTCONCUSSION HEADACHES
After a seemingly trivial head injury and particularly after a rear-end motor vehicle collision, many people report admixtures of headache, vertigo, and impaired
memory and concentration for months or years after the injury. This syndrome is usually not associated with an anatomic lesion of the brain and may occur whether or
not the person was rendered unconscious by head trauma. In general, this headache is neurobiologic rather than psychologic. The syndrome usually persists long
after the settlement of a lawsuit. Some evidence suggests that concussion perturbs neurotransmission within the brain and that restoration of this condition is typically
delayed. Understanding this common problem is contingent upon clarification of the biology of cerebral concussion. Treatment is symptomatic, including repeated
encouragement that the syndrome eventually remits.
GIANT CELL ARTERITIS
This is a common disorder in elderly patients; the average annual incidence is 77 per 100,000 people aged 50 and older. Women account for 65% of cases, and the
average age at onset is 70 years, with a range of 50 to 85 years. The inflammatory process may result in blindness in 50% of patients if corticosteroid treatment is not
instituted; indeed, the ischemic optic neuropathy of giant cell arteritis is the major cause of rapidly developing bilateral blindness after age 60 years.
The most common initial symptoms are headache, polymyalgia rheumatica, jaw claudication, fever, and weight loss (see Chapter 155). Headache is the dominant
symptom and usually appears with malaise and muscle aches. Head pain may be unilateral or bilateral and is located temporally in 50% of patients but may involve
any and all aspects of the cranium. Pain usually appears gradually over a few hours before peak intensity is reached; occasionally, it is explosive in onset. The quality
of pain is only seldom throbbing; it is almost invariably described as dull and boring with superimposed episodic ice picklike lancinating pains similar to the sharp
pains that appear in migraine. Most patients can recognize that the origin of their head pain is superficial, and external to the skull, rather than deep within the
cranium (the site of pain in migraine). Scalp tenderness is present, often to a marked degree; brushing the hair or resting the head on a pillow may be impossible
because of pain. Headache is usually worse at night and is often aggravated by exposure to cold. Reddened tender nodules or red streaking of the skin overlying the
temporal arteries is found in highest frequency in patients with headache, as is tenderness of the temporal or, less commonly, the occipital arteries. Temporal artery
biopsy may be followed by cessation of headache.
The erythrocyte sedimentation rate is often but not always elevated; a normal erythrocyte sedimentation rate does not exclude giant cell arteritis. After the temporal
artery biopsy, prednisone is given at 80 mg daily for the first 4 to 6 weeks, when clinical suspicion is high. Because patients with migraine also report amelioration of
headaches with prednisone therapy, therapeutic responses are not diagnostic. Contrary to widespread notions, the prevalence of migraine among the elderly
population is substantial, considerably higher than that of giant cell arteritis.
LUMBAR PUNCTURE HEADACHE
Headache after lumbar puncture usually begins within 48 hours but may be delayed for up to 12 days. The mean incidence is about 30%. Head pain is dramatically
positional; it begins when the patient sits or stands upright and subsides on reclining or with abdominal compression. The longer the patient is upright, the longer the
latency before head pain subsides. It is worsened by head shaking or jugular vein compression. The pain is usually a dull ache but may be throbbing; the location is
occipitofrontal. Nausea and stiff neck often accompany headache, and some patients report blurred vision, photophobia, tinnitus, and vertigo. The symptoms resolve
over a few days but may persist for weeks or months.
Loss of CSF volume decreases the supportive cushion of the brain; when the patient is erect, vascular dilatation probably results and tension is placed on anchoring
intracranial structures, including the pain-sensitive dural sinuses. There is often intracranial hypotension, but the full-blown syndrome may occur with normal CSF
pressure.
Treatment is remarkably effective. Intravenous caffeine sodium benzoate given over a few minutes as a 500-mg dose promptly terminates headache in 75% of
patients; a second dose 1 hour later brings the total success rate to 85%. An epidural blood patch accomplished by injection of 15 mL of the patient's blood rarely fails
for those who do not respond to caffeine. The mechanism for these treatment effects is not clear because the blood patch has an immediate effect; thus, the sealing of
a dural hole with blood clot is an unlikely mechanism of action.
BRAIN TUMOR HEADACHE
About 30% of patients with brain tumors consider headache their chief complaint. The head pain syndrome is nondescript; a deep dull aching quality of moderate
intensity occurs intermittently, is worsened by exertion or change in position, and is associated with nausea and vomiting. This pattern of symptoms results from
migraine far more often than from brain tumor. Headache disturbs sleep in about 10% of patients. Vomiting that precedes the appearance of headache by weeks is
highly characteristic of posterior fossa brain tumors.
SUGGESTED READINGS
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Ferrari MD. Migraine. Lancet 1998;351:10431051.
Goadsby PJ. A triptan too far? J Neurol Neurosurg Psychiatry 1998;64:143147.
Goadsby PJ, Gundlach AL. Localization of 3H-dihydroergotamine binding sites in the cat central nervous system: relevance to migraine. Ann Neurol 1991;29:9194.
Grimson BS, Thompson HS. Raeder's syndrome. A clinical review. Surg Ophthalmol 1980;24:199210.
Hoskin KL, Kaube H, Goadsby PJ. Sumatriptan can inhibit trigeminal afferents by an exclusively neural mechanism. Brain 1996;119:14191428.
Lance JW, Goadsby PJ. Mechanism and management of headache, 6th ed. London: Butterworth Scientific, 1998.
Nyholt DR, Lea RA, Goadsby PJ, et al. Familial typical migraine. Neurology 1998;50:14281432.
Olesen J. Cerebral and extracranial circulatory disturbances in migraine: pathophysiological implications. Cerebrovasc Brain Metab Rev 1991;3:128.
Raps EC, Rogers JD, Galetta SL, et al. The clinical spectrum of unruptured intracranial aneurysms. Arch Neurol 1993;30:265268.
Raskin NH. Lumbar puncture headache: a review. Headache 1990;30:197200.
Raskin NH. Short-lived head pains. Neurol Clin 1997;15:143152.
Schraeder PL, Burns RA. Hemiplegic migraine associated with an aseptic meningeal reaction. Arch Neurol 1980;37:377379.
Silberstein SD. The pharmacology of ergotamine and dihydroergotamine. Headache 1997;37[Suppl]:S15S25.
Symonds C. Cough headache. Brain 1956;79:557568.
Weiller C, May A, Limmroth V, et al. Brain stem activation in spontaneous human migraine attacks. Nat Med 1995;1:658660.
CHAPTER 140. EPILEPSY
MERRITTS NEUROLOGY
CHAPTER 140. EPILEPSY

TIMOTHY A. PEDLEY, CARL W. BAZIL AND MARTHA J. MORRELL
Classification of Seizures and Epilepsy

Selected Generalized Epilepsy Syndromes
Selected Localization-Related Epilepsy Syndromes
Epidemiology
Initial Diagnostic Evaluation
Long-Term Monitoring
Medical Treatment
Reproductive Health Issues
Gene Defects in Epilepsy
Psychosocial and Psychiatric Issues
Suggested Readings
An epileptic seizure is the result of a temporary physiologic dysfunction of the brain caused by a self-limited, abnormal, hypersynchronous electrical discharge of
cortical neurons. There are many different kinds of seizures, each with characteristic behavioral changes and electrophysiologic disturbances that can usually be
detected in scalp electroencephalographic (EEG) recordings. The particular manifestations of any single seizure depend on several factors: whether most or only a
part of the cerebral cortex is involved at the beginning, the functions of the cortical areas where the seizure originates, the subsequent pattern of spread of the
electrical ictal discharge within the brain, and the extent to which subcortical and brainstem structures are engaged.
A seizure is a transient epileptic event, a symptom of disturbed brain function. Although seizures are the cardinal manifestation of epilepsy, not all seizures imply
epilepsy. For example, seizures may be self-limited in that they occur only during the course of an acute medical or neurologic illness; they do not persist after the
underlying disorder has resolved. Some people, for no discoverable reason, have a single unprovoked seizure. These kinds of seizures are not epilepsy.
Epilepsy is a chronic disorder, or group of chronic disorders, in which the indispensable feature is recurrence of seizures that are typically unprovoked and usually
unpredictable. About 40 million people are affected worldwide. Each distinct form of epilepsy has its own natural history and response to treatment. This diversity
presumably reflects the fact that epilepsy can arise from a variety of underlying conditions and pathophysiologic mechanisms, although most cases are classified as
idiopathic or cryptogenic.
CLASSIFICATION OF SEIZURES AND EPILEPSY
Accurate classification of seizures and epilepsy is essential for understanding epileptic phenomena, developing a rational plan of investigation, making decisions
about when and for how long to treat, choosing the appropriate antiepileptic drug, and conducting scientific investigations that require delineation of clinical and EEG
phenotypes.
Classification of Seizures
The classification used today is the 1981 Classification of Epileptic Seizures developed by the International League Against Epilepsy (ILAE) ( Table 140.1). This
system classifies seizures by clinical symptoms supplemented by EEG data.
TABLE 140.1. ILAE CLASSIFICATION OF EPILEPTIC SEIZURES
Inherent in the classification are two important physiologic principles. First, seizures are fundamentally of two types: those with onset limited to a part of one cerebral
hemisphere partial or focal seizures) and those that seem to involve the brain diffusely from the beginning ( generalized seizures). Second, seizures are dynamic and
evolving; clinical expression is determined as much by the sequence of spread of electrical discharge within the brain as by the area where the ictal discharge
originates. Variations in the seizure pattern exhibited by an individual imply variability in the extent and pattern of spread of the electrical discharge.
Both generalized and partial seizures are further divided into subtypes. For partial seizures, the most important subdivision is based on consciousness, which is
preserved in simple partial seizures or lost in complex partial seizures. Simple partial seizures may evolve into complex partial seizures, and either simple or complex
partial seizures may evolve into secondarily generalized seizures. In adults, most generalized seizures have a focal onset whether or not this is apparent clinically.
For generalized seizures, subdivisions are based mainly on the presence or absence and character of ictal motor manifestations.
The initial events of a seizure, described by either the patient or an observer, are usually the most reliable clinical indication to determine whether a seizure begins
focally or is generalized from the moment of onset. Sometimes, however, a focal signature is lacking for several possible reasons:
1. The patient may be amnesic after the seizure, with no memory of early events.
2. Consciousness may be impaired so quickly or the seizure generalized so rapidly that early distinguishing features are blurred or lost.
3. The seizure may originate in a brain region that is not associated with an obvious behavioral function; thus, the seizure becomes clinically evident only when the
discharge spreads beyond the ictal onset zone or becomes generalized.
Partial Seizures
Simple partial seizures result when the ictal discharge occurs in a limited and often circumscribed area of cortex, the epileptogenic focus. Almost any symptom or
phenomenon can be the subjective (aura) or observable manifestation of a simple partial seizure, varying from elementary motor (jacksonian seizures, adversive
seizures) and unilateral sensory disturbance to complex emotional, psychoillusory, hallucinatory, or dysmnesic phenomena. Especially common auras include an
epigastric rising sensation, fear, a feeling of unreality or detachment, deja vu and jamais vu experiences, and olfactory hallucinations. Patients can interact normally
with the environment during simple partial seizures except for limitations imposed by the seizure on specific localized brain functions.
Complex partial seizures, on the other hand, are defined by impaired consciousness and imply bilateral spread of the seizure discharge, at least to basal forebrain
and limbic areas. In addition to loss of consciousness, patients with complex partial seizures usually exhibit automatisms, such as lip-smacking, repeated swallowing,
clumsy perseveration of an ongoing motor task, or some other complex motor activity that is undirected and inappropriate. Postictally, patients are confused and
disoriented for several minutes, and determining the transition from ictal to postictal state may be difficult without simultaneous EEG recording. Of complex partial
seizures, 70% to 80% arise from the temporal lobe; foci in the frontal and occipital lobes account for most of the remainder.
Generalized Seizures
Generalized tonic-clonic (grand mal) seizures are characterized by abrupt loss of consciousness with bilateral tonic extension of the trunk and limbs ( tonic phase),
often accompanied by a loud vocalization as air is forcedly expelled across contracted vocal cords ( epileptic cry), followed by synchronous muscle jerking (clonic
phase). In some patients, a few clonic jerks precede the tonic-clonic sequence; in others, only a tonic or clonic phase is apparent. Postictally, patients are briefly
unarousable and then lethargic and confused, often preferring to sleep. Many patients report inconsistent nonspecific premonitory symptoms ( epileptic prodrome) for
minutes to a few hours before a generalized tonic-clonic seizure. Common symptoms include ill-defined anxiety, irritability, decreased concentration, and headache or
other uncomfortable feelings.
Absence (petit mal) seizures are momentary lapses in awareness that are accompanied by motionless staring and arrest of any ongoing activity. Absence seizures
begin and end abruptly; they occur without warning or postictal period. Mild myoclonic jerks of the eyelid or facial muscles, variable loss of muscle tone, and
automatisms may accompany longer attacks. When the beginning and end of the seizure are less distinct, or if tonic and autonomic components are included, the
term atypical absence seizure is used. Atypical absences are seen most often in retarded children with epilepsy or in epileptic encephalopathies, such as the
Lennox-Gastaut syndrome (defined later).
Myoclonic seizures are characterized by rapid brief muscle jerks that can occur bilaterally, synchronously or asynchronously, or unilaterally. Myoclonic jerks range
from isolated small movements of face, arm, or leg muscles to massive bilateral spasms simultaneously affecting the head, limbs, and trunk.
Atonic (astatic) seizures, also called drop attacks, are characterized by sudden loss of muscle tone, which may be fragmentary (e.g., head drop) or generalized,
resulting in a fall. When atonic seizures are preceded by a brief myoclonic seizure or tonic spasm, an acceleratory force is added to the fall, thereby contributing to
the high rate of self-injury with this type of seizure.
Classification of Epilepsy (Epileptic Syndromes)
Attempting to classify the kind of epilepsy a patient has is often more important than describing seizures, because the formulation includes other relevant clinical data
of which the seizures are only a part. The other data include historical information (e.g., a personal history of brain injury or family history of first-degree relatives with
seizures); findings on neurologic examination; and results of EEG, brain imaging, and biochemical studies.
The ILAE classification separates major groups of epilepsy first on the basis of whether seizures are partial ( localization-related epilepsies) or generalized
(generalized epilepsies) and second by cause (idiopathic, symptomatic, or cryptogenic epilepsy). Subtypes of epilepsy are grouped according to the patient's age and,
in the case of localization-related epilepsies, by the anatomic location of the presumed ictal onset zone.
Classification of the epilepsies has been less successful and more controversial than the classification of seizure types. A basic problem is that the classification
scheme is empiric, with clinical and EEG data emphasized over anatomic, pathologic, or specific etiologic information. This classification is useful for some
reasonably well-defined syndromes, such as infantile spasms or benign partial childhood epilepsy with central-midtemporal spikes, especially because of the
prognostic and treatment implications of these disorders. On the other hand, few epilepsies imply a specific disease or defect. A further drawback to the ILAE
classification is that the same epileptic syndrome (e.g., infantile spasms or Lennox-Gastaut syndrome) may be produced by a specific disease (e.g., tuberous
sclerosis), considered cryptogenic on the basis of nonspecific imaging abnormalities, or categorized as idiopathic. Another biologic incongruity is the excessive
detail in which some syndromes are identified, with specific entities culled from what are more likely simply different biologic expressions of the same abnormality
(e.g., childhood and juvenile forms of absence epilepsy).
With these reservations, there is little question that defining common epilepsy syndromes has practical value. Table 140.2 gives a modified version of the ILAE
classification, which continues to evolve.
TABLE 140.2. MODIFIED CLASSIFICATION OF EPILEPTIC SYNDROMES
SELECTED GENERALIZED EPILEPSY SYNDROMES
Infantile Spasms (West Syndrome)
The term infantile spasms denotes a unique age-specific form of generalized epilepsy that may be either idiopathic or symptomatic. When all clinical data are
considered, including results of imaging studies, only about 15% of patients are now classified as idiopathic. Symptomatic cases result from diverse conditions,
including cerebral dysgenesis, tuberous sclerosis, phenylketonuria, intrauterine infections, or hypoxic-ischemic injury.
Seizures are characterized by sudden flexor or extensor spasms that involve the head, trunk, and limbs simultaneously. The attacks usually begin before 6 months of
age. The EEG is grossly abnormal, showing chaotic high-voltage slow activity with multifocal spikes, a pattern termed hypsarrhythmia. The treatment of choice is
corticotropin or prednisone; spasms are notoriously refractory to conventional antiepileptic drugs. Vigabatrin, an antiepileptic drug that is not approved for use in the
United States but is widely available elsewhere, is an exception. Several small series indicate that vigabatrin is an effective alternative to corticotropin in selected
cases. Although corticotropin therapy usually controls spasms and reverses the EEG abnormalities, it has little effect on long-term prognosis. Only about 5% to 10%
of children with infantile spasms have normal or near-normal intelligence, and more than 66% have severe disabilities.
Childhood Absence (Petit Mal) Epilepsy
This disorder begins most often between the ages of 4 and 12 years and is characterized predominantly by recurrent absence seizures, which, if untreated, can occur
literally hundreds of times each day. EEG activity during an absence attack is characterized by stereotyped, bilateral, 3-Hz spike-wave discharges. Generalized
tonic-clonic seizures also occur in 30% to 50% of cases. Most children are normal, both neurologically and intellectually. Ethosuximide and valproate are equally
effective in treating absence seizures, but valproate or lamotrigine are preferable if generalized tonic-clonic seizures coexist. Topiramate may also be effective in
generalized-onset seizures.
Lennox-Gastaut Syndrome
This term is applied to a heterogeneous group of childhood epileptic encephalopathies that are characterized by mental retardation, uncontrolled seizures, and a
distinctive EEG pattern. The syndrome is not a pathologic entity, because clinical and EEG manifestations result from brain malformations, perinatal asphyxia, severe
head injury, central nervous system infection, or, rarely, a progressive degenerative or metabolic syndrome. A presumptive cause can be identified in 65% to 70% of
affected children. Seizures usually begin before age 4 years, and about 25% of children have a history of infantile spasms. No treatment is consistently effective, and
80% of children continue to have seizures as adults. Best results are generally obtained with broad-spectrum antiepileptic drugs, such as valproate, lamotrigine, or
topiramate. Despite the higher incidence of severe side effects, felbamate is often effective when these other agents do not result in optimal seizure control.
Refractory cases may be considered for corpus callosotomy.
Juvenile Myoclonic Epilepsy
This subtype of idiopathic generalized epilepsy most often begins in otherwise healthy individuals between the ages of 8 and 20 years. The fully developed syndrome
comprises morning myoclonic jerks, generalized tonic-clonic seizures that occur just after waking, normal intelligence, a family history of similar seizures, and an EEG
that shows generalized spikes, 4- to 6-Hz spike waves, and multiple spike (polyspike) discharges. The myoclonic jerks vary in intensity from bilateral massive
spasms and falls to minor isolated muscle jerks that many patients consider nothing more than morning clumsiness. Valproate is the treatment of choice and controls
seizures and myoclonus in more than 80% of cases. Lamotrigine or acetazolamide are alternatives, although lamotrigine can exacerbate myoclonus in some patients.
Some linkage studies have identified a marker for juvenile myoclonic epilepsy on the short arm of chromosome 6; the gene product is not known.
SELECTED LOCALIZATION-RELATED EPILEPSY SYNDROMES
Benign Focal Epilepsy of Childhood
Several benign focal epilepsies occur in children, of which the most common is the syndrome associated with central-midtemporal spikes on EEG. This form of
idiopathic focal epilepsy, also known as benign rolandic epilepsy, accounts for about 15% of all pediatric seizure disorders.
Onset is between 4 and 13 years; children are otherwise normal. Most children have attacks mainly or exclusively at night. Sleep promotes secondary generalization,
so that parents report only generalized tonic-clonic seizures; any focal manifestations go unobserved. In contrast, seizures that occur during the day are clearly focal
with twitching of one side of the face; speech arrest; drooling from a corner of the mouth; and paresthesias of the tongue, lips, inner cheeks, and face. Seizures may
progress to include clonic jerking or tonic posturing of the arm and leg on one side. Consciousness is usually preserved.
The interictal EEG abnormality is distinctive and shows stereotyped di- or triphasic sharp waves over the central-midtemporal (rolandic) regions. Discharges may be
unilateral or bilateral. They increase in abundance during sleep and, when unilateral, switch from side to side on successive EEGs. In about 30% of cases,
generalized spike-wave activity also occurs. The EEG pattern is inherited as an autosomal dominant trait with age-dependent penetrance. The inheritance pattern of
the seizures, although clearly familial, is probably multifactorial and less well understood. More than half the children who show the characteristic EEG abnormality
never have clinical attacks. Linkage has recently been reported in some families to chromosome 15q14.
The prognosis is uniformly good. Seizures disappear by mid to late adolescence in all cases. Seizures in many children appear to be self-limited, and more physicians
now defer treatment until after the second or third attack, a policy with which we agree. Because seizures are easily controlled and self-limited, drugs with the fewest
adverse effects, such as carbamazepine or gabapentin, should be used. Low doses, often producing subtherapeutic blood concentrations, are generally effective.
Temporal Lobe Epilepsy
This is the most common epilepsy syndrome of adults. In most cases, the epileptogenic region involves mesial temporal lobe structures, especially the hippocampus,
amygdala, and parahippocampal gyrus. Seizures usually begin in late childhood or adolescence, and a history of febrile seizures is common. Virtually all patients
have complex partial seizures, some of which secondarily generalize. Auras are frequent; visceral sensations are particularly common. Other typical behavioral
features include a motionless stare, loss of awareness that may be gradual, and oral-alimentary automatisms, such as lip-smacking. A variable but often prolonged
period of postictal confusion is the rule. Interictal EEGs show focal temporal slowing and epileptiform sharp waves or spikes over the anterior temporal region.
Antiepileptic drugs are usually successful in suppressing secondarily generalized seizures, but 50% or more of patients continue to have partial attacks. When
seizures persist, anterior temporal lobe resection is the treatment of choice. In appropriately selected patients, complete seizure control is achieved in more than 80%
of cases.
Frontal Lobe Epilepsy
The particular pattern of the many types of frontal lobe seizures depends on the specific location where the seizure discharge originates and on the pathways
subsequently involved in propagation. Despite this variability, the following features, when taken together, suggest frontal lobe epilepsy:
1. Brief seizures that begin and end abruptly with little, if any, postictal period;
2. A tendency for seizures to cluster and to occur at night;
3. Prominent, but often bizarre, motor manifestations, such as asynchronous thrashing or flailing of arms and legs, pedaling leg movements, pelvic thrusting, and
loud, sometimes obscene, vocalizations, all of which may suggest psychogenic seizures;
4. Minimal abnormality on scalp EEG recordings;
5. A history of status epilepticus.
Posttraumatic Seizures
Seizures occur within 1 year in about 7% of civilian and in about 34% of military head injuries. The differences relate mainly to the much higher proportion of
penetrating wounds in military cases. The risk of developing posttraumatic epilepsy is directly related to the severity of the injury and also correlates with the total
volume of brain lost as measured by computed tomography (CT). Depressed skull fractures may or may not be a risk; the rate of posttraumatic epilepsy was 17% in
one series but not increased above control levels in another. Head injuries are classified as severe if they result in brain contusion, intracerebral or intracranial
hematoma, unconsciousness, or amnesia for more than 24 hours or in persistent neurologic abnormalities, such as aphasia, hemiparesis, or dementia. Mild head
injury (brief loss of consciousness, no skull fracture, no focal neurologic signs, no contusion or hematoma) do not increase the risk of seizures significantly above
general population rates.
Nearly 60% of those who have seizures have the first attack in the first year after the injury. In the Vietnam Head Injury Study, however, more than 15% of patients did
not have epilepsy until 5 or more years later. Posttraumatic seizures are classified as early (within the first 1 to 2 weeks after injury) or late. Only recurrent late
seizures (those that occur after the patient has recovered from the acute effects of the injury) should be considered posttraumatic epilepsy. Early seizures, however,
even if isolated, increase the chance of developing posttraumatic epilepsy. About 70% of patients have partial or secondarily generalized seizures. Impact seizures
occur at the time of or immediately after the injury. These attacks are attributed to an acute reaction of the brain to trauma and do not increase the risk of later
epilepsy.
Overt seizures should be treated according to principles reviewed later in this chapter. The most controversial issue concerns the prophylactic use of antiepileptic
drugs to retard or abort the development of subsequent seizures. Based on the data of Temkin et al. (1990), we recommend treating patients with severe head
trauma, as just defined, with phenytoin for the first week after injury to minimize complications from seizures occurring during acute management. Phenytoin, or
fosphenytoin, should be given intravenously in a loading dose of about 20 mg/kg; subsequent doses should be adjusted to maintain blood levels of 15 to 20 g/mL. If
seizures have not occurred, we do not continue phenytoin beyond the initial 1 to 2 weeks, because evidence does not show that longer treatment prevents the
development of later seizures or of posttraumatic epilepsy. Recent data have also shown that valproate is less effective than phenytoin in suppressing acute seizures
and also ineffective in preventing the development of posttraumatic seizures.
Epilepsia Partialis Continua
Epilepsia partialis continua (EPC) refers to unremitting motor seizures involving part or all of one side of the body. They typically consist of repeated clonic or
myoclonic jerks that may remain focal or regional or may march from one muscle group to another, with the extent of motor involvement waxing and waning in endless
variation. In adults, EPC occurs in diverse settings, such as with subacute or chronic inflammatory diseases of the brain (Kozhevnikov Russian spring-summer
encephalitis; Behet disease) or with acute strokes, metastases, and metabolic encephalopathies, especially hyperosmolar nonketotic hyperglycemia.
The most distinctive form of EPC, known as the Rasmussen syndrome, occurs in children; it usually begins before the age of 10 years. The underlying disorder is
chronic focal encephalitis, although an infectious agent has not been identified consistently. About two-thirds of patients report an infectious or inflammatory illness 1
to 6 months before onset of EPC. Generalized tonic-clonic seizures are often the first sign and appear before the EPC establishes itself. About 20% of cases begin
with an episode of convulsive status epilepticus. Slow neurologic deterioration inevitably follows, with development of hemiparesis, mental impairment, and, usually,
hemianopia. If the dominant hemisphere is affected, aphasia occurs. EEGs are always abnormal, but findings are not specific, and they frequently do not correlate
with clinical manifestations. Magnetic resonance imaging (MRI) may be normal early but later show unilateral cortical atrophy and signal changes consistent with
gliosis. Antiepileptic drugs are usually ineffective, as are corticosteroids and antiviral agents. When seizures have not spontaneously remitted by the time hemipleiga
and aphasia are complete, functional hemispherectomy can control seizures and leads to substantial improvement in many patients. Whether hemispherectomy
should be performed before the maximal motor or language deficit has developed is controversial.
EPIDEMIOLOGY
In the United States, about 6.5 persons per 1,000 population are affected with recurrent unprovoked seizures, so-called active epilepsy. Based on 1990 census
figures, age-adjusted annual incidence rates for epilepsy range from 31 to 57 per 100,000 in the United States ( Fig. 140.1). Incidence rates are highest among young
children and the elderly; epilepsy affects males 1.1 to 1.5 times more often than females.
FIG. 140.1. Age-specific incidence of epilepsy in Rochester, Minnesota, 19351984. (From Hauser et al. [1993].)
Complex partial seizures are the most common seizure type among newly diagnosed cases, but age-related variability occurs in the proportions of different seizure
types (Fig. 140.2). The cause of epilepsy also varies somewhat with age. Despite advances in diagnostic capabilities, however, the unknown etiologic category
remains larger than any other for all age groups ( Fig. 140.3). Cerebrovascular disease, associated developmental neurologic disorders (e.g., cerebral palsy and
mental retardation), and head trauma are the other most commonly identified causes.
FIG. 140.2. Proportion of seizure types in newly diagnosed cases of epilepsy in Rochester, Minnesota, 19351984. (From Hauser et al. [1993].)
FIG. 140.3. Etiology of epilepsy in all cases of newly diagnosed seizures in Rochester, Minnesota, 19351984 (From Hauser et al. [1993].)
Although defined genetic disorders account for only about 1% of epilepsy cases, heritable factors are important. Monozygotic twins have a much higher concordance
rate for epilepsy than do dizygotic twins. By age 25, nearly 9% of children of mothers with epilepsy and 2.4% of children of affected fathers develop epilepsy. The
reason for an increased risk of seizures in children of women with epilepsy is not known.
Some forms of epilepsy are more heritable than others. For example, children of parents with absence seizures have a higher risk of developing epilepsy (9%) than do
offspring of parents with other types of generalized seizures or partial seizures (5%). As a general rule, though, even offspring born to a high-risk parent have a 90%
or greater chance of being unaffected by epilepsy.
Many persons who experience a first unprovoked seizure never have a second. By definition, these people do not have epilepsy and generally do not require
long-term drug treatment. Unfortunately, our ability to identify such individuals with accuracy is incomplete. Treatment decisions must be based on epidemiologic and
individual considerations. Some seizure types, such as absence and myoclonic, are virtually always recurrent by the time the patient is seen by a physician. On the
other hand, patients with convulsive seizures may seek medical attention after a first occurrence because of the dramatic nature of the attack. Prospective studies of
recurrence after a first seizure indicate a 2-year recurrence risk of about 40%, which is similar in children and adults. The risk is lowest in people with an idiopathic
generalized first seizure and normal EEG (about 24%), higher with idiopathic generalized seizures and an abnormal EEG (about 48%), and highest with symptomatic
(i.e., known preceding brain injury or neurologic syndrome) seizures and an abnormal EEG (about 65%). Epileptiform, but not nonepileptiform, EEG abnormalities
impart a greater risk for recurrence. If the first seizure is a partial seizure, the relative risk of recurrence is also increased. The risk for further recurrence after a
second unprovoked seizure is greater than 80%; a second unprovoked seizure is, therefore, a reliable marker of epilepsy.
About 4% of persons living to age 74 have at least one unprovoked seizure. When provoked seizures (i.e., febrile seizures or those related to an acute illness) are
included, the likelihood of experiencing a seizure by age 74 increases to at least 9%. The risk of developing epilepsy is about 3% by age 74.
Of persons with epilepsy, 60% to 70% achieve remission of seizures with antiepileptic drug therapy. Factors that favor remission include an idiopathic (or cryptogenic)
form of epilepsy, normal findings on neurologic examination, and onset in early to middle childhood (except neonatal seizures). Unfavorable prognostic factors include
partial seizures, an abnormal EEG, and associated mental retardation or cerebral palsy ( Table 140.3).
TABLE 140.3. PREDICTORS OF INTRACTABILITY
Mortality is increased in persons with epilepsy, but the risk is incurred mainly by symptomatic cases in which higher death rates are related primarily to the underlying
disease rather than to epilepsy. Accidental deaths, especially drowning, are more common, however, in all patients with epilepsy. Sudden unexplained death is nearly
25 times more common in patients with epilepsy than in the general population; estimates of incidence rates range from 1 in 500 to 1 in 2,000 per year. Severe
epilepsy and uncontrolled generalized convulsions are risk factors.
INITIAL DIAGNOSTIC EVALUATION
The diagnostic evaluation has three objectives: to determine if the patient has epilepsy; to classify the type of epilepsy and identify an epilepsy syndrome, if possible;
and to define the specific underlying cause. Accurate diagnosis leads directly to proper treatment and formulation of a rational plan of management. The differential
diagnosis is considered in Chapter 3.
Because epilepsy comprises a group of conditions and is not a single homogeneous disorder, and because seizures may be symptoms of both diverse brain disorders
and an otherwise normal brain, it is neither possible nor desirable to develop inflexible guidelines for what constitutes a standard or minimal diagnostic evaluation.
The clinical data from the history and physical examination should allow a reasonable determination of probable diagnosis, seizure and epilepsy classification, and
likelihood of underlying brain disorder. Based on these considerations, diagnostic testing should be undertaken selectively.
History and Examination
A complete history is the cornerstone for establishing a diagnosis of epilepsy. An adequate history should provide a clear picture of the clinical features of the
seizures and the sequence in which manifestations evolve; the course of the epileptic disorder; seizure precipitants, such as alcohol or sleep deprivation; risk factors
for seizures, such as abnormal gestation, febrile seizures, family history of epilepsy, head injury, encephalitis or meningitis, and stroke; and response to previous
treatment. In children, developmental history is important.
In describing the epileptic seizure, care should be taken to elicit a detailed description of any aura. The aura was once considered to be the warning of an impending
attack, but it is actually a simple partial seizure made apparent by subjective feelings or experiential phenomena observable only by the patient. Auras precede many
complex partial or generalized seizures and are experienced by 50% to 60% of adults with epilepsy. Auras confirm the suspicion that the seizure begins locally within
the brain; they may also provide direct clues about the location or laterality of the focus. Information about later events in the seizure usually are obtained from an
observer because of the patient's impaired awareness or frank loss of consciousness or because of postictal amnesia even though responses to questions during the
seizure indicate preserved responsiveness.
The nature of repetitive automatic or purposeless movements (automatisms), sustained postures, presence of myoclonus, and the duration of the seizure help to
delineate specific seizure types or epileptic syndromes. Nonspecific postictal findings of lethargy and confusion must be distinguished from focal neurologic
abnormalities, such as hemiparesis or aphasia, that point to the hemisphere of seizure onset.
Information about risk factors (Table 140.4) may suggest a particular cause and assist in prognosis. Discussion with parents may be necessary, because children or
adults may be uninformed about, or may not recall, early childhood events, such as perinatal encephalopathy, febrile seizures, brain infections, head injuries, or
intermittent absence seizures. Age at seizure onset and course of the seizure disorder should be clarified, because these features differ in the various epilepsy
syndromes.
TABLE 140.4. RISK FACTORS FOR EPILEPSY
Findings on neurologic examination are usually normal in patients with epilepsy but occasionally may provide etiologic clues. Focal signs indicate an underlying
cerebral lesion. Asymmetry of the hand or face may indicate localized or hemispheric cerebral atrophy contralateral to the smaller side. Phakomatoses are commonly
associated with seizures and may be suggested by cafe-au-lait spots, facial angioma, conjunctival telangiectasia, hypopigmented macules, fibroangiomatous nevi, or
lumbosacral shagreen patches.
Electroencephalography
Because epilepsy is fundamentally a physiologic disturbance of brain function, the EEG is the most important laboratory test in evaluating patients with seizures. The
EEG helps both to establish the diagnosis of epilepsy and to characterize specific epileptic syndromes. EEG findings may also help in management and in prognosis.
Epileptiform discharges (spikes and sharp waves) are highly correlated with seizure susceptibility and can be recorded on the first EEG in about 50% of patients.
Similar findings are recorded in only 1% to 2% of normal adults and in a somewhat higher percentage of normal children. When multiple EEGs are obtained,
epileptiform abnormalities eventually appear in 60% to 90% of adults with epilepsy, but the yield of positive studies does not increase substantially after three or four
tests. It is important to remember, therefore, that 10% to 40% of patients with epilepsy do not show epileptiform abnormalities on routine EEG; a normal or
nonspecifically abnormal EEG never excludes the diagnosis. Sleep, hyperventilation, photic stimulation, and special electrode placements are routinely used to
increase the probability of recording epileptiform abnormalities.
Different and distinctive patterns of epileptiform discharge occur in specific epilepsy syndromes as summarized in Chapter 14.
Brain Imaging
MRI should be performed in all patients over age 18 years and in children with abnormal development, abnormal findings on physical examination, or seizure types
that are likely to be manifestations of symptomatic epilepsy. CT will often miss common epileptogenic lesions such as hippocampal sclerosis, cortical dysplasia, and
cavernous malformations. Because CT is very sensitive for detecting brain calcifications, a noncontrast CT (in addition to MRI) may be helpful in patients at risk for
neurocysticercosis.
Routine imaging is not necessary for children with idiopathic epilepsy, including the benign focal epilepsy syndromes (see later section). Brain MRI, although more
costly, is more sensitive than CT in detecting potentially epileptogenic lesions, such as cortical dysplasia, hamartomas, differentiated glial tumors, and cavernous
malformations. Both axial and coronal planes should be imaged with both T1 and T2 sequences. Gadolinium injection does not increase the sensitivity for detecting
cerebral lesions but may assist in differentiating possible causes.
Imaging in the coronal plane perpendicular to the long axis of the hippocampus and other variations in technique have improved the detection of hippocampal atrophy
and gliosis, findings that are highly correlated with mesial temporal sclerosis ( Fig. 140.4) and an epileptogenic temporal lobe. An even more sensitive measure of
hippocampal atrophy is MRI measurement of the volume of the hippocampus. Hippocampal volume measurements in an individual patient then can be compared with
those of normal control subjects.
FIG. 140.4. Mesial temporal sclerosis. A and B: Short-tau inversion recovery (STIR) coronal magnetic resonance images through the temporal lobes show increased
signal and decreased size of right hippocampus as compared with left. These findings are characteristic of mesial temporal sclerosis. Note incidental focal dilatation
of left choroid fissure, which represents a choroid fissure cyst, and is a normal variant. (Courtesy of Dr. S. Chan, Columbia University College of Physicians and
Surgeons, New York, NY.)
Other Laboratory Tests
Routine blood tests are rarely diagnostically useful in healthy children or adults. They are necessary in newborns and in older patients with acute or chronic systemic
disease to detect abnormal electrolyte, glucose, calcium, or magnesium values or impaired liver or kidney function that may contribute to seizure occurrence. In most
patients, serum electrolytes, liver function tests, and a complete blood count are useful mainly as baseline studies before initiating antiepileptic drug treatment.
Any suspicion of meningitis or encephalitis mandates lumbar puncture. Urine or blood toxicologic screens should be considered when otherwise unexplained
new-onset generalized seizures occur.
LONG-TERM MONITORING
The most direct and convincing evidence of an epileptic basis for a patient's episodic symptoms is the recording of an electrographic seizure discharge during a
typical behavioral attack. This recording is especially necessary if the history is ambiguous, EEGs are repeatedly normal or nonspecifically abnormal, and reasonable
treatment has failed. Because most patients have seizures infrequently, routine EEG rarely records an attack. Long-term monitoring permits EEG recording for a
longer time, thus increasing the likelihood of recording seizures or interictal epileptiform discharges. Two methods of long-term monitoring are now widely available:
simultaneous closed-circuit television and EEG (CCTV/EEG) monitoring and ambulatory EEG. Both have greatly improved diagnostic accuracy and the reliability of
seizure classification and both provide continuous recordings through one or more complete waking-sleep cycles and capture ictal episodes. Each has additional
specific advantages and disadvantages. The method used depends on the question posed by a particular patient.
Long-term monitoring using CCTV/EEG, usually in a specially designed hospital unit, is the procedure of choice to document psychogenic seizures and other
nonepileptic paroxysmal events. It can also establish electrical-clinical correlations and localize epileptogenic foci for resective surgery. The emphasis in monitoring
units is usually on behavioral events, not interictal EEG activity. The availability of full-time technical or nursing staff ensures high-quality recordings and permits
examination of patients during clinical events. Antiepileptic drugs can be discontinued safely to facilitate seizure occurrence. Computerized detection programs are
used to screen EEG continuously for epileptiform abnormalities and subclinical seizures.
The other method of long-term monitoring is designed for outpatient use in the patient's home, school, or work environment. Ambulatory EEG is often especially
helpful in pediatrics, because children are often more comfortable in their familiar and unrestricted home environment. The major limitations of ambulatory monitoring
are the limited coverage of cortical areas, variable technical quality resulting from lack of expert supervision, frequent distortion of EEG data by environmental
contaminants, and the absence of video documentation of behavioral changes. Ambulatory monitoring is most useful in documenting interictal epileptiform activity
when routine EEGs have been repeatedly negative or in recording ictal discharges during typical behavioral events. At present, however, ambulatory EEG is not a
substitute for CCTV/EEG monitoring, especially when psychogenic seizures are an issue or when patients are being evaluated for epilepsy surgery.
MEDICAL TREATMENT
Therapy of epilepsy has three goals: to eliminate seizures or reduce their frequency to the maximum extent possible, to avoid the side effects associated with
long-term treatment, and to assist the patient in maintaining or restoring normal psychosocial and vocational adjustment. No medical treatment now available can
induce a permanent remission (cure) or prevent development of epilepsy by altering the process of epileptogenesis.
The decision to institute antiepileptic drug therapy should be based on a thoughtful and informed analysis of the issues involved. Isolated infrequent seizures, whether
convulsive or not, probably pose little medical risk to otherwise healthy persons. However, even relatively minor seizures, especially those associated with loss or
alteration of alertness, have many psychosocial, vocational, and safety ramifications. Finally, the probability of seizure recurrence varies substantially among patients,
depending on the type of epilepsy and any associated neurologic or medical problems. Drug treatment, on the other hand, carries a risk of adverse effects, which
approaches 30% after initial treatment. Treatment of children raises additional issues, especially the unknown effects of long-term antiepileptic drug use on brain
development, learning, and behavior.
These considerations mean that although drug treatment is indicated and beneficial for most patients with epilepsy, certain circumstances call for antiepileptic drugs
to be deferred or used for only a limited time. As a rule of thumb, antiepileptic drugs should be prescribed when the potential benefits of treatment clearly outweigh
possible adverse effects of therapy.
Acute Symptomatic Seizures
These seizures are caused by, or associated with, an acute medical or neurologic illness. A childhood febrile seizure is the most common example of an acute
symptomatic seizure, but other frequently encountered causes include metabolic or toxic encephalopathies and acute brain infections. To the extent that these
conditions resolve without permanent brain damage, seizures are usually self-limited. The primary therapeutic concern in such patients should be identification and
treatment of the underlying disorder. If antiepileptic drugs are needed to suppress seizures acutely, they generally do not need to be continued after the patient
recovers.
The Single Seizure
About 25% of patients with unprovoked seizures come to a physician after a single attack, nearly always a generalized tonic-clonic seizure. Most of these people have
no risk factors for epilepsy, have normal findings on neurologic examination, and show a normal first EEG. Only about 25% of these patients later develop epilepsy.
For this group, the need for treatment is questionable. For many years, no convincing data indicated any beneficial effect of treatment on preventing recurrence. In
1993, a large multicenter randomized study from Italy convincingly demonstrated that antiepileptic drugs reduce the risk of relapse after the first unprovoked
convulsive seizure. Among nearly 400 children and adults, treatment within 7 days of a first seizure was followed by a recurrence rate of 25% at 2 years. In contrast,
untreated patients had a recurrence rate of 51%. When patients with previous uncertain spells were excluded from the analysis, treatment benefit was still evident,
but the magnitude of the effect was reduced to a recurrence rate of 30% in the treated group and 42% in untreated patients.
Although treatment of first seizures reduces the relapse rate even in low-risk patients, there is no evidence that such treatment alters the prognosis of epilepsy. Thus,
treatment should not be automatic, and the decision to treat should be made only in consultation with the patient or parents after weighing the unique circumstances
posed by that individual. In most patients with idiopathic epilepsy, deferring treatment until a second seizure occurs is a reasonable and often preferable decision.
Benign Epilepsy Syndromes
Several electroclinical syndromes begin in childhood and are associated with normal development, normal findings on neurologic examination, and normal brain
imaging studies. They have a uniformly good prognosis for complete remission in mid to late adolescence without long-term behavioral or cognitive problems. The
most common and best characterized of these syndromes is benign partial epilepsy of childhood with central-midtemporal sharp waves (rolandic epilepsy). Most
seizures occur at night as secondarily generalized convulsions. Focal seizures occur during the day and are characterized by twitching of one side of the face,
anarthria, salivation, and paresthesias of the face and inner mouth followed variably by hemiclonic movements or hemitonic posturing. Other benign syndromes
include benign partial epilepsy with occipital spike waves and benign epilepsy with affective symptoms.
Because of the good prognosis, the sole goal of treatment in such cases is to prevent recurrence. Because many children, especially those who are older, tend to
have only a few seizures, treatment is not always necessary. Antiepileptic drugs are usually reserved for children whose seizures are frequent or relatively severe or
whose parents, or the children themselves, are distressed at the prospect of future episodes. With these considerations in mind, only about half the children with
benign partial epilepsy require treatment.
Antiepileptic Drugs
Selection of Antiepileptic Drugs
Two nationwide collaborative Veterans Administration Cooperative Studies (1985 and 1992) compared the effectiveness of antiepileptic drugs. In the 1985 study,
carbamazepine, phenytoin, primidone, and phenobarbital were equally effective in controlling complex partial and secondarily generalized seizures. In the 1992 study,
carbamazepine was slightly more effective than valproate in treating complex partial seizures, but both drugs were of equal efficacy in controlling secondarily
generalized seizures. These studies also demonstrated that despite their relatively uniform ability to suppress seizures, the drugs had different risks of adverse
effects. Considering both efficacy and tolerability, carbamazepine and phenytoin are drugs of first choice for patients with partial and secondarily generalized
seizures. For patients who have predominantly secondarily generalized seizures, valproate is also effective.
No clinical trials have addressed the relative efficacy of antiepileptic drugs against different symptomatic localization- related epilepsies. There are also few data
about the effectiveness of newer antiepileptic drugs (those approved since 1993) compared with older agents or each other. Preliminary studies from Europe indicate
that lamotrigine is comparable in effectiveness with phenytoin and carbamazepine and that gabapentin shows similar efficacy to carbamazepine for treatment of
new-onset partial seizures. Drugs are therefore chosen based on the patient's predominant seizure type.
In general, valproate is the drug of choice for generalized-onset seizures and can be used advantageously as monotherapy when several generalized seizure types
coexist (Table 140.5). Lamotrigine and probably topiramate are alternatives if valproate is ineffective or not tolerated. Phenytoin and carbamazepine are also effective
against generalized tonic-clonic seizures, but the response is less predictable than that with valproate. Carbamazepine, phenytoin, gabapentin, and sometimes
lamotrigine can aggravate myoclonic seizures; all of these except lamotrigine also sometimes exacerbate absence seizures. Tiagabine can aggravate or induce
absence seizures. Ethosuximide is as effective as valproate in controlling absence seizures and has fewer side effects. Ethosuximide is ineffective against tonic-clonic
seizures, however, so its main use is as an alternative to valproate in patients who only have absence seizures.
TABLE 140.5. DRUGS USED IN TREATING DIFFERENT TYPES OF SEIZURES
Adverse Effects of Antiepileptic Drugs
All antiepileptic drugs have undesirable effects in some patients. Although interindividual variation occurs, most adverse drug effects are mild and dose related. Many
are common to virtually all antiepileptic drugs, especially when treatment is started. These include sedation, mental dulling, impaired memory and concentration,
mood changes, gastrointestinal upset, and dizziness. Other adverse effects are relatively specific for individual agents.
Dose-related Side Effects
These typically appear when a drug is first given or when the dosage is increased. They usually, but not always, correlate with blood concentrations of the parent drug
or major metabolites (Table 140.6). Dose-related side effects are always reversible on lowering the dosage or discontinuing the drug. Adverse effects frequently
determine the limits of treatment with a particular drug and have a major influence on compliance with the prescribed regimen. Because dose-related side effects are
broadly predictable, they are often the major differentiating feature in choosing among otherwise equally effective therapies.
TABLE 140.6. TOXICITY OF ANTIEPILEPTIC DRUGS
Idiosyncratic Side Effects
Idiosyncratic reactions account for most serious and virtually all life-threatening adverse reactions to antiepileptic drugs. All antiepileptic drugs can cause similar
serious side effects (Table 140.6), but with the exception of rash, these are fortunately rare. For example, the risk of carbamazepine-induced agranulocytosis or
aplastic anemia is about 2 per 575,000; with felbamate, the risk of aplastic anemia may be as high as 1 per 5,000. Idiosyncratic reactions are not dose related; rather
they arise either from an immune-mediated reaction to the drug or from poorly defined individual factors, largely genetic, that convey an unusual sensitivity to the
drug. An example of the genetic mechanism is valproate-induced fatal hepatotoxicity. Valproate, like most antiepileptic drugs, is metabolized in the liver, but several
biochemical pathways are available to the drug. Clinical and experimental data indicate that one of these pathways results in a hepatotoxic compound that may
accumulate and lead to microvesicular steatosis with necrosis. The extent to which this pathway is involved in biotransformation is age dependent and promoted by
concurrent use of other drugs that are eliminated in the liver. Thus, most patients who have had fatal hepatotoxicity were younger than 2 years of age and treated with
polytherapy (Table 140.7). In addition, most had severe epilepsy associated with mental retardation, developmental delay, or congenital brain anomalies. No hepatic
deaths have occurred in persons older than 10 years of age treated with valproate alone.
TABLE 140.7. EFFECT OF AGE AND TREATMENT ON RISK OF DEVELOPING FATAL VALPROATE HEPATOTOXICITY
No laboratory test, certainly not untargeted routine blood monitoring, identifies individuals specifically at risk for valproate hepatotoxicity or any other drug-related
idiosyncratic reaction. Clinical data, however, permit identification of groups of patients at increased risk for serious adverse drug reactions, including patients with
known or suspected metabolic or biochemical disorders, a history of previous drug reactions, and medical illnesses affecting hematopoesis or liver and kidney
function.
Antiepileptic Drug Pharmacology
Table 140.8 provides summary information about dose requirements, pharmacokinetic properties, and therapeutic concentration ranges for the major antiepileptic
drugs available in the United States. Of patients with epilepsy, 60% to 70% achieve satisfactory control of seizures with currently available antiepileptic drugs, but
fewer than 50% of adults achieve complete control without drug side effects. Many patients continue to have frequent seizures despite optimal medical therapy.
TABLE 140.8. ANTIEPILEPTIC DRUGS: DOSAGE AND PHARMACOKINETIC DATA
Therapy should start with a single antiepileptic drug chosen according to the type of seizure or epilepsy syndrome and then be modified, as necessary, by
considerations of side effects, required dosing schedule, and cost. Phenytoin, phenobarbital, and gabapentin can be loaded acutely. In most cases, however,
antiepileptic drugs should be started in low dosages to minimize acute toxicity and then increased according to the patient's tolerance and the drug's
pharmacokinetics. The initial target dose should produce a serum concentration in the low-to-mid therapeutic range. Further increases can then be titrated according
to the patient's clinical progress, which is measured mainly by seizure frequency and the occurrence of drug side effects. A drug should not be judged a failure unless
seizures remain uncontrolled at the maximal tolerated dosage, regardless of the blood level.
Dosage changes generally should not be made until the effects of the drug have been observed at steady-state concentrations (a time about equal to five drug
half-lives). If the first drug is ineffective, an appropriate alternative should be gradually substituted ( Table 140.5). Combination treatment using two drugs should be
attempted only when monotherapy with primary antiepileptic drugs fails. Combination therapy is sometimes effective, but the price of improved seizure control is often
additional drug toxicity. Sometimes combination therapy with relatively nonsedating drugs (e.g., carbamazepine, lamotrigine, gabapentin, or valproate) is preferable to
high-dose monotherapy with a sedating drug (e.g., phenobarbital or primidone). When used together, carbamazepine and lamotrigine result in a pharmacodynamic
interaction that often produces neurotoxicity at dosages that are usually well tolerated when either drug is used alone.
Dosing intervals should usually be less than one-third to one-half the drug's half-life to minimize fluctuations between peak and trough blood concentrations. Large
fluctuations can result in drug-induced side effects at peak levels and in breakthrough seizures at trough concentrations. Sometimes, however, a drug has a relatively
long pharmacodynamic half-life, so that twice a day dosing is reasonable even if the pharmacokinetic half-life is short. This is typically the case with valproate,
tiagabine, and, possibly, gabapentin.
Therapeutic drug monitoring has improved the care of patients with epilepsy, but published therapeutic ranges are only guidelines. Most patients who achieve drug
concentrations within a standard therapeutic range usually achieve adequate seizure control with minimal side effects, but notable exceptions occur. Some patients
develop unacceptable side effects at subtherapeutic concentrations; others benefit from toxic concentrations without adverse effects.
Determining serum drug concentrations when seizure control has been achieved or when side effects appear can assist in future management decisions. Drug levels
are also useful in documenting compliance and in assessing the magnitude and significance of known or suspected drug interactions. Therapeutic drug monitoring is
an essential guide to treating neonates, infants, young children, elderly persons, and patients with diseases (e.g., liver or kidney failure) or physiologic conditions
(e.g., pregnancy) that alter drug pharmacokinetics. Although the total blood concentrations that are routinely reported are satisfactory for most indications, unbound
(free) concentrations are useful when protein binding is altered, as in renal failure, pregnancy, extensive third-degree burns, and combination therapy using two or
more drugs that are highly bound to serum proteins (e.g. phenytoin, valproate, tiagabine).
Specific Drugs
Phenytoin is unique among antiepileptic drugs because it exhibits nonlinear elimination at therapeutically useful serum concentrations. That is, hepatic enzyme
systems metabolizing phenytoin become increasingly saturated at plasma concentrations greater than 10 to 12 g/mL and metabolic rate approaches a constant
value at high concentrations. With increasing doses, phenytoin plasma concentrations rise exponentially ( Fig. 140.5), so that steady-state concentration at one dose
cannot be used to predict directly the steady-state concentration at a higher dose. Clinically, this requires cautious titration within the therapeutic range, using dose
increments of 30 mg to avoid toxic effects.
FIG. 140.5. Phenytoin dose-concentration curves from three representative adult patients. Note the markedly nonlinear relationship in the 200- to 400-mg dose range.
Careful dose titration is necessary in this portion of the curve to avoid neurotoxicity. Km, Michaelis-Menten constant; Vmax, maximum elimination rate.
Carbamazepine induces activation of the enzymes that metabolize it. The process, termed autoinduction, is time dependent. When carbamazepine is first introduced,
the half-life approximates 30 hours. With increasing hepatic clearance in the first 3 to 4 weeks of therapy, however, the half-life shortens to 11 to 20 hours. As a result,
the starting dose should be low, the dosage should be increased gradually, and dosing should be frequent (three or four times daily). Recently introduced
extended-release formulations now permit twice a day administration. The principal metabolite is carbamazepine-10,11-epoxide, which is pharmacologically active.
Under certain circumstances (e.g., when coadministered with valproate or felbamate), the epoxide metabolite accumulates selectively, thereby producing neurotoxic
effects even though the plasma concentration of the parent drug is in the therapeutic range or low.
Valproate is highly bound to plasma proteins, but the binding is concentration dependent and nonlinear. The unbound fraction increases at plasma concentrations
greater than 75 g/mL because protein binding sites become saturated. For example, doubling the plasma concentration from 75 to 150 g/mL can result in a more
than sixfold rise in concentration of free drug (from 6.5 to 45 g/mL). Therefore, as the dose of valproate is increased, side effects may worsen rapidly because of the
increasing proportion of unbound drug. Furthermore, adverse effects may vary in the course of a single day or from day to day, because concentrations of unbound
drug fluctuate despite seemingly small changes in total blood levels. Additionally, circulating fatty acids displace valproate from protein binding sites. If fatty acid
levels are high, the amount of unbound valproate increases. Lamotrigine and felbamate prolong valproates half-life; reduced dosage is typically necessary when
these drugs are added.
Gabapentin requires an intestinal amino acid transport system for absorption. Because the transporter is saturable, the percentage of drug that is absorbed after an
oral dose decreases with increasing dosage. More frequent dosing schedules using smaller amounts may therefore be necessary to increase blood levels. When
dosages above 3,600 mg/day are used, blood levels can be helpful in demonstrating that an increase in dosage is reflected in an increased serum concentration.
Gabapentin does not interact to any clinically significant degree with any other drugs, which makes it especially useful when antiepileptic drug polytherapy is
necessary and in patients with medical illnesses that also require drug treatment. It is not metabolized in the liver, but as it is excreted unchanged by the kidneys,
dose adjustment is required in patients with renal failure.
Lamotrigine is very sensitive to coadministration of other antiepileptic drugs. Enzyme-inducing agents, such as phenytoin and carbamazepine, decrease lamotrigine's
half-life from 24 to 16 hours (or less). In contrast, enzyme inhibition by valproate increases lamotrigine's half-life to 60 hours. Therefore, lamotrigine dosing depends
very much on whether it is used as monotherapy or in combination with other antiepileptic drugs. Lamotrigine has little or no effect on other classes of drugs. Rash
occurs in about 10% of patients; it is more common in children and rarely leads to Stevens-Johnson syndrome. The incidence of rash can be minimized by slow
titration schedules.
Topiramate is also affected by coadministered antiepileptic drugs. Carbamazepine, phenytoin, and phenobarbital shorten topiramates half-life, but valproate has little
effect. Topiramate does not affect most other drugs, although phenytoin blood levels may increase by 25%. Adverse cognitive effects frequently limit dosage,
especially word-finding difficulties and memory impairment. These are usually dose dependent and can be minimized with slow titration schedules. Doses above 400
mg/day do not usually lead to better seizure control but are associated with an increasing incidence of side effects.
Tiagabine is highly bound to serum proteins and will therefore displace other drugs (e.g., phenytoin, valproate) that are also protein bound. Other drugs do not affect
tiagabine's metabolism significantly. Gastrointestinal side effects usually limit the rate at which the dosage may be increased.
Felbamate has a much higher risk of serious adverse reactions, including aplastic anemia and hepatic failure, than other antiepileptic drugs. For this reason, its use is
currently restricted to patients who are refractory to other agents and in whom the risk of continued seizures outweighs the risk of side effects. Use of felbamate is
also limited by other common but less serious adverse effects, including anorexia, weight loss, insomnia, and nausea, and by numerous complex drug interactions.
Nonetheless, felbamate remains useful in cases of severe epilepsy such as Lennox-Gastaut syndrome.
Gender-based differences in antiepileptic drug pharmacokinetics, sex steroid hormones, and reproductive life events raise special issues for women with epilepsy.
The management of pregnancy in the woman with epilepsy is discussed in detail in Chapter 156. This section focuses on the effects of reproductive hormones on
seizures and on the effects of seizures and antiepileptic drugs on reproductive health.
Although the prevalence of epilepsy is not higher in women, epilepsy in women may be specially affected by changes in reproductive steroids. Estrogen is a
proconvulsant drug in animal models of epilepsy, whereas progesterone and its metabolites have anticonvulsant effects. Ovarian steroid hormones act at the neuronal
membrane and on the genome to produce immediate and long-lasting effects on excitability. Estrogen reduces GABA-mediated inhibition, whereas progesterone
enhances GABA effects. Estrogen also potentiates the action of excitatory neurotransmitters in some brain regions and increases the number of excitatory synapses.
These dynamic and significant changes in neuronal excitability are observed with changes in estrogen and progesterone concentrations similar to those observed in
the human menstrual cycle.
Approximately one-third of women with epilepsy report patterns of seizure occurrence that relate to phases of the menstrual cycle ( catamenial seizures). Women with
catamenial seizures indicate that seizures are more frequent, or more severe, just before menstruation and during the time of menstrual flow. In some women,
seizures also increase at ovulation. These are times in the menstrual cycle when estrogen levels are relatively high and progesterone concentration is relatively low.
Several small clinical trials have described benefit from chronic progesterone therapy in women with catamenial seizure patterns. Changes in seizures related to
puberty and menopause are not well understood.
The pharmacokinetics of some antiepileptic drugs can complicate epilepsy management in women. Antiepileptic drugs that induce activity of the cytochrome P450
enzyme system (carbamazepine, phenytoin, phenobarbital, primidone, and, to a lesser extent, topiramate) interfere with the effectiveness of estrogen-based hormonal
contraception. In women taking these drugs, the metabolism and binding of contraceptive steroids is enhanced, thus reducing the biologically active fraction of steroid
hormone. The failure rate of oral contraceptive pills exceeds 6% per year in women taking enzyme-inducing antiepileptic drugs, in contrast to a failure rate of less that
1% per year in medication-compliant women without epilepsy. Women motivated to avoid pregnancy should consider using a contraceptive preparation containing 50
g or more of an estrogenic compound or using an additional barrier method of contraception. Alternatively, they should discuss with their physician the possibility of
selecting an antiepileptic drug that does not alter steroid metabolism or binding.
Reproductive health may be compromised in both women and men with epilepsy. Fertility rates for men and women with epilepsy are one-third to two-thirds those of
men and women without epilepsy. Lower birth rates cannot be explained on the basis of lower marriage rates, because marriage rates for women with epilepsy are
now similar to those of nonepileptic women. Reduced fertility appears to be the direct result of a disturbance in reproductive physiology.
Men and women with epilepsy show a higher than expected frequency of reproductive endocrine disturbances. These include abnormalities both in the cyclic release
and concentration of pituitary luteinizing hormone and prolactin and in the concentration of gonadal steroid hormones. Some of these abnormalities are likely to be a
consequence of seizure activity. Seizures involving mesial temporal lobe structures are associated with an immediate and significant (three- to fivefold) increase in
pituitary prolactin levels. Similar disturbances have been reported with pituitary luteinizing hormone. Changes in these pituitary hormones may be one mechanism for
the increased likelihood of anovulatory menstrual cycles and abnormalities in length of the menstrual cycle that are seen in about one-third of women with epilepsy.
Antiepileptic drugs can also alter concentrations of gonadal steroids by affecting steroid hormone metabolism and binding. Antiepileptic drugs that increase steroid
metabolism and binding reduce steroid hormone feedback at the hypothalamus and pituitary. Antiepileptic drugs that inhibit steroid metabolism (e.g., valproate)
increase concentrations of steroid hormones, particularly androgens.
Polycystic ovaries are more common in women with epilepsy: Multiple ovarian cysts are detected in 25% to 40% of women with epilepsy. The basis of this association
is not known but may be related to antiepileptic drugs (especially valproate) or to seizures. In nonepileptic women, polycystic ovaries are associated with infertility,
carbohydrate intolerance (insulin resistance), dyslipidemia, and elevated lifetime risk for endometrial carcinoma and other gynecologic malignancies. The long-term
consequences of polycystic ovaries in women with epilepsy are unknown.
Sexual dysfunction affects about one-third of men and women with epilepsy. Men report low sexual desire, difficulty achieving or maintaining an erection, or delayed
ejaculation. Women with epilepsy can experience painful intercourse because of vaginismus and lack of lubrication. Although there are certainly psychosocial reasons
for sexual dysfunction in some people with epilepsy, physiologic causes are demonstrable in others. Physiologic causes of sexual dysfunction include disruption of
brain regions controlling sexual behavior by epileptogenic discharges, abnormalities of pituitary and gonadal hormones, and side effects of antiepileptic drugs.
Women with epilepsy who have difficulty conceiving, irregular or abnormal menstrual cycles, midcycle menstrual bleeding, sexual dysfunction, obesity, or hirsutism
should undergo a reproductive endocrine evaluation. This includes pituitary luteinizing hormone and prolactin levels, estrogen, testosterone and progesterone levels,
and ovarian ultrasound examination. Men with sexual dysfunction or difficulty conceiving should also have an endocrine evaluation and semen analysis. All the
reproductive disorders seen in people with epilepsy are potentially treatable.
Discontinuing Antiepileptic Drugs
Epidemiologic studies indicate that 60% to 70% of patients with epilepsy become free of seizures for at least 5 years within 10 years of diagnosis. Similarly,
prospective clinical trials of treated patients whose seizures were in remission for 2 years or more showed that a nearly identical percentage of patients remained
seizure free after drug withdrawal. These studies also identified predictors that permit patients to be classified as being at low or high risk for seizure relapse after
drug therapy ends. The risk of relapse was high if patients required more than one antiepileptic drug to control seizures, if seizure control was difficult to establish, if
the patient had a history of generalized tonic-clonic seizures, and if the EEG was significantly abnormal when drug withdrawal was considered. Continued freedom
from seizures is favored by longer seizure-free intervals (up to 4 years) before drug withdrawal is attempted, few seizures before remission, monotherapy, normal
EEG and examination, and no difficulty establishing seizure control.
All benign epilepsy syndromes of childhood carry an excellent prognosis for permanent drug-free remission. In contrast, juvenile myoclonic epilepsy has a high rate of
relapse when drugs are discontinued, even in patients who have been seizure free for years. The prognosis for most other epilepsy syndromes is largely unknown.
Discontinuing antiepileptic drug therapy in appropriate patients is reasonable when they have been seizure free for at least 2 years. The most powerful argument for
stopping antiepileptic drugs is concern about long-term systemic and neurologic toxicity, which may be insidious and not apparent for many years after a drug has
been introduced. On the other hand, however, is the concern of the patient or family about seizure recurrence. Even a single seizure can have disastrous
psychosocial and vocational consequences, particularly in adults. Therefore, the decision to withdraw drugs must be weighed carefully in the light of individual
circumstances. If a decision is made to discontinue antiepileptic drugs, we favor slow withdrawal, over 3 to 6 months, but this recommendation is controversial
because few studies have been conducted of different withdrawal rates.
SURGICAL TREATMENT
Surgery should be considered when seizures are uncontrolled by optimal medical management and when they disrupt the quality of life. Quantifying these issues,
however, has defied strict definition, perhaps deservedly, because intractability is clearly more than continued seizures. Only patients know how their lives differ from
what they would like them to be; the concept of disability includes both physical and psychologic components. Some patients with refractory seizures suffer little
disability; others, for whatever reason, find their lives severely compromised by infrequent attacks. Still others have had their seizures completely cured by surgery but
are still disabled and incapable of functioning productively. The determination of which patients are medically refractory and which are satisfactorily controlled can
always be argued in the abstract. Fortunately, there is usually general agreement in practice about which patients should be referred for surgical evaluation.
Few patients benefit from further attempts at medical treatment if seizures have not been controlled after two trials of high-dose monotherapy using two appropriate
drugs and one trial of combination therapy. These therapeutic efforts can be accomplished within 1 to 2 years; the detrimental effects of continued seizures or drug
toxicity warrant referral to a specialized center after that time.
There are few blanket contraindications to epilepsy surgery today, although patients with severe concurrent medical illness and progressive neurologic syndromes are
usually excluded. Some centers prefer not to operate on patients with psychosis or other serious psychiatric disorder, those older than 50, and those with an IQ of
less than 70. Patients in these categories, however, must be considered individually. Many patients who undergo corpus callosum section for atonic seizures
associated with Lennox-Gastaut syndrome have an IQ under 70. Although surgery for epilepsy is increasingly performed in children, functional resections in infancy
remain controversial for several reasons: the uncertain natural history of seizures in many of these patients; the unknown effects of surgery on the immature brain;
and the lack of data about long-term neurologic, behavioral, and psychologic outcomes.
Because of technical advances in imaging and electrophysiologic monitoring, epilepsy surgery is no longer automatically contraindicated in patients with multifocal
interictal epileptiform abnormalities or even foci near language or other eloquent cortical areas.
Resective Procedures
Focal brain resection is the most common type of epilepsy surgery. Resection is appropriate if seizures begin in an identifiable and restricted cortical area, if the
surgical excision will encompass all or most of the epileptogenic tissue, and if the resection will not impair neurologic function. These criteria are met most often by
patients with temporal lobe epilepsy, but extratemporal resections are increasingly common.
Anterior Temporal Lobe Resection
This resective procedure is the most common, but the operation varies in what is considered standard, especially with regard to how much lateral neocortical and
mesial limbic structures are removed. At our institution, most patients with unilateral temporal foci undergo Spencer's (1991) anteromedial temporal lobe resection,
which includes removal of the anterior middle and inferior temporal gyri, parahippocampal gyrus, 3.5 to 4 cm of hippocampus, and a variable amount of amygdala. For
nondominant foci, this approach is slightly modified to include the anterior superior temporal gyrus as well. Patients with medial temporal lobe epilepsy associated
with hippocampal sclerosis are ideal candidates for anterior temporal lobe resection, because over 80% will become seizure free with the remainder having
substantial improvement.
Lesionectomy
Well-circumscribed epileptogenic structural lesions (cavernous malformations, hamartomas, gangliogliomas, and other encapsulated tumors) can be removed by
stereotactic microsurgery. The extent to which tissue margins surrounding the lesion are included in the resection depends on how the margins are defined
(radiologic, visual, electrophysiologic, or histologic inspection) and the surgeon's preference. Seizures are controlled by this method in 50% to 60% of patients. A
lesion involving the cerebral cortex should always be considered the source of a patient's seizures unless compelling EEG evidence suggests otherwise.
Nonlesional Cortical Resections
When a lesion cannot be visualized by MRI, it is difficult to demonstrate a restricted ictal onset zone outside the anterior temporal lobe. This situation almost always
requires placement of intracranial electrodes to map the extent of epileptogenic tissue and to determine its relation to functional brain areas. Outcome after
nonlesional cortical resections is not as good as with anterior temporal lobectomy or lesionectomy, mainly because the boundaries of epileptogenic cortical areas
often cannot be delineated precisely, and removal of all the epileptogenic tissue often is not possible.
Corpus Callosotomy
Section of the corpus callosum disconnects the two hemispheres and is indicated for treatment of patients with uncontrolled atonic or tonic seizures in the absence of
an identifiable focus suitable for resection. Most patients referred for corpus callosotomy have severe and frequent seizures of multiple types, usually with mental
retardation and a severely abnormal EEG (the Lennox-Gastaut syndrome).
Unlike resective surgery, corpus callosotomy is palliative, not curative. Nonetheless, it can be strikingly effective for generalized seizures, with 80% of patients
experiencing complete or nearly complete cessation of atonic, tonic, and tonic-clonic attacks. This outcome is often remarkably beneficial because it eliminates falls
and the associated self-injury. The effect on partial seizures, however, is inconsistent and unpredictable. Complex partial seizures are reduced or eliminated in about
half the patients, but simple or complex partial seizures are exacerbated in about 25%. Therefore, refractory partial seizures alone are not an indication for corpus
callosotomy. Similarly, absence, atypical absence, and myoclonic seizures either do not benefit or show an inconsistent response.
Hemispherectomy
Removal or disconnection of large cortical areas from one side of the brain is indicated when the epileptogenic lesion involves most or all of one hemisphere.
Because hemispherectomy guarantees permanent hemiplegia, hemisensory loss, and usually hemianopia, it can be considered only in children with a unilateral
structural lesion that has already resulted in those abnormalities and who have refractory unilateral seizures. Examples of conditions suitable for hemispherectomy
include infantile hemiplegia syndromes, Sturge-Weber disease, Rasmussen syndrome, and severe unilateral developmental anomalies, such as
hemimegalencephaly. In appropriate patients, the results are dramatic. Seizures cease, behavior improves, and development accelerates ( Table 140.9).
TABLE 140.9. OUTCOME AFTER EPILEPSY SURGICAL PROCEDURES
Preoperative Evaluation
The objective in evaluating patients for focal resection is to demonstrate that all seizures originate in a limited cortical area that can be removed safely. This
determination requires more extensive evaluation than is necessary in the routine management of patients with epilepsy. The different tests used provide
complementary information about normal and epileptic brain functions.
CCTV/EEG monitoring is necessary to record a representative sample of the patient's typical seizures to confirm the diagnosis and classification and also to localize
the cortical area involved in ictal onset. Volumetric or other special MRI techniques may demonstrate unilateral hippocampal atrophy or other anatomic abnormalities
that may be epileptogenic. Positron emission tomography and ictal single-photon emission CT are useful to demonstrate focal abnormalities in glucose metabolism or
cerebral blood flow that correspond to the epileptogenic brain region. Neuropsychologic testing is useful in demonstrating focal cognitive dysfunction, especially
language and memory. Intracarotid injection of amobarbital (the Wada test) to determine hemispheric dominance for language and memory competence is generally
considered necessary before temporal lobectomy, but the implications of a failed test are uncertain.
Intracranial electrodes are necessary if noninvasive methods do not unequivocally localize the epileptogenic area or if different noninvasive tests give conflicting
results. Intracranial electrode placement is also necessary when vital brain functions (language, motor cortex) must be mapped in relation to the planned resection.
Vagal Nerve Stimulation
Vagal nerve stimulation is a novel nonpharmacologic treatment for medically refractory partial seizures. Like corpus callosotomy, vagal nerve stimulation is a palliative
procedure, because very few patients become seizure free. Vagal nerve stimulation is delivered via a stimulating lead attached to the left vagus nerve. The stimulus
generator is implanted in the upper left chest. The device is usually programmed to give a 30-second electrical pulse every 5 minutes, although stimulus parameters
can be adjusted to the requirements of an individual patient. In patients with aura, a magnetic wand can be used to deliver vagal nerve stimulation on demand, which
may abort seizure progression. About 30% to 35% of patients have at least a 50% reduction in seizure frequency, which compares favorably with the efficacy of new
antiepileptic drugs. Chronic adverse effects include hoarseness and difficulty swallowing, both of which increase at the time of stimulation.
REPRODUCTIVE HEALTH ISSUES
Status Epilepticus
Convulsive status epilepticus is a medical emergency, and failure to treat the condition in a timely and appropriate manner can result in serious systemic and
neurologic morbidity. At least 65,000 cases of status epilepticus occur each year in the United States. It is diagnosed if seizures last longer than 10 minutes or if two
or more seizures occur in close succession without recovery of consciousness.
Status epilepticus may be either convulsive or nonconvulsive. The most life-threatening pattern, and that requiring the most urgent treatment, is convulsive status
epilepticus, which, like seizures and epileptic syndromes, may be a manifestation either of idiopathic (i.e., nonfocal) epilepsy or secondary to spread from a localized
epileptogenic brain region. Nonconvulsive status epilepticus occurs as a kind of twilight confusional state and is caused by either continuing generalized absence
seizures or complex partial seizures.
Status epilepticus is most frequent in infants and young children and in elderly persons, but it occurs at all ages. More than 50% of those affected do not have a
history of epilepsy. In about 10% of patients with epilepsy, status epilepticus is the first manifestation, and about 15% of patients with epilepsy have had one or more
episodes of status at some time.
In two-thirds of cases of status epilepticus, an acute cause or precipitating factor, such as systemic metabolic derangement, alcohol or other drug abuse, hypoxia,
head trauma, infection, or a cerebral lesion, such as a stroke or tumor, can be identified. Therefore, part of the emergency evaluation of patients in status is
determining the probable cause ( Table 140.10).
TABLE 140.10. CAUSES OF STATUS EPILEPTICUS
Convulsive Status Epilepticus
Convulsive status epilepticus generates metabolic and physiologic stresses that contribute to permanent brain damage, including hyperthermia, hypoxia, lactic
acidosis, hypoglycemia, and hypotension. Plasma catecholamine levels are acutely elevated during the attack and may trigger fatal cardiac arrhythmias. Death
usually results from the underlying condition rather than from the status epilepticus itself. Nonetheless, death from status epilepticus per se occurs in 2% to 3% of
children and in 7% to 10% of adults.
The goals of treatment are to eliminate all seizure activity and to identify and treat any underlying medical or neurologic disorder. Initial management is that of any
comatose patient: to ensure airway and oxygenation, to access circulation and maintain blood pressure, and to monitor cardiac function ( Table 140.11). Blood should
be obtained for antiepileptic drug levels, blood count, and routine chemistries. Brain imaging should be done in all adult patients with status epilepticus and in all
children with nonfebrile status epilepticus. Patients should be in stable condition, and CT is usually sufficient to exclude an acute brain lesion. MRI should be obtained
later if the CT was normal. Lumbar puncture should be performed in any febrile patient, even if signs of meningitis are not present. If brain infection is strongly
suspected, the need for lumbar puncture is urgent, and the procedure should be carried out immediately. If signs of increased intracranial pressure are apparent or if
a mass lesion is suspected, antibiotics should be given immediately and a CT obtained first.
TABLE 140.11. PROTOCOL AND TIMETABLE FOR TREATING STATUS EPILEPTICUS IN ADULTS AT THE NEUROLOGICAL INSTITUTE OF NEW YORK
COLUMBIA-PRESBYTERIAN MEDICAL CENTER
If the history is at all uncertain, glucose should be given, preceded by thiamine in adults. Although several antiepileptic drug regimens are effective for treating status
epilepticus, we begin with lorazepam, 0.1 mg/kg, or diazepam, 0.2 mg/kg, followed immediately by phenytoin (or fosphenytoin), 20 mg/kg. If there is no response,
additional phenytoin (or fosphenytoin), 5 mg/kg, should be administered. If status persists, the patient should be intubated and anesthetized with pentobarbital or
midazolam with EEG monitoring to ensure complete suppression of all electrical ictal activity.
Fosphenytoin is a phosphate ester prodrug of phenytoin. Unlike intravenous phenytoin, fosphenytoin is compatible with all intravenous solutions in common use.
Because it is much less alkaline, it causes only minimal local irritation and can be infused at much faster rates than phenytoin. After entering the blood, fosphenytoin
is converted rapidly to phenytoin by phosphatases in the liver and red blood cells. Fosphenytoins pharmacologic properties are identical to those of phenytoin and is
dosed in phenytoin equivalents. Unique side effects are paresthesias in the low back and groin, probably due to the phosphate load.
After the patient has been stabilized and seizures controlled, a rigorous search for an underlying condition should be instituted.
Nonconvulsive Status Epilepticus

This condition is difficult to diagnose clinically and is frequently unrecognized. Patients are most often middle-aged or elderly and usually have no past history of
seizures. Onset is generally abrupt, and all patients show altered mentation and behavioral changes that typically last for days to weeks. Patients in nonconvulsive
status are characteristically alert (although dull), and the absence of stupor or coma contributes to misdiagnosis. A psychiatric diagnosis is often the first consideration
if the condition presents as bizarre behavior and change in affect, often with hallucinations, paranoia, or catatonia. When memory loss, disorientation, and mood
changes predominate, diagnostic possibilities include dementia, stroke, or metabolic/toxic encephalopathy.
Once the suspicion of nonconvulsive status epilepticus has been raised, diagnosis depends on demonstrating ictal patterns in the EEG while the patient is
symptomatic. Most patients show continuous or nearly continuous 1- to 2.5-Hz generalized spike-wave (atypical spike-wave) activity. In these cases, status
epilepticus is presumed to be a manifestation of generalized-onset epilepsy akin to absence status epilepticus in children. Occasionally, the EEG ictal activity is
localized, usually to the frontal or temporal lobes, thus indicating that in these patients the nonconvulsive status is a form of continuous partial seizure activity.
Diagnosis of nonconvulsive status epilepticus is confirmed by the response to intravenous diazepam (5 to 10 mg) or lorazepam (1 to 2 mg): Epileptiform EEG
abnormalities disappear, and the patient's mental state reverts to normal. Long-term seizure control is achieved using valproate, phenytoin, or carbamazepine.
Laboratory studies are usually normal, but occasionally they identify a cause for the nonconvulsive status epilepticus, such as nonketotic hyperglycemia, electrolyte
imbalance, drug toxicity (e.g., lithium), or a focal cerebral lesion (e.g., frontal lobe infarction).
GENE DEFECTS IN EPILEPSY
Genetic factors have been implicated strongly in several epilepsy syndromes, and twin studies have confirmed important genetic determinants in both
localization-related and generalized types of seizure disorders. Hereditary aspects are easiest to discern in childhood absence epilepsy, juvenile myoclonic epilepsy,
benign rolandic epilepsy, and idiopathic grand mal seizures. However, genetic epidemiologic studies have demonstrated clearly that complex polygenic
susceptibilities exist in both the idiopathic and symptomatic epilepsies. Thus, a major challenge facing investigators today is to clarify how different genes alter an
individual's susceptibility to seizures and epilepsy in the presence of acquired brain pathology or as a reaction to acute or subacute cerebral dysfunction. This is no
easy task, however, because the number of genes that encode molecules that regulate cortical excitability directly through membrane and synaptic functions and the
second messenger cascades that indirectly regulate membrane proteins involved in signal transduction is very large.
These considerations imply a continuum between idiopathic and symptomatic epilepsies, with the development of epilepsy deriving from the complex interrelation of
genetic factors and brain pathology. In any given patient, therefore, the relative contribution of genetic or acquired pathologic factors determines whether the epilepsy
presents clinically as an idiopathic disorder or a symptomatic one.
Linkage studies have identified specific gene loci for several human epilepsies ( Table 140.12). Genes have been identified for three autosomal recessive progressive
myoclonic epilepsies (Unverricht-Lundborg disease, Lafora disease, and the form of neuronal ceroid lipofuchsinosis known as Batten's disease), an autosomal
dominant idiopathic generalized epilepsy (benign familial neonatal seizures), an autosomal dominant form of febrile seizures, and one type of idiopathic partial
epilepsy (autosomal dominant nocturnal frontal lobe epilepsy). The defective gene in Unverricht-Lundborg disease encodes cystatin B, a ubiquitous inhibitor of
cysteine protease, a lysosomal enzyme that cannot, at the present time, be related easily to any known epileptogenic mechanism, although programmed neuronal cell
death may be involved. An abnormal potassium-channel gene results in the syndrome of benign familial neonatal seizures, and an abnormal sodium channel gene
leads to an autosomal dominant form of febrile seizures. Some, but not all, families with autosomal dominant frontal lobe epilepsy have an abnormality in the gene for
the a 4-subunit of the neuronal nicotinic acetylcholine receptor. A point mutation in mitochondrial DNA results in myoclonic epilepsy with ragged red fibers (MERRF).
TABLE 140.12. HUMAN EPILEPSY GENES AND GENE DEFECTS
PSYCHOSOCIAL AND PSYCHIATRIC ISSUES
The impact of epilepsy on the quality of life is usually greater than the limitations imposed by the seizures alone. The diagnosis of epilepsy frequently carries other
consequences that can greatly alter the lives of many patients. For adults, the most important problems are discrimination at work and driving restrictions, which lead
to loss of mobility and independence. Children and adults alike may be shunned by uninformed friends. Patients must learn to avoid situations that precipitate
seizures, and a change in lifestyle may be necessary. Common factors that increase the likelihood of seizure occurrence include sleep deprivation, alcohol (and other
drugs), and emotional stress ( Table 140.13). Compliance with antiepileptic drug treatment is often an issue, especially with adolescents. Psychiatric symptoms,
especially depression, may complicate management.
TABLE 140.13. FACTORS THAT LOWER THE SEIZURE THRESHOLD
Some restrictions are medically appropriate, at least for limited times. For example, when seizures impair consciousness or judgment, driving and certain kinds of
employment (working at exposed heights or with power equipment) and a few other activities (swimming alone) should be interdicted. On the other hand, legal
prohibitions on driving vary in different states in the United States and in different countries and are often not medically justified. Employers frequently have unrealistic
fears about the physical effects of a seizure, the potential for liability, and the impact on insurance costs. In fact, the Americans with Disabilities Act prohibits denying
employment to persons with disability if the disability does not prevent them from meeting job requirements.
Children have special problems because their seizures affect the entire family. Parents may, with the best of intentions, handicap the child by being overly restrictive.
The necessary and special attention received by the sick child may encourage passive manipulative behavior and overdependence while unintentionally
exacerbating normal sibling rivalries.
The physician must be sensitive to these important quality of life concerns, even when they are not raised spontaneously by the patient or family. In fact, psychosocial
issues often become the major focus of follow-up visits after the diagnosis has been made, the initial evaluation completed, and treatment started. We cannot
emphasize too much the physician's responsibility to educate society to counter misperceptions and prejudices and to separate myth from medical fact. The Epilepsy
Foundation (Landover, Maryland; 1-800-EFA-1000; www.efa.org) and its nationwide system of affiliates have a wealth of materials about epilepsy suitable for patient,
family, and public education.
Compliance
The most common cause of breakthrough seizures is noncompliance with the prescribed therapeutic regimen. Only about 70% of patients take antiepileptic
medications as prescribed. For phenytoin or carbamazepine, noncompliance can be inferred when sequential blood levels vary by more than 20%, assuming similarly
timed samples and unchanged dosage. Persistently low antiepileptic drug levels in the face of increasing dosage also generally imply poor compliance. Caution is
warranted with phenytoin, however, because as many as 20% of patients have low levels as a result of poor absorption or rapid metabolism.
Noncompliance is especially common in adolescents and elderly persons, when seizures are infrequent or not perceived as disabling, when antiepileptic drugs must
be taken several times each day, and when toxic effects persist. Compliance can be improved by patient education, by simplifying drug regimens, and by tailoring
dosing schedules to the patient's daily routines. Pill box devices that alert the patient to scheduled doses can be useful.
Depression and Psychosis
In referral centers, depression and suicide are more common in patients with epilepsy than in patients with other neurologic disorders or in disease-free control
subjects. Whether this predilection is true for the epilepsy population at large is not known because few community-based population studies have been conducted.
Depression in epilepsy may be influenced by several factors: the type or severity of the seizures, the location of the epileptogenic focus, associated neurologic or
medical conditions, the antiepileptic drugs used, and by the personal stigma and limitations that accompany the diagnosis. Curiously, depression sometimes follows
successful epilepsy surgery.
Treatment of depression begins with optimal treatment of the seizure disorder. Barbiturate and succinimide drugs may adversely affect mood, inducing symptoms that
mimic endogenous depression. Although tricyclic antidepressants reduce the seizure threshold in experimental models of epilepsy, this is not a practical concern
because they only rarely trigger seizures or increase seizure frequency in humans. Monoamine oxidase inhibitors neither induce seizures nor increase seizure
frequency. Modern electroconvulsive therapy does not worsen epilepsy. We have used both sertraline and fluoxetine without exacerbating seizures.
The relation between psychosis and epilepsy is controversial. No convincing evidence shows that interictal psychosis is a manifestation of epilepsy, but some
demographic features are overrepresented in patients with epilepsy.
Phenothiazines, butyrophenones, and clozapine lower seizure threshold in experimental animals and occasionally seem to induce seizures in nonepileptic patients.
Most occurrences have been associated with high drug doses or a rapid increase in dose. With the possible exception of clozapine, however, little evidence supports
the notion that reasonable and conservative use of antipsychotic medications increases seizure frequency in patients with epilepsy.
Interictal aggressive behavior is not more common in people with epilepsy. Directed aggression during seizures occurs in less than 0.02% of patients with severe
epilepsy; it is almost certainly less common in the general epilepsy population. Undirected pushing or resistance occasionally occurs postictally when attempts are
made to restrain confused patients.
Postictal psychosis is a limited period of psychosis that follows a flurry of seizures, usually after an interval of appropriate behavior. This uncommon condition does
not lead to chronic psychosis.
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Engel J Jr, ed. Surgical treatment of the epilepsies, 2nd ed. New York: Raven Press, 1993.
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Hauser WA, Rich SS, Annegers, JF, Anderson VE. Seizure recurrence after a 1st unprovoked seizure: an extended follow-up. Neurology 1990;40:11631170.
Hauser WA, Rich SS, Lee JR-J, Annegers JF, Anderson VE. Risk of recurrent seizures after two unprovoked seizures. N Engl J Med 1998;338:429434.
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CHAPTER 141. FEBRILE SEIZURES
MERRITTS NEUROLOGY
CHAPTER 141. FEBRILE SEIZURES

DOUGLAS R. NORDLI JR. AND TIMOTHY A. PEDLEY
Diagnosis
Prognosis and Treatment
Suggested Readings
Febrile seizures are generalized convulsions that occur during a febrile illness that does not involve the brain. They represent acute symptomatic or reactive seizures,
and even when recurrent they do not warrant the designation of epilepsy. Most febrile seizures occur in children between the ages of 6 months and 4 years; they are
occasionally seen in children as old as 6 or 7 years.
Febrile seizures are the most frequent cause of a convulsion in a child: Between 3%; and 5%; of all children in the United States and Europe and 6%; to 9%; of
children in Japan have at least one febrile seizure before age 5 years. Hauser (1994) estimated 100,000 cases of febrile seizures in the United States in 1990.
Genetic factors are important; overall, siblings and offspring of affected probands have a two- to threefold increased risk of seizures with fever. Recent linkage studies
in a few large families indicate that febrile seizure susceptibility genes are located on portions of chromosomes 8 and 19 (see Chapter 140). The role of such genes in
sporadic febrile seizures remains to be determined.
CLINICAL MANIFESTATIONS
Febrile seizures appear typically early in the febrile illness, while the temperature is rapidly rising. In many children, the seizure is the first indication of illness.
Although generalized convulsions are the rule, focal features or a Todd's paresis are seen in about 10%; of patients. Febrile seizures are subdivided operationally
into simple and complex types. Simple (also called benign) febrile seizures are brief isolated occurrences that lack focal manifestations. Complex febrile seizures are
frequently focal, last longer than 15 minutes, and tend to occur repeatedly within 24 hours.
DIAGNOSIS
Diagnosis is made by excluding other possible causes of the convulsion, such as meningitis, metabolic abnormalities, or structural brain lesions. Depending on the
manifestations and the clinician's experience, laboratory tests are not always necessary. Usually, a clinically identifiable infection, such as otitis media, roseola
infantum, pharyngitis, or gastroenteritis, is present. Fever after immunization may also trigger a febrile seizure. Any suspicion of meningitis, however, mandates
lumbar puncture. The typical indicators of meningeal irritation, such as nuchal rigidity and the Brudzinki sign, are not reliable in young infants. If the seizure has focal
features or if the examination elicits focal neurologic abnormalities, brain imaging is necessary. Electroencephalography is not a useful test because it does not
provide information regarding either risk of recurrence of febrile seizures or later development of epilepsy.
PROGNOSIS AND TREATMENT
About one-third of children with febrile seizures have more than one attack. Recurrence is highest in infants whose first febrile seizure occurred before the age of 1
year and in children with a family history of febrile seizures. When the first seizure is a typical simple febrile seizure, only 1%; of patients have prolonged convulsions
later.
The risk of developing epilepsy is increased in children with febrile seizures, but the magnitude of the risk depends on several factors. In children with simple febrile
seizures, the risk of later epilepsy is 2%; to 3%;. The incidence of epilepsy increases to about 10%; to 13%; in children who have had complex febrile seizures, who
have a family history of afebrile seizures, or who were neurologically abnormal before the first febrile seizure. Young children who have unprovoked seizures after a
febrile convulsion are at much greater risk of further seizures with subsequent febrile illnesses.
Neither simple nor complex febrile seizures are associated with, nor do they lead to, mental retardation, low global IQ, poor school achievement, or behavioral
problems. Some differences have been reported, however. Children with febrile seizures in the first year of life are more likely to require special schooling than those
who have them later. In children with prolonged febrile convulsions, nonverbal intelligence measures may be slightly lower compared with children with simple febrile
seizures. Mortality is not increased in children with febrile seizures who are neurologically normal.
Because most children with febrile seizures have no long-term consequences, most clinicians now avoid chronic prophylactic treatment with antiepileptic drugs, even
after two or three isolated convulsions. Although both phenobarbital and valproate are effective in reducing recurrence, evidence does not show that treatment alters
the risk of later epilepsy. In addition, adverse drug effects occur in as many as 40%; of infants and children treated with phenobarbital, and valproate carries a risk of
idiosyncratic fatal hepatotoxicity and pancreatitis. Phenytoin is ineffective.
If treatment is considered at all, it should be reserved for children with complex febrile seizures who are neurologically abnormal or who have a strong family history of
afebrile seizures. A reasonable alternative to chronic drug therapy is intermittent treatment using rectal diazepam. Several studies have shown that rectal
administration of diazepam during febrile illnesses is safe and as effective as phenobarbital in reducing seizure recurrence. A rectal formulation of diazepam (Diastat)
is now available in the United States, although the U.S. Food and Drug Administration has not yet approved it for use in prolonged febrile seizures.
Watching their child have a convulsion is one of the most frightening experiences that parents can have. The physician therefore must provide reassurance to dispel
any myths the family may have, emphasizing in particular that febrile seizures are neither life-threatening nor damaging to the brain.
SUGGESTED READINGS
American Academy of Pediatrics. Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. Practice parameter: the neurodiagnostic evaluation of the child with a first
simple febrile seizure. Pediatrics 1996;97:769772.
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Berg AT, Shinnar S, Darefsky AS, et al. Predictors of recurrent febrile seizures. A prospective cohort study. Arch Pediatr Adolesc Med 1997;151:371378.
Berg AT, Shinnar S, Shapiro ED, et al. Risk factors for a first febrile seizure: a matched case-control study. Epilepsia 1995;36:334341.
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Kugler SL, Johnson WG. Genetics of the febrile seizure susceptibility trait. Brain Dev 1998;20:265274.
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Rosman NP, Colton T, Labazzo RNC, et al. A controlled trial of diazepam administered during febrile illnesses to prevent recurrence of febrile seizures. N Engl J Med 1993;329:7984.
Tarkka R, Rantala H, Huhari M, Pokka T. Risk of recurrence and outcome after the first febrile seizure. Pediatr Neurol 1998;18:218220.
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CHAPTER 142. NEONATAL SEIZURES
MERRITTS NEUROLOGY
CHAPTER 142. NEONATAL SEIZURES

DOUGLAS R. NORDLI JR. AND TIMOTHY A. PEDLEY
Classification
Etiology
Evaluation
Treatment
Prognosis
Suggested Readings
Seizures are the most common sign of neurologic dysfunction in the neonate. They occur in 0.5% of all newborns, more often in preterm babies, and frequently signify
injury to the developing brain. They are thus an urgent clinical problem that requires prompt diagnosis and treatment.
CLASSIFICATION
The clinical semiology and electroencephalographic (EEG) features of neonatal seizures have been recognized for years to differ substantially from those of older
children and adults. Therefore, the classification schemes used for seizures in older patients are inappropriate for newborns.
Neonatal seizures are almost always identified by clinical observation, and traditionally, clinical features have been used for classification. Analysis of simultaneous
closed-circuit television and EEG recordings has revealed that not all clinical seizure behaviors are accompanied by an EEG seizure discharge. Also, not all EEG ictal
patterns produce clinical behavioral changes.
The current classification proposed by Volpe (1989) recognizes four general patterns of clinical behavior and describes each by the presence or absence of a
consistent EEG discharge (Table 142.1). Focal clonic, focal tonic, and some myoclonic seizures are accompanied by characteristic EEG discharges. In contrast,
generalized tonic seizures, most motor automatisms (mouthing, pedaling, stepping, rotary arm movements), and some myoclonic seizures have inconsistent or no
reliable EEG changes. Autonomic phenomena are common, especially in term newborns, but they almost always accompany other behavioral manifestations. In
preterm infants, however, isolated autonomic phenomena may be the only evidence of seizure activity. Apnea is rarely the sole manifestation of an ictal event. A
complete generalized tonic-clonic sequence does not occur in newborns.
TABLE 142.1. CLASSIFICATION OF NEONATAL SEIZURES
ETIOLOGY
Although the incidence of neonatal seizures has not changed much in several decades, the frequency of different causes has been modified considerably. Former
frequent causes of seizures in the newborn, such as hypocalcemia and obstetric injury, are rare today. Now, hypoxic-ischemic encephalopathy is the major cause
(Table 142.2). Infants at highest risk for developing seizures second to asphyxia have low 5-minute Apgar scores, require intubation in the delivery room, and have
severe acidemia. Other important causes of neonatal seizures include intraventricular and intracerebral hemorrhage, intrauterine or postnatal infection, cerebral
malformations, and metabolic disorders, including hypoglycemia, hypocalcemia, hypomagnesemia, and inborn errors of metabolism (nonketotic hyperglycinemia, urea
cycle defects). In many babies, multiple factors coexist (e.g., hypoxia and intraventricular hemorrhage), and concurrent metabolic abnormalities, especially
hypoglycemia and hypocalcemia, occur frequently. A potassium channel gene defect has been identified as the cause of benign familial neonatal convulsions.
TABLE 142.2. CAUSES OF NEONATAL SEIZURES
EVALUATION
As in older patients with seizures, the history is the most important component of the neurologic assessment, including the family history and details of the infant's
gestation and delivery. With patience, seizures often can be observed directly. If not, the nursery attendant is a reliable source of information. Examination should
assess the overall well-being of the child, the infant's resting posture and quality of spontaneous movements, and whether any abnormal postures or movements can
be elicited by stimulation or positioning. The infant's head circumference should be determined, and note should be made of any congenital anomalies, signs of a
neurocutaneous disorder, or organomegaly.
Laboratory tests, including lumbar puncture and blood cultures, must be obtained rapidly to identify treatable metabolic abnormalities, sepsis, and meningitis.
Ultrasound, head computed tomography, or brain magnetic resonance imaging assess possible hydrocephalus, intracranial hemorrhage, or major anomalies.
Magnetic resonance imaging is usually necessary to detect more subtle developmental abnormalities, such as partial lissencephaly, polymicrogyria, or cortical
dysplasia. Properly performed, magnetic resonance imaging demonstrates brain abnormalities in two-thirds of newborns with seizures, and diffuse brain lesions,
irrespective of etiology, are associated with a high mortality rate. EEG provides important information about the physiologic state of the brain and may be diagnostic if
a seizure is recorded.
The timing of the first seizure helps to distinguish diagnostic possibilities. Seizures resulting from severe brain malformations, intracerebral hemorrhage, and
hypoxic-ischemic injury occur within 24 to 48 hours. Seizures caused by infection and inborn errors of metabolism typically begin toward the end of the first week of
life or later. Seizures related to passive drug withdrawal usually occur within the first 3 days (e.g., alcohol, short-acting barbiturates) but may not appear for 2 to 3
weeks (e.g., methadone). Seizures resulting from sepsis occur at any time.
Seizures must be distinguished from other paroxysmal phenomena in the newborn, including jitteriness, benign sleep myoclonus, dyskinesias (common with severe
bronchopulmonary dysplasia), and the movements of rapid eye movement sleep. Brief generalized tonic postures occur with poor cerebral perfusion or with resolving
encephalopathies; they do not signify convulsions. Epileptic (associated with an EEG ictal discharge) must be separated from nonepileptic seizures because of the
therapeutic implications. Seizures without EEG changes are probably caused by subcortical or brainstem release phenomena rather than by cortical events and
therefore result from different pathophysiologic mechanisms.
TREATMENT
Treatment should be based on assumed physiologic mechanism. Epileptic seizures should be treated with antiepileptic drugs. Antiepileptic drugs are probably
ineffective, however, in seizures that are not associated with an EEG discharge, and drugs may worsen already depressed forebrain function. It must be recognized,
however, that some clinical and experimental evidence suggests that deep subcortical or brainstem structures may give rise to seizures in newborns without an EEG
correlate. More controversial is the end point of therapy. Antiepileptic drug treatment often suppresses clinical manifestations whereas electrical seizure activity
persists. Although experimental evidence indicates that prolonged electrical seizures can injure the brain, there is uncertainty and debate about the extent to which
EEG ictal discharges contribute, by themselves, and in the absence of hypoxia and ischemia, to permanent neurologic sequelae. We recommend using antiepileptic
drugs to the point that clinical seizure activity is eliminated or a high therapeutic blood level is achieved without compromising respiratory or circulatory function. We
do not attempt to suppress EEG seizure activity that continues after clinical seizures end, mainly because the drug dosages necessary to achieve this end usually
lead to obtundation, ventilatory failure, or cardiac depression. More data are needed about the possible long-term deleterious effects of subclinical electrical seizure
discharges.
Phenobarbital is the most frequently used antiepileptic drug in newborns. The infant should be given 20 mg/kg intravenously over 15 to 20 minutes. If seizures persist,
then additional 5-mg/kg increments of phenobarbital can be given every 20 minutes up to a total loading dose of 40 mg/kg. The maintenance dose for phenobarbital is
between 3 to 6 mg/kg/day. Therapeutic levels are 15 to 35 g/mL; levels higher than 40 g/mL produce lethargy.
Phenytoin is an alternative drug when phenobarbital fails. It is given intravenously over about 20 minutes in a loading dose of 20 mg/kg. Some clinicians advise
dividing the loading dose into two 10-mg/kg increments to minimize cardiac toxicity. Maintenance doses are 3 to 4 mg/kg/day. Fosphenytoin, the water-soluble
phosphorylated version of phenytoin, has been administered safely to small groups of neonates as young as 26 weeks conceptional age. Midazolam, 0.1 to 0.4
mg/kg/hr administered by continuous intravenous infusion, may be useful in suppressing seizures refractory to phenobarbital and phenytoin.
Hypoglycemia should be treated using a 10% glucose solution infused in a dosage of 2 ml/kg.
When to stop antiepileptic drugs is a matter of judgment. If the infant is normal and the EEG is normal or near normal, we generally discontinue antiepileptic drug
therapy before the child is discharged from the hospital. In other cases, we wait 1 to 3 months after the last seizure.
PROGNOSIS
The long-term prognosis relates not to the seizures but to the underlying cause. Perinatal asphyxia, severe intracranial hemorrhage, and cerebral malformations all
have a high correlation with permanent brain damage. Therefore, prognosis is guarded for most newborns with seizures; 33% to 50% have neurologic sequelae.
Recurrent seizures from the first day of life that interfere with respiration and feeding schedules also carry a poor prognosis. Serial EEG studies assist in identifying
term infants at high risk for abnormal neurologic outcome. Several EEG patterns (suppression-burst background activity, unreactive low-voltage recording, continuous
multifocal ictal events) reliably predict a fatal outcome or disabling brain damage more than 90% of the time. EEG is less useful in predicting which infants will
continue to have seizures beyond the neonatal period. About 15% to 30% of infants with neonatal seizures develop epilepsy.
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Bye AM, Cunningham CA, Chee KY, Flanagan D. Outcome of neonates with electrographically identified seizures, or at risk of seizures. Pediatr Neurol 1997;16:225231.
Clancy RR, Legido A, Lewis D. Occult neonatal seizures. Epilepsia 1988;29:256261.
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1998;132:345348.
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Lanska MJ, Lanska DJ. Neonatal seizures in the United States: results of the National Hospital Discharge Survey, 19801991. Neuroepidemiology 1996;15:117125.
Leth H, Toft PB, Herning M, et al. Neonatal seizures associated with cerebral lesions shown by magnetic resonance imaging. Arch Dis Child Fetal Neonat Med 1997;77:F105F110.
Mizrahi EM, Kellaway P. Characterization and classification of neonatal seizures. Neurology 1987;37:18371844.
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Sher MS. Seizures in the newborn infant. Diagnosis, treatment, and outcome. Clin Perinatol 1997;24:735772.
Sher MS, Aso K, Beggarly ME, et al. Electrographic seizures in preterm and full-term neonates: Clinical correlates, associated brain lesions, and risk of neurologic sequelae. Pediatrics
1993;91:128134.
Sheth RD, Buckley DJ, Gutierrez AR, et al. Midazolam in the treatment of refractory neonatal seizures. Clin Neuropharmacol 1996;19:156170.
Strober JB, Bienkowski RS, Maytal J. The incidence of acute and remote seizures in children with intraventricular hemorrhage. Clin Pediatr 1997;36:643647.
Volpe JJ. Neonatal seizures: current concepts and revised classification. Pediatrics 1989;84:422428.
CHAPTER 143. TRANSIENT GLOBAL AMNESIA
MERRITTS NEUROLOGY
CHAPTER 143. TRANSIENT GLOBAL AMNESIA

JOHN C.M. BRUST
Suggested Readings
Transient global amnesia (TGA) is characterized by sudden inability to form new memory traces ( anterograde amnesia) in addition to retrograde memory loss for
events of the preceding days, weeks, or even years. During attacks, which affect both verbal and nonverbal memory, there is often bewilderment or anxiety and a
tendency to repeat one or several questions (e.g., Where am I?). Physical and neurologic examinations, including mental status, are otherwise normal. Immediate
registration of events (e.g., serial digits) is intact, and self-identification is preserved. Attacks last minutes or hours, rarely longer than a day, with gradual recovery.
Retrograde amnesia clears in a forward fashion, often with permanent loss for events occurring within minutes or a few hours of the attack; there is also permanent
amnesia for events during the attack itself. TGA sometimes seems to be precipitated by physical or emotional stress, such as sexual intercourse, driving an
automobile, or swimming in cold water. Because amnesia can accompany a variety of neurologic disturbances, such as head trauma, intoxication, partial complex
seizures, or dissociative states, criteria for diagnosing TGA should include observation of the attack by others.
Patients are usually middle-aged or elderly and otherwise healthy. Recurrent attacks occur in less than 25% of cases, and fewer than 3% have more than three
attacks. Intervals between attacks range from 1 month to 19 years. Permanent memory loss is rare, although subtle defects have been reported after only one attack.
The cause of TGA is uncertain. Casecontrol series and anecdotal reports variably implicate stroke, seizures, or migraine.
In a large series of patients with TGA, the cause was epileptic in 7%. Attacks in this group were nearly always less than 1 hour in duration and tended to occur on
awakening; two-thirds had additional seizure types, usually simple or complex partial seizures. Sleep, but not interictal, electroencephalograms revealed temporal
lobe epileptiform discharges.
Major risk factors for stroke (hypertension, diabetes mellitus, tobacco, ischemic heart disease, atrial fibrillation, and past stroke or transient ischemic attack) are no
more common among patients with TGA than in age-matched controls, and TGA is not a risk factor for stroke. On the other hand, attacks have been associated with
cerebral angiography (especially vertebral), polycythemia, cardiac valvular disease, and patent foramen ovale. Patients with amnestic stroke due to documented
posterior cerebral artery occlusion do not report previous TGA; their neurologic signs include more than simple amnesia (e.g., visual impairment), and they do not
exhibit repetitive queries. Reduced blood flow to the thalamus or temporal lobes has been documented during attacks of TGA but could be secondary to neuronal
dysfunction rather than its cause.
Epidemiologic studies confirm an association of TGA with migraine, even though in the great majority of patients migraine attacks are recurrent, whereas attacks of
TGA are not. Sometimes, both amnestic and migrainous attacks (including visual symptoms and vomiting) have occurred simultaneously or followed one another.
Spreading depression of Leao (possibly the pathophysiologic basis of cerebral symptoms in migraine) could, by affecting the hippocampus, explain some cases of
TGA, as well. Diffusion-weighted magnetic resonance imaging during or soon after an attack of TGA in several patients revealed signal abnormalities in one or both
temporal lobes that were more suggestive of spreading depression than primary ischemia.
Thus, even when strict diagnostic criteria are applied, TGA probably has diverse origins. In patients in whom epilepsy and migraine can be excluded and who have
risk factors for cerebrovascular disease, antiplatelet drugs may be considered, but the benign natural history makes it difficult to evaluate any preventive treatment.
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Zorzon M, Antonutti L, Mas G, et al. Transient global amnesia and transient ischemic attack: natural history, vascular risk factors, and associated conditions. Stroke 1995;26:15361542.
CHAPTER 144. MENIERE SYNDROME
MERRITTS NEUROLOGY
CHAPTER 144. MENIERE SYNDROME

JACK J. WAZEN
Signs and Symptoms

Diagnosis
Etiology and Pathogenesis
Treatment
Suggested Readings
First described in 1861 by the French physician Prosper Meniere, this syndrome affects people of all ages, especially those in middle age or older. It is characterized
by a recurrent and episodic triad of spinning vertigo, hearing loss, and tinnitus.
SIGNS AND SYMPTOMS
Patients with Meniere syndrome are usually asymptomatic between attacks. The acute episode may be preceded by warning symptoms of pressure sensation or
fullness in one ear, which feels blocked. Hearing then drops, accompanied by a loud roaring tinnitus. Vertigo soon follows and lasts from a few minutes to many
hours, rarely lasting as long as 24 hours. The interval between the onset of symptoms and the peak of vertigo varies from a few minutes to a full day or so. Depending
on the severity of the vertigo, patients may experience nausea, vomiting, or diarrhea. Pallor and cold sweat are common. Early in the disease, once the spell is over,
the ear clears, hearing returns to normal, and the tinnitus may subside. The patient may feel weak and unsteady for 1 or 2 days following a severe attack. A dull
unilateral headache may accompany the sensation of blockage and fullness in the ear.
Recurrence of the attacks is a cardinal feature. The attacks are of unpredictable frequency. At first, patients may have one attack per year. Then attacks may occur
more frequently, once a week or even daily. The more frequent the spells, the more disabled the patient becomes; anxiety and panic reactions are generated by the
fear that vertigo may occur at any moment.
The hearing loss is usually most severe in the low frequencies. At first, it fluctuates. With progression of the disease, hearing loss becomes permanent, and the high
frequencies are affected, resulting in a flat sensorineural hearing loss. Despite the progressive hearing loss, patients often complain of noise intolerance, which is
attributed to recruitment in the cochlea. Recruitment is an abnormally rapid increase in the sense of loudness as sound intensity increases. The comfortable range of
hearing becomes narrow, and patients become intolerant of sounds barely above their hearing threshold. Recruitment makes it difficult but still feasible to fit a patient
with a hearing aid.
Examination of a patient during a vertigo attack invariably reveals a rotatory-horizontal nystagmus beating toward the affected ear. This nystagmus of peripheral
labyrinthine origin is reduced or abolished by visual fixation. A patient with Meniere syndrome does not necessarily experience all features of the syndrome with each
attack, especially in the initial stages of the disease. Recurrent, fluctuating hearing loss may occur without vertigo, or recurrent vertigo may occur without hearing loss.
Depending on the major symptom, the disorder may be considered primarily cochlear or vestibular. Eventually, however, the full complement of symptoms ensues.
A few patients with Meniere syndrome experience drop attacks or tumarcin crisis. The vertigo is so sudden in onset and so intense that patients find themselves on
the floor as if pushed by an invisible force, even from a sitting position, with no loss of consciousness or other neurologic symptoms.
Symptoms in the contralateral ear occur in 20% to 30% of patients. The risk of bilateral disease depends on the cause of the syndrome (see below).
DIAGNOSIS
The diagnosis is usually evident from the history. Audiologic tests confirm the low-frequency sensorineural hearing loss. Repeated audiograms reveal the fluctuating
nature of the loss. Electronystagmography reveals a vestibular disorder in the affected ear. Other vestibular tests, such as rotational chair testing or dynamic platform
posturography, are also diagnostic of a peripheral vestibular disorder, but they do not lateralize the lesion. The auditory brainstem response is consistent with a
cochlear lesion. Computed tomography and magnetic resonance imaging are usually normal.
ETIOLOGY AND PATHOGENESIS
Extensive research into the cause of this symptom complex has led to the present understanding that Meniere syndrome is not the result of any particular cause but is
the reaction of the inner ear to different offending agents that cause disruption of endolymphatic homeostasis. Recognized causes include congenital inner ear
deformities, labyrinthitis, physical trauma to the head and ear, acoustic trauma, congenital or acquired syphilis, allergic disorders, autoimmune disorders, and vascular
disorders, including diabetes and hypertension. Most cases, however, are idiopathic. These idiopathic cases are labeled as Meniere disease.
Postmortem histopathologic studies of temporal bones from patients with the syndrome revealed endolymphatic hydrops, which describes dilatation and ballooning of
the endolymphatic compartment in the scala media of the cochlea, as well as of the saccule, utricle, and the semicircular canals. These findings suggest that the
condition is caused by oversecretion or malabsorption of the endolymph. Disorders of endolymph malabsorption through the endolymphatic duct and sac are now
believed to cause the dilatation. Some investigators noted that ruptures in the Reisner membrane, with sudden decompression and mixing of perilymph with
endolymph, could result in loss of endocochlear potentials or hair cell injury. The membrane ruptures, however, may be caused by fixing artifacts. Current research
centers on the functions of the endolymphatic sac, including its fluid absorption and immunologic properties.
TREATMENT
Medical Management
Treatment is directed to reducing the impact of the acute attack and the frequency of spells. Controlled trials of the efficacy of any treatment of an acute attack have
been difficult to complete because of the unpredictable and variable nature of the syndrome. As a result, many drugs, such as meclizine hydrochloride (Antivert),
diazepam, promethazine hydrochloride, and prochlorperazine, are used as labyrinthine sedatives. Similarly, no regimen has proved effective in reducing the
frequency of attacks. Some authorities advocate a strict low-salt diet and diuretics to reduce the endolymphatic hydrops. Patients are advised to discontinue the use
of caffeine, tobacco, and alcohol. Vasodilator therapy with histamine and nicotinic acid offers inconsistent results. Patients whose syndrome is allergic or has
immunologic factors may respond well to a course of steroids. Patients are also encouraged to address anxiety, depression, and other psychologic symptoms that
result from fear of attacks.
Surgical Treatment
About 20% of patients fail to respond to medical management and become candidates for surgery to relieve disabling vertigo. Patients who have lost hearing respond
well to a labyrinthectomy, which is the complete removal of the vestibular end-organ. For patients who still have serviceable hearing, vestibular neurectomy is the
procedure of choice, offering a 90% to 95% success rate in vertigo control while preserving hearing. Endolymphatic sac surgery with decompression and shunting of
the endolymph into the mastoid cavity is still performed despite controversies about long-term effectiveness.
Chemical Labyrinthectomy
Nonsurgical candidates and patients who refuse surgery but yet fail to respond to medical treatments may benefit from the intratympanic injection of gentamicin
sulfate, an aminoglycoside known for its ototoxicity. Gentamicin has a greater affinity for vestibular hair cells and thus causes a significant loss of vestibular function
before attacking the cochlear hair cells. Given in the appropriate dose and with close supervision, intratympanic gentamicin is absorbed through the round window
membrane, creating a chemical labyrinthectomy with hearing preservation.
Bilateral Meniere Disease
Patients with active bilateral Meniere disease are treated with systemic injections of streptomycin sulfate. As an ototoxic agent, streptomycin has a stronger affinity for
vestibular hair cells than for cochlear hair cells. Given in daily 1-g injections with close monitoring of vestibular function, treatment is interrupted after the first signs of
vestibular ototoxicity and before the onset of hearing loss. Reduction in the vestibular hair cell population decreases the severity of the vertigo. Total bilateral ablation
of vestibular hair cells leads to oscillopsia and permanent ataxia and therefore should be avoided.
SUGGESTED READINGS
Arenberg IK. Endolymphatic hypertension and hydrops in Meniere's disease: current perspectives. Am J Otol 1982;4:52s65.
Baloh RW. Dizziness, hearing loss, and tinnitus: essentials of neurology. Philadelphia: FA Davis Co, 1984.
Blakeley BW. Clinical forum: a review of intratympanic therapy. Am J Otol 1997;18:520526.
Brackman DE. Neurological surgery of the ear and skull base. New York: Raven Press, 1982.
Brookes GB. The pharmacological treatment of Meniere's disease. Clin Otolaryngol 1996;21:311.
Brookes GB, Hodge RA, Booth JB, Morrison AW. The immediate effects of acetazolamide in Meniere's disease. J Laryngol Otol 1982;96:5772.
Dandy WE. Treatment of Meniere's disease by section of only the vestibular portion of the acoustic nerve. Bull Johns Hopkins Hosp 1933;53:5255.
Hallpike CS, Cairns H. Observations on the pathology of Meniere's syndrome. J Laryngol 1938;53:625654.
Meniere P. Sur une forme particulire de surdit grave dependant d'une lesion de l'oreille interne. Gaz Med Paris 1861;16:29.
Pulec JL. Meniere's disease: etiology, natural history, and results of treatment. Otolaryngol Clin North Am 1973;6:2539.
Stahle J, Wilbrand HF, Rask-Andersen H. Temporal bone characteristics in Meniere's disease. Ann N Y Acad Sci 1981;374:794807.
Tomiyama S, Harris JP. The endolymphatic sac: its importance in inner ear immune responses. Laryngoscope 1986;96:685691.
Wazen JJ, Foyt D, Huang CC. Quantitative immunochemical studies of the endolymphatic sac in Meniere's disease. In: Barbara M, Filipo R, eds. Meniere's disease: pathogenesis, pathophysiology,
diagnosis and treatment. proceedings of the third international symposium. Amsterdam: Kugler, 1994.
Wazen JJ, Spitzer J, Kasper C, Anderson B. Long-term hearing results following vestibular surgery in Meniere's disease. Laryngoscope 1998;108:14701473.
CHAPTER 145. SLEEP DISORDERS
MERRITTS NEUROLOGY
CHAPTER 145. SLEEP DISORDERS

JUNE M. FRY
Sleep Physiology
Diagnostic Procedures
Specific Disorders of Sleep
Suggested Readings
The clinical application of scientific knowledge of sleep physiology and biologic rhythms led to the development of standards for normal sleep and arousal, diagnostic
tests, and a classification of sleep disorders ( Table 145.1). This classification is based on clinical signs, symptoms, age at onset, and natural history. Clinical
polysomnography is an important diagnostic tool that provides objective confirmation of the clinical syndromes.
TABLE 145.1. INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS
SLEEP PHYSIOLOGY
Sleep is an active and complex state comprising four stages of nonrapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. Wakefulness and
sleep stages are characterized by physiologic measures that are assessed by polysomnography. Standardized sleep scoring is based on the electroencephalogram
(EEG), the electrooculogram (EOG; a measurement of eye movements), and the electromyogram (EMG) of the mentalis muscle (chin EMG). Stage 1 sleep is
characterized by a low-voltage, mixed-frequency EEG and slow, rolling eye movements. Reactivity to outside stimuli is decreased, and mentation may occur but is no
longer reality-oriented. Stage 2 consists of a moderate low-voltage background EEG with sleep spindles (bursts of 12- to 14-Hz activity lasting 0.5 to 2 seconds) and
K-complexes (brief high-voltage discharges with an initial negative deflection followed by a positive component). Heart and respiratory rates are regular and slightly
slower. Stage 3 sleep consists of high-amplitude theta (5 to 7 Hz) and delta (1 to 3 Hz) frequencies, as well as interspersed K-complexes and sleep spindles. Stage 4
sleep is similar to stage 3, except that high-voltage delta waves make up at least 50% of the EEG and sleep spindles are few or absent. Stages 3 and 4 are often
combined and referred to as delta sleep, slow-wave sleep, or deep sleep. During this deeper sleep, heart and respiratory rates are slowed and regular. During NREM
sleep, the tonic chin EMG is of moderately high amplitude but less than that of quiet wakefulness.
The EEG pattern during REM sleep consists of low-voltage, mixed-frequency activity and is similar to that of stage 1 sleep. Moderately high-amplitude, 3- to 5-Hz
triangular waveforms called saw-tooth waves are intermittently present and are unique to REM sleep. Intermittent bursts of rapid conjugate eye movements occur.
Tonic chin EMG activity is absent or markedly reduced, and phasic muscle discharges occur in irregular bursts. The decreased EMG activity is a reflection of muscle
paralysis resulting from active inhibition of muscle activity during REM sleep. During REM sleep, heart and respiratory rates are increased and irregular, and vivid
dreaming occurs.
NREM sleep alternates with REM sleep at intervals of 85 to 100 minutes. The normal healthy adult typically falls asleep within 10 minutes and goes through the
sequence of stages 1 through 4 followed by the reverse (stages 4, 3, and 2). Afterward, the first REM sleep period occurs. This normal sleep pattern consists of three
to five such cycles. Typically, stages 3 and 4 are more prominent during the first half of the sleep period, and the REM sleep episodes increase in duration and
intensity of REM activity during the second half of the sleep period.
DIAGNOSTIC PROCEDURES
Clinical polysomnography, the simultaneous recording of sleep and multiple physiologic variables, provides objective documentation of sleep disorders. An all-night
polysomnogram consists of continuous EEG, EOG, mentalis EMG, surface EMG of the anterior tibialis muscles for detection of leg movements in sleep,
electrocardiogram, and measurement of nasal and oral airflow, respiratory effort, and oxygen saturation. Polysomnographic tracings are analyzed in detail to
determine a patient's sleep pattern and the presence and severity of a sleep disorder.
Patients with excessive daytime sleepiness are also evaluated by the multiple sleep latency test (MSLT), a series of four or five nap opportunities with sleep
recordings at 2-hour intervals throughout the day. The nap is terminated 15 minutes after sleep onset. If no sleep occurs, each recording session is terminated after
20 minutes. The sleep latency (time it takes to fall asleep) is determined for each nap and provides an objective measure of daytime sleepiness. Patients with
pathologic daytime sleepiness generally fall asleep in less than 5 minutes on all naps. Normally alert individuals take more than 10 minutes to fall asleep or often
remain awake. The MSLT is also used to determine the presence of sleep-onset REM periods found in narcolepsy, and REM sleep rebound.
SPECIFIC DISORDERS OF SLEEP
Only selected disorders are described, primarily the most common and those of particular interest to neurologists.
Disorders with a Complaint of Insomnia
Transient insomnia lasts less than 3 weeks, is usually situational, and is caused by emotions such as excitement, sorrow, or anxiety resulting from a specific situation,
or by a schedule change, such as jet lag or a work-shift change. A short course (2 weeks or less) of a hypnotic may be indicated for treatment of transient situational
insomnia. Benzodiazepines became the drugs of choice soon after becoming available in the 1960s. New hypnotics, the imidazopyridines, have favorable properties
and are useful for sleep-onset difficulties, but because of very short half-lives, they are less useful for middle-of-the-night or early-morning awakenings.
Persistent or chronic insomnia has many underlying causes. When the cause is a psychiatric disorder, pain, gastroesophageal reflux, or drug or alcohol abuse, the
underlying cause should be treated. Long-term use of hypnotic drugs is one cause of persistent insomnia.
A common dyssomnia is psychophysiologic insomnia. This disorder usually follows a situational insomnia and results from somatized anxiety that is manifested as
restlessness, apprehension, ruminative thoughts, and hypervigilance, all of which interfere with sleep. These factors, combined with negative conditioning, lead to a
vicious cycle: The more the patient tries to sleep, the less successful the attempts become. The most effective treatment for this disorder is behavioral therapy
consisting of relaxation therapy, stimulus control, good sleep hygiene ( Table 145.2), and sleep restriction.
TABLE 145.2. PRINCIPLES OF SLEEP HYGIENE
Alveolar hypoventilation syndrome, a cause of sleep disruption, is associated with major changes in respiratory function during sleep, including central sleep apnea
and hypopnea associated with recurrent hypoxemia, hypercapnia, and a decreased tidal and minute volume. REM sleep is the time of greatest abnormality with the
longest apneic episodes and the greatest fall in oxygen saturation. This syndrome may be idiopathic or associated with other disorders; these include chronic residual
poliomyelitis, muscle diseases (e.g., myotonic dystrophy, anterior horn cell disease), involvement of thoracic cage bellows action or diaphragmatic muscle weakness,
cervical spinal cordotomy, brainstem lesions of structures that control ventilation, dysautonomia syndromes, and massive obesity.
Restless Legs Syndrome and Periodic Limb Movement Disorder
In the restless legs syndrome (RLS), the patient feels an irresistible urge to move the legs, especially when sitting or lying down. There is a discomfort deep inside the
leg, most commonly between the knee and ankle, that makes the patient move the legs or walk about vigorously. The symptoms interfere with and delay sleep onset,
may recur during the night, and cause an insomnia complaint. Periodic limb movements in sleep (PLMS) are found in most patients with RLS who are studied with
polysomnography.
PLMS are stereotyped periodic movements of one or both legs and feet during sleep. The movements, which occur primarily in NREM sleep, consist of dorsiflexion of
the foot, extension of the big toe, and often flexion of the leg at the knee and hip. This triple flexion movement has a mean duration of 1.5 to 2.5 seconds. Similar
movements can occur in the upper extremities but are much less common. Limb movements may be accompanied by an arousal or awakening. These movements are
remarkably periodic, with 20- to 40-second intervals, and may continue for minutes to hours. In contrast to most movement disorders, which are inhibited by sleep
(e.g., cerebellar and extrapyramidal tremors, chorea, dystonia, hemiballism), PLMS are initiated by sleep or drowsiness. They are different from hypnic jerks (sleep
starts), which are nonperiodic, isolated myoclonic movements that occur at sleep onset and simultaneously involve the muscles of the trunk and extremities. Hypnic
jerks are considered normal.
Patients with periodic limb movement disorder (PLMD) complain of chronically disturbed sleep or daytime sleepiness. The severity of symptoms appears to be related
to the frequency of limb movements and associated arousals and awakenings. RLS, PLMD, or both occur in association with other sleep disorders, including sleep
apnea, narcolepsy-cataplexy, and drug dependency. They may develop in patients being treated with antidepressants and during withdrawal from drugs (e.g.,
barbiturates, benzodiazepines), and in patients with chronic uremia, anemia, and iron deficiency.
For many years, the treatment of choice for PLMD and RLS has been clonazepam (Klonopin), 0.5 to 3.0 mg in the evening, at bedtime, or both. Other
benzodiazepines have also proved beneficial. Temazepam (Restoril) is often preferred for its intermediate half-life. Levodopa plus benzerazide or carbidopa is
effective, but patients often experience increased or rebound daytime symptoms, when treated only at night. Dopaminergic agonists now appear to be the drugs of
choice. Pergolide mesylate (Permax) and bromocriptine mesylate (Parlodel) have been used most commonly, and the doses required are very much smaller than
those used for Parkinson disease. Pergolide is generally effective with doses of 0.15 to 0.50 mg daily. Opiates are also useful, especially in severe cases.
Disorders of Excessive Somnolence
The clinical neurologist is asked to evaluate symptoms of excessive daytime sleepiness more than any other major category of sleep complaint. Therefore, a patient's
complaint and symptoms must be well-defined to provide the physician with a rational basis for a diagnostic and treatment decision. The major symptoms include
sleepiness and napping during a time of day when the patient wishes to be awake. The complaint has often been present for months or years and includes an
increased amount of unavoidable napping, apparent increase in total sleep during the 24-hour day, or difficulty in achieving full alertness after awakening in the
morning. These symptoms should not be confused with complaints of tiredness or lack of energy, motivation, or drive, which may reflect dysphoric symptoms such as
those that might accompany depression.
Excessive sleepiness is caused by an insufficient quantity of sleep or poor sleep quality resulting from a sleep disorder, other disturbance, or both. Excessive
sleepiness leads to impaired performance and diminished intellectual capacity, and is often a major factor or direct cause of accidents and catastrophes.
Several common disorders must be considered in patients with a complaint of excessive daytime sleepiness ( Table 145.3). Obstructive sleep apnea (OSA) syndrome
and narcolepsy account for most patients with a complaint of daytime sleepiness evaluated in sleep disorders centers.
TABLE 145.3. DIFFERENTIAL DIAGNOSIS FOR EXCESSIVE DAYTIME SLEEPINESS
Obstructive Sleep Apnea Syndrome
A patient with OSA syndrome often falls asleep at inappropriate or dangerous times (e.g., while eating, driving a car, waiting for a red light) and has pervasive
sleepiness throughout the day that seriously interferes with work, as well as leisure time. Almost all patients have loud snoring. The snoring pattern is recurrent, with
pauses between snores of 20 to 50 seconds. Each cycle comprises a series of three to six loud snores and gasps followed by a relatively silent period. During the
nonsnoring period, the patient makes ineffective respiratory efforts because of an obstructed upper airway. In addition to loud cyclic snoring, sleep is restless, with
frequent brief arousals and unusual sleeping postures. The patient may talk during sleep, have nocturnal enuresis, fall out of bed, and wake in the morning with a
generalized severe headache and a feeling of having had an unrefreshing night.
In adults, OSA syndrome occurs predominantly between the fourth and sixth decades and is about 2.5 times more common in men. The prevalence of OSA syndrome
increases with age and is higher in individuals with habitual snoring and obesity. Numerous congenital and acquired abnormalities of the upper airway are associated
with OSA. These include micrognathia, deviated nasal septum, narrow nasal passages from a previous fracture, enlarged adenoids or tonsils, palatopharyngeal
abnormalities (e.g., Pierre-Robin syndrome, post-cleft-palate repair, Treacher Collins syndrome), enlarged tongue in acromegaly, hypothyroidism with myxedema of
the upper-airway soft tissues, and temporomandibular joint abnormalities.
In addition to daytime hypersomnia and nighttime sleep disturbances, many patients with OSA syndrome have systemic hypertension, primarily diastolic, and a wide
variety of cardiac arrhythmias during sleep. Recognized systemic complications of OSA syndrome are pulmonary hypertension, cardiac enlargement, myocardial
infarction, stroke, elevated hematocrit, and an increased risk of sudden death during sleep.
Sleep apnea also occurs in infants and children. In infants, it has been associated with the acute life-threatening event, as well as familial, congenital, and acquired
dysautonomia syndromes and craniofacial disorders. The peak incidence in children is around age 4 years and is often associated with adenotonsillar hypertrophy.
Central sleep apnea syndrome is characterized by intermittent cessation or decreases in respiratory effort with associated decreases in oxygen saturation during
sleep. It causes complaints of frequent awakenings and restless unrefreshing sleep and is much less common than OSA syndrome.
An all-night polysomnographic recording is used to diagnose OSA and to quantify the frequency, severity, and type of respiratory disturbance. An apnea is defined as
the cessation of airflow for 10 seconds or longer. A central apnea is the absence of respiratory effort. An obstructive apnea is the absence of airflow despite the
presence of respiratory effort. A mixed apnea consists of an initial central component followed by obstruction. A hypopnea is a reduction in airflow for at least 10
seconds and may be central or obstructive. These respiratory events are accompanied by oxygen desaturation and usually by arousals. During recurrent apnea
episodes in severe cases, oxygen saturation often falls to less than 50% and bradycardia (less than 60 beats per minute [beats/min]) alternates with tachycardia
(greater than 110 beats/min) for each snoring cycle. Stages 3 and 4 sleep are diminished or absent, and there are many stage changes and arousals. The duration of
apneic episodes and the degree of oxygen desaturation usually increase in REM sleep.
Nasal continuous positive airway pressure (CPAP) is the most common and effective treatment for moderate and severe OSA syndrome. Air pressure is generated by
a small blower, delivered via tubing to a nasal mask, and controlled by a pressure valve. Each patient must have a treatment trial during polysomnography to
determine the pressure required to alleviate airway obstruction during sleep. If successful and well tolerated, a commercially available nasal CPAP unit is prescribed
for home use. Prior to nasal CPAP, tracheostomy was the only reliably effective treatment and is still indicated for severe OSA if CPAP is not tolerated.
In some patients, especially children and young adults, the removal of enlarged tonsils and adenoids relieves the obstruction. The surgical procedure,
uvulopalatopharyngoplasty, has been an inconsistently beneficial treatment, and selection criteria are not well established. Hyoidplasty and mandibular advancement
have successfully treated patients with structural abnormalities causing hypopharyngeal obstruction. Other treatments for less severe cases have been sustained
weight loss in obese patients and use during sleep of a dental appliance that advances the lower jaw.
Narcolepsy
Narcolepsy (MIM 161400) is an incurable lifelong neurologic disorder. The classic narcolepsy tetrad consists of (1) excessive daytime sleepiness, (2) cataplexy, (3)
sleep paralysis, and (4) hypnagogic hallucinations. Narcolepsy is not rare. Estimates of prevalence range between 2 and 10 per 10,000 individuals in North America
and Europe. It is about five times more prevalent in Japan, and the incidence is only 1 per 500,000 in Israel.
The onset of narcolepsy typically occurs between ages 15 and 30 years, although cases have been reported with onset as early as age 5 years and as late as 63
years. Men and women are equally affected. Daytime sleepiness is usually the first symptom to appear. Recognition that the patient has a medical disorder often
takes years.
Excessive daytime sleepiness is always present and is usually the most prominent symptom. Patients often complain of fatigue and impaired performance. Irresistible
sleep occurs more frequently throughout the day if the patient is inactive, but also occurs at inappropriate times, such as during a conversation, eating, driving, or a
monotonous or repetitious activity. These spontaneous naps are usually brief and somewhat refreshing. Patients with narcolepsy generally do not sleep more, but
need to sleep more frequently. They have difficulty in sustaining wakefulness. More than 50% of narcoleptic patients have automatic behavior that they describe as
memory lapses or blackouts. These episodes are caused by microsleeps that intrude into wakefulness. Patients are capable of carrying out semipurposeful activity
associated with amnesia; thus, they can neither monitor the activity nor remember it later. Common examples include getting lost while driving, typing or writing
gibberish, misplacing things, or walking into objects. Automatic behavior also occurs in other disorders of excessive sleepiness. Other complaints, such as poor
memory and visual disturbances, appear to be related to excessive daytime sleepiness. The symptom of excessive daytime sleepiness is disabling and often leads to
personal, social, and economic problems.
In a patient with excessive daytime sleepiness, the presence of cataplexy is pathognomonic of narcolepsy. Cataplexy consists of a brief episode of paralysis or
weakness of voluntary muscles without change in consciousness, and is precipitated by strong but normal emotions. The onset of cataplexy usually follows excessive
daytime sleepiness by months or years. It only rarely appears before the sleepiness. The severity of cataplexy is variable. Some patients may have as few as two or
three episodes in a lifetime, whereas others may have several episodes every day. A full range of severity exists between these extremes. The most common
precipitant is laughter. Other strong emotions include anger, surprise, fear, and anticipation. Cataplexy may be partial and affect only certain muscles; common
examples include dysarthria, drooping of the head, and slight buckling of the knees. Severe global attacks affect all skeletal muscles, except muscles of respiration,
and cause collapse. Most episodes last only seconds, but severe attacks can last minutes.
REM sleep mechanisms are involved in the pathophysiology of narcolepsy. Manifestations or fragments of REM sleep appear during waking hours and at sleep onset.
Cataplexy is the appearance of the paralysis of REM sleep during wakefulness. REM sleep in a narcoleptic patient often begins within 10 minutes of sleep onset
instead of after 85 to 100 minutes, as in the normal individual. This abnormal timing of REM sleep is called a sleep-onset REM period, which may include sleep
paralysis, hypnagogic hallucinations, or both.
Sleep paralysis is a global paralysis of voluntary muscles that occurs at the entry into or emergence from sleep. This muscle weakness is thought to result from the
same motor inhibition that occurs during cataplexy in the narcoleptic individual and in REM sleep in everyone. Sleep paralysis without narcolepsy can occur in an
isolated form in otherwise healthy individuals or in a familial form genetically transmitted. Isolated sleep paralysis most frequently occurs upon awakening. Familial
sleep paralysis and sleep paralysis associated with narcolepsy occur more often at sleep onset. In isolated cases, sleep paralysis may occur only when precipitated by
predisposing factors, such as irregular sleep habits, sleep deprivation, work shift, jet lag, and psychologic stress. Although the familial form and that associated with
narcolepsy are more chronic, the frequency of episodes can be increased by the same factors. Hypnagogic hallucinations are vivid dreamlike images that the
narcoleptic person experiences during sleep onset and offset. They are simple or bizarre visual hallucinations that can have auditory and tactile components. The
patient is usually aware of the surroundings and has difficulty in discerning the hallucinations from reality; these hallucinations are often frightening. Hypnagogic
hallucinations are most likely the result of dissociated central nervous system (CNS) processes involved in dreaming during REM sleep. They can be precipitated by
sleep deprivation in normal individuals.
Narcolepsy symptoms produce major social, familial, educational, and economic consequences for both patients and their family. Patients often do not achieve their
intellectual potential and suffer frequent failures of occupation, education, and marriage. Family members, friends, and even patients often interpret the symptoms as
indicating laziness, lack of ambition, delayed maturation, or psychologic defects. Because these symptoms begin during the crucial period of maturation from puberty
to adulthood, misinterpretation and lack of a diagnosis can greatly affect a patient's personality and feelings of self-esteem.
Genetic research shows the existence of a susceptibility gene in the region of the major histocompatibility complex located on the short arm of chromosome 6. Genetic
family studies suggest that this gene is not sufficient and that an additional gene or genes may be needed for disease expression. The identification of several pairs of
monozygotic twins discordant for narcolepsy indicates a role for environmental factors in the development of narcolepsy.
Several clinical reports have described structural disease in the upper brainstemhypothalamus area with narcoleptic symptoms and cataplectic-like behavior. This
has been produced in cats after microinjection of cholinergic drugs in the pontine reticular formation; however, no pathology has been reported thus far in humans or
animal models of narcolepsy-cataplexy.
The current treatment for the sleepiness of narcolepsy is the use of adrenergic stimulant drugs: pemoline (Cylert), methylphenidate hydrochloride (Ritalin HCl), and
amphetamines. Modafinil, a new wakefuless-promoting agent that is chemically and pharmacologically distinct from the above stimulants, has been shown to be
effective in reducing daytime sleepiness in patients with narcolepsy. Use of stimulant drugs should be carefully monitored; patients and physicians should cooperate
in adjusting the amount and timing of doses to meet functional daytime needs and scheduling of patients' activities. Cataplexy, when present to a significant degree, is
usually well controlled with the tricyclic compounds imipramine hydrochloride (e.g., imipramine, 10 to 25 mg, two or three times daily), protriptyline hydrochloride
(Vivactil), or clomipramine; however, impotence can be an undesirable side effect in men. Selective serotonin reuptake inhibitors such as paroxetine hydrochloride
(Paxil) and fluoxetine hydrochloride (Prozac) are also effective. These medications are thought to effectively treat cataplexy because they suppress REM sleep. An
important adjunctive treatment for narcolepsy is the rational scheduling of daytime naps and the maintenance of proper sleep hygiene. The physician's role in
providing the patient with a clear understanding of the nature of the symptoms and with emotional support in coping with the many adaptive difficulties cannot be
overemphasized.
Recurrent hypersomnia (Kleine-Levin syndrome) consists of recurrent episodes of hypersomnia and binge eating lasting up to several weeks, with an interval of 2 to
12 months between episodes. Neurobehavioral and psychologic changes, such as disorientation, forgetfulness, depression, depersonalization, hallucinations,
irritability, aggression, and sexual hyperactivity, often accompany the episodes of hypersomnia. Onset is typically in early adolescent boys, but rarely in girls and
adults. Episodes decrease in frequency and severity with age and are rarely present after the fourth decade.
A definitive treatment for Kleine-Levin syndrome is not known, but there are reports of limited success with amphetamines and methylphenidate. Because of
similarities between Kleine-Levin syndrome and bipolar depression, lithium has been used.
Other Conditions Associated with Excessive Daytime Somnolence
Various neurologic and medical conditions are associated with excessive daytime sleepiness; these include endocrine and metabolic disorders, liver failure, uremia,
chronic pulmonary disease (with hypercapnia), hypothyroidism (severe with myxedema), incipient coma with diabetes mellitus, and severe hypoglycemia. Neurologic
disorders, such as tumors in the area of the third ventricle (e.g., glioma, craniopharyngioma, dysgerminoma, pinealoma, pituitary adenoma), obstructive
hydrocephalus, increased intracranial pressure, viral encephalitis, and other infections of the brain and surrounding membranes, can cause increased daytime
somnolence. The postconcussion syndrome may also be associated with increased sleepiness. However, complaints of tiredness, fatigue, difficulty in concentrating,
and memory impairment are usually more prominent symptoms.
Disorders of the SleepWake Schedule
The study of human chronobiology has been important for the understanding of clinical disorders of the daily sleepwake cycle. Many functions, including body
temperature, plasma and urine hormones, renal functions, psychologic performance measures, and internal sleep-stage organization, all participate in this circadian
rhythm. Evidence for the importance of these cyclic physiologic systems in sleep disturbances comes from studies of acute phase shifts, such as those that occur after
transmeridian air flights or in shift work. The daily sleep period is disturbed after acute shifts in such a way that intrusive awakenings take place, sleep length is
shortened, and REM phase advances relative to sleep onset. Adaptation is slower after an eastward flight or a phase advance in the laboratory than after a phase
delay (westward flight).
Disorders of the circadian sleepwake cycle are divided into two major categories, transient and persistent. The transient disorders include the temporary sleep
disturbance following an acute work-shift change and a rapid time-zone change (jet lag). Both sleep deprivation and the circadian phase shift produce symptoms
including frequent arousals, especially at the end of sleep episodes, and excessive sleepiness. Affected individuals are fatigued, sleepy, and intermittently inattentive
when they should be awake, and have partial insomnia during the daily time for sleep. A wide range of important occupations is involved in these acute phase-shift
syndromes (e.g., doctors, nurses, police, firemen, airline pilots, air-traffic controllers, diplomats, international business executives, radar operators, postal workers,
long-distance truck drivers, and others).
Persistent sleepwake cycle disorders are divided into several major clinical categories. Persons who frequently change their sleepwake schedule (e.g., shift
workers) have a mixed pattern of excessive sleepiness alternating with arousal at inappropriate times of the day. Sleep is typically shortened and disrupted. Waking is
associated with a decrease in performance and vigilance. The physician caring for such patients should be aware that the syndrome often disrupts social and family
life and becomes intolerable.
The delayed-sleep-phase syndrome is a specific chronobiologic sleep disorder characterized by a chronic inability to sleep at the desired time to meet required work
or study schedules. Patients are typically unable to fall asleep until some time between 2 and 6 a.m. On weekends and vacation days, they sleep until late morning or
early afternoon and feel refreshed, but have great difficulty awakening at the required 7 or 8 a.m. for work or school. These patients have a normal sleep length and
internal organization of sleep when clock time of sleep onset and sleep offset coincides with the circadian timing that controls daily sleep. When sleep onset is
attempted at earlier times, there is usually a long latency to sleep onset.
Successful treatment has been a phase shift of the time of the daily sleep episode by progressive phase delay of the sleep time. By delaying the time of going to sleep
and awakening by 2 or 3 hours each day (i.e., a 26- or 27-hour sleepwake cycle), the patient's sleep timing can be successfully reset to the preferred clock time.
Alternatively, treatment with bright light, which phase-shifts the circadian rhythm of core body temperature, has proved helpful in achieving and maintaining a desired
schedule.
The advanced-sleep-phase syndrome is rare and is more likely to occur in elderly persons. Typical sleep onset is between 6 and 8 p.m., with wake times between 1
and 3 a.m. despite efforts to delay sleep time. The patient with the non-24-hour sleepwake disorder is completely out of touch with the 24-hour cycle of the rest of
society. These rare individuals maintain a 25- to 27-hour biologic day despite all attempts to entrain themselves to a 24-hour cycle. A personality disorder or blindness
may predispose to this condition.
An irregular sleepwake pattern consists of considerable irregularity without an identifiable persistent sleepwake rhythm. There are frequent daytime naps at
irregular times and a disturbed nocturnal sleep pattern. Most patients with this syndrome have congenital, developmental, or degenerative brain dysfunction, although
it does occur rarely in cognitively intact outpatients. Treatment is difficult but should include regularly scheduled activities and time in bed based on sleep hygiene
principles.
Parasomnias
Parasomnias are disorders of arousal, partial arousal, and sleep-stage transition characterized by undesirable behaviors during sleep that are manifestations of CNS
activation. Autonomic nervous system changes and skeletal muscle activity are prominent features.
The arousal disorders include the classic disorders of sleepwalking and sleep terrors, as well as the more recently designated disorder confusional arousals. These
behaviors typically emerge from slow-wave sleep during the first third of the night. Confusion during and following arousal and amnesia for the episodes are features
common to the three disorders. Sleepwalking consists of complex behaviors, including automatic and semipurposeful motor acts, such as sitting up in bed, walking,
opening and closing doors, opening a window, climbing stairs, dressing, and even preparing food. A subgroup of patients, usually young adult men, perform acts that
are destructive or harmful to themselves, such as breaking furniture, throwing objects, and climbing out or walking through a window. A small nightly dose of a
benzodiazepine, such as diazepam or temazepam, is useful, especially when violent behavior is present.
A sleep terror is typically initiated with a sudden, loud, high-pitched scream and sitting up in bed. The patient appears agitated and frightened. Major autonomic
changes occur, including rapid pulse and respiration, sweating, and pupillary dilation. Arousal disorders are common in children and generally benign, and decrease
in frequency and severity or resolve with increasing age. These disorders, however, must be distinguished from recurrent nocturnal seizure disorders, such as partial
complex seizures. Polysomnography with additional EEG channels and videotape of the behaviors is extremely useful for differentiating arousal disorders from
sleep-related epilepsy.
REM sleep behavior disorder (RBD), a parasomnia occurring during REM sleep, is characterized by intermittent loss of REM sleep atonia accompanied by motor
activity consistent with dream enactment. RBD appears to be uncommon, but the true incidence is unknown. It is more common in older men and often associated with
degenerative neurologic disorders, especially Parkinson disease or cerebrovascular disease. Injury to self or bed partner is a significant complication. The diagnosis
is usually suggested by history and confirmed by polysomnography. Recordings show persistent muscle tone and complex behaviors during REM sleep. Most patients
respond to treatment with a small dose (0.5 to 2 mg) of clonazepam at bedtime. However, daytime carry-over effects causing drowsiness and cognitive dysfunction
must be carefully monitored in elderly patients.
Sleep Disorders Associated with Neurologic Disorders
Degenerative neurologic disorders, including dementia and Parkinson disease, have associated sleep disturbances. Sleep may be abnormal because of involvement
of brain structures that control and regulate sleep and wakefulness or because of abnormal movements or behaviors that occur during sleep.
Fatal familial insomnia is a rare prion disease (see elsewhere in this volume).
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CHAPTER 146. ENDOCRINE DISEASES
MERRITTS NEUROLOGY
SECTION XXII. SYSTEMIC DISEASES AND GENERAL MEDICINE

CHAPTER 146. ENDOCRINE DISEASES
GARY M. ABRAMS AND EARL A. ZIMMERMAN
Pituitary
Thyroid
Parathyroid
Pancreas
Adrenal
Gonads
Suggested Readings
Endocrine secretions have a profound influence on the metabolism of the nervous system. Disturbances of consciousness and cognition, along with other neurologic
symptoms, may occur with endocrine diseases. This chapter considers the common structural and secretory endocrine disorders that may cause important neurologic
symptoms.
PITUITARY
Hypopituitarism
Hypofunction of the pituitary may follow damage to the gland by tumors, inflammatory processes, vascular lesions, or trauma. The location of the lesion may be the
pituitary itself, the stalk that connects it with the hypothalamus, or the hypothalamus. Destruction of the hypophyseal portal system in the stalk or the median
eminence above by a tumor, such as a craniopharyngioma, or sarcoidosis deprives the anterior pituitary of hypothalamic regulatory hormones. In hypothalamic
disease, as in pituitary disease, peripheral blood levels of all the anterior pituitary hormones may be reduced except for prolactin (PRL), which is normally under
inhibitory control by hypothalamic dopamine. Diabetes insipidus (DI; see later), which may result from disruption of neurosecretory pathways terminating in the
posterior pituitary, is also a feature of some structural diseases causing hypopituitarism. Additionally, neurologic manifestations of hypopituitarism are due to
neighborhood effects resulting from the contiguous location of the pituitary to the visual pathways and cranial nerves controlling ocular motility.
Secretory and nonsecretory pituitary tumors are the most common causes of neurologic symptoms of hypopituitarism. The size of the lesion usually determines the
extent of neurologic symptoms and the degree of hypopituitarism. Headache and visual loss are common when tumors are large and extend into the suprasellar
region in the vicinity of the optic chiasm. Lateral extension of masses may produce syndromes involving structures in the cavernous sinus. Growth of tumors superiorly
may compress the hypothalamus and obstruct the cerebrospinal fluid (CSF) pathways to cause hydrocephalus.
Vascular lesions of the pituitary may cause dramatic and life-threatening onset of hypopituitarism. In pituitary apoplexy, sudden hemorrhage into a pituitary tumor may
cause headache, meningismus, visual loss, oculomotor abnormalities, and alteration in the level of consciousness. Hypopituitarism, including acute adrenal
insufficiency, may result from a combination of vascular necrosis and compression by the enlarging pituitary mass. Neurosurgical decompression can improve
neurologic and endocrine function.
Sheehan syndrome or postpartum necrosis of the pituitary may also cause actue hypopituitarism and local neurologic symptoms. Hypotension or shock from obstetric
hemorrhage or infection causes occlusive spasm of pituitary arteries with anoxic-ischemic necrosis of a pituitary gland that has hypertrophied under estrogen
stimulation from pregnancy. Acutely, there may be a shocklike syndrome with obtundation, hypotension, tachycardia, and hypoglycemia. Acute and chronic Sheehan
syndromes are both characterized by syndromes of anterior pituitary insufficiency, particularly amenorrhea and failure to lactate. Rarely, DI occurs. A neurologic
disorder might be suspected if patients complain of lightheadedness or diminished libido.
In adults, hypopituitarism is often recognized first by impaired secretion of gonadotropins with irregular menstrual periods or amenorrhea in women or loss of libido,
potency, or fertility in men. The skin is often thin, smooth, and dry; the peculiar pallor (alabaster skin) and inability to tan have been related to loss of melanotropic
(melanocyte-stimulating hormone) or adrenocorticotropic (ACTH) hormones. Axillary and pubic hair may be sparse, with relatively infrequent facial shaving.
Depending on the severity of the decrease of production of ACTH and thyroid-stimulating hormone (TSH), patients may note lethargy, weakness, fatigability, cold
intolerance, and constipation. There may be an acute adrenal crisis with nausea, vomiting, hypoglycemia, hypotension, and circulatory collapse, particularly in
response to stress. Hypothalamic hypopituitarism may additionally be accompanied by hyperprolactinemia with galactorrhea.
Evaluation of patients with pituitary insufficiency caused by an intrasellar or hypothalamic lesion depends on measurement of pituitary hormone levels in the
peripheral blood, coupled with functional assessment of the target organs. The basic endocrine evaluation includes thyroid functions (triiodothyronine [T 3], thyroxine
[T 4], and TSH), PRL determination, and assessment of adrenal reserve, such as ACTH stimulation for cortisol responsiveness. Pituitary hormone levels must be
interpreted in the context of clinical findings. For example, normal gonadotropin levels (follicle-stimulating hormone, luteinizing hormone) may indicate pituitary
insufficiency after menopause, when elevated levels would be expected. Elevated levels of gonadotropin or TSH suggest primary gonadal or thyroid failure but, rarely,
may be secreted by pituitary tumors. Dynamic tests of pituitary reserve or stimulation tests with synthetic hypothalamic releasing factors are sometimes needed to
detect mild hypopituitarism or to distinguish between pituitary and hypothalamic causes of hypopituitarism.
Pituitary Tumors
Most pituitary tumors are associated with oversecretion of one or more anterior pituitary hormones or their subunits. These tumors produce symptoms related to the
metabolic or trophic effect of the secreted hormone. Symptoms may be associated with variable degrees of hypopituitarism, depending on the extent of destruction
caused by the tumor. Microadenomas (less than 10 mm) typically cause only symptoms referable to the secreted hormone; macroadenomas (greater than 10 mm)
more often cause neural or pituitary dysfunction. Fewer than 10% of microadenomas that secrete PRL show progressive enlargement.
The PRL-secreting adenoma, or prolactinoma, is the most common secretory adenoma of the pituitary. It is the most common cause of clinically manifest
hyperprolactinemia. In women, there is often a microadenoma with amenorrhea and galactorrhea. In men, the endocrine effects of hyperprolactinemia include
impotence, infertility, or, rarely, galactorrhea. In men, prolactinoma is more commonly associated with mass effects of the macroadenoma: headaches, visual-field
deficits, and ocular motility problems.
The causes of hyperprolactinemia are listed in Table 146.1. In prolactinoma, serum PRL levels may be less than 200 ng/mL and must be distinguished from other
causes of hyperprolactinemia. Values above 200 ng/mL, however, are nearly always associated with a prolactinoma. There is a rough positive correlation between the
PRL level and the size of the tumor. Several random PRL levels of more than 200 ng/mL establish the diagnosis of prolactinoma; more modest elevations may be
caused by drugs, hypothalamic disorders, or hypothyroidism (see Table 146.1). In primary hypothyroidism, thyrotropin-releasing hormone (TRH) secretion is
presumably enhanced in response to the low circulating levels of thyroid hormone; TRH is a potent stimulus for PRL release. The pituitary may be enlarged ( Fig.
146.1).
TABLE 146.1. CAUSES OF ELEVATED PROLACTIN LEVELS
FIG. 146.1. Pituitary enlargement in association with primary hypothyroidism is shown on MRI.
Computed tomography (CT) or magnetic resonance imaging (MRI) establishes the diagnosis of sellar or parasellar mass lesions. Prolactinoma does not have specific
imaging characteristics; the diagnosis is established by correlation with clinical and laboratory findings. Important diagnostic considerations include carotid aneurysm,
inflammatory (e.g., lymphocytic hypophysitis) and hormonal causes of pituitary enlargement (e.g., primary hypothyroidism), and craniopharyngioma.
Treatment of hyperprolactinemia is accomplished with dopaminergic agonists, such as bromocriptine mesylate (Parlodel), which usually reduce serum PRL levels to
normal, but treatment of the primary pathology (e.g., thyroid failure) may be more appropriate. Return of PRL levels to normal is usually associated with restoration of
gonadal function and cessation of galactorrhea. In patients with a prolactinoma, bromocriptine therapy is often accompanied by reduction of tumor size, resolution of
neurologic symptoms, and reversal of pituitary insufficiency. Long-term therapy is required because the tumor recurs if bromocriptine is withdrawn. Both
microadenomas and macroadenomas can be removed by transsphenoidal adenomectomy. Cure rates are correlated with tumor size and PRL level, but surgery is
most effective for rapid decompression of the optic nerves or chiasm. Surgical cures have been associated with tumor recurrence rates of 20% to 50% after 5 years.
Radiotherapy alone or in combination with surgery or pharmacotherapy is also a therapeutic option.
Infertility in women as a result of hyperprolactinemia from a pituitary tumor can be successfully treated with bromocriptine. If pregnancy results, bromocriptine therapy
is discontinued, although there has been no evidence of teratogenesis. Estrogen stimulation of prolactinoma during pregnancy causes tumor enlargement, but
clinically significant enlargement occurs in only 10% to 15% of macroadenomas. Bromocriptine therapy may be reintroduced with successful control of symptoms; in
unusual cases, transsphenoidal surgery can be used.
Excessive Growth Hormone and Acromegaly
Growth hormone (GH)-secreting pituitary tumors are the most common cause of acromegaly (Fig. 146.2,Fig. 146.3 and Fig. 146.4). When fully developed, acromegaly
is easily recognized by excessive skeletal and soft tissue growth. Facial features are coarse, with a large bulbous nose, prominent supraorbital ridges, a protruding
mandible, separated teeth, and thick lips. Hands and feet are enlarged, and sweating is frequently increased. These changes are usually slowly progressive. Patients
complain of headaches, fatigue, muscular pain, visual disturbances, and impairment of gonadal function. Paresthesia, sometimes with a typical carpal tunnel
syndrome, may be present. Generalized arthritis and diabetes mellitus (DM) are frequent components; mortality is increased with acromegaly. In young patients
before epiphyseal closure, excessive secretion of GH results in gigantism.
FIG. 146.2. Tufting of the terminal phalanges in acromegaly. (Courtesy of Dr. Juan Taveras.)
FIG. 146.3. Pituitary tumor with ballooning of the sella turcica, prognathism, and enlargement of the skull bones. (Courtesy of Dr. Juan Taveras.)
FIG. 146.4. Prognathism and enlargement of nose in acromegaly secondary to pituitary adenoma. (Courtesy of Dr. E. Herz.)
The neuroendocrine regulation of GH secretion is complex. The major releasing factor is GH-releasing hormone; the major inhibitory agent is somatostatin. GH has a
predominantly nocturnal pattern of secretion and is influenced by age and sleep. The diagnosis of acromegaly is most easily established by demonstrating sustained
elevation of GH that cannot be suppressed by physiologic stimuli, such as glucose. Paradoxic elevation of GH may occur with glucose or TRH, suggesting
hypothalamic dysfunction. Many actions of GH are mediated by insulin-like growth factor I (formerly somatomedin C), and these levels may be elevated with
acromegaly.
MRI is sensitive in localizing even small GH-secreting adenomas, and surgical removal is the treatment of choice. Cure rate is highest for microadenomas. Surgical
decompression and radiation therapy may be the best alternative for larger tumors. Bromocriptine therapy has been useful in some patients. The long-acting
somatostatin analog octreotide acetate (Sandostatin) offers specific adjunctive therapy for control of GH secretion.
Excessive Adrenocorticotropic Hormone
Cushing disease results from hypersecretion of ACTH by a pituitary tumor. Such tumors are usually small and often difficult to detect. Cushing disease may be difficult
to distinguish from other causes of hyperadrenalism, such as adrenal adenoma or ectopic ACTH production by neoplasms. The symptoms of Cushing disease include
plethoric facies, centripetal obesity, hypertension, DM, amenorrhea, hirsutism, acne, and osteoporosis. Mental status changes or myopathy may be prominent.
The differential diagnosis of Cushing syndrome can be challenging. Elevated urinary free cortisol levels and suppressibility of cortisol secretion by dexamethasone
are the key tests for establishing the diagnosis of pituitary-dependent Cushing syndrome. Direct assay of plasma ACTH may be helpful; high levels are seen with
ectopic ACTH production. The ACTH response to corticotropin-releasing factor may distinguish Cushing disease from other causes of hypercortisolism. Selective
sampling of ACTH levels from the petrosal sinuses may help localize an adenoma within the pituitary.
MRI with gadolinium is the most sensitive procedure for detecting these tumors. Transsphenoidal adenomectomy is the treatment of choice. In patients treated by
bilateral adrenalectomy, an aggressive ACTH-secreting pituitary tumor may develop to cause the hyperpigmentation of Nelson syndrome. The hypothalamus may play
a role in the pathogenesis of both Cushing disease and Nelson syndrome. Ketoconazole (Nizoral), an inhibitor of adrenal steroidogenesis, may inhibit the adverse
effects of hypercortisolism.
The empty sella syndrome rarely poses difficulty in the diagnosis of pituitary tumors. The syndrome develops with herniation of the subarachnoid space through the
diaphragma sellae either idiopathically or following destruction or surgical removal of the pituitary gland. Remodeling and enlargement of the bony sella turcica may
occur, and the sella may appear enlarged on skull x-ray film. CT or MRI usually clarifies the diagnosis. Pituitary dysfunction is uncommon and, if present, suggests
that the apparently empty sella is accompanied by a pituitary tumor. The clinical accompaniments of the empty sella syndromeobese women with headacheare
similar to those of pseudotumor cerebri; chronically increased CSF pressure may precipitate the development of an empty sella.
Diabetes Insipidus
DI is characterized by excessive excretion of urine and an abnormally large fluid intake caused by impaired production of antidiuretic hormone (arginine vasopressin)
in the posterior pituitary. There are two general groups of patients. In primary DI, there is no known lesion in the pituitary or hypothalamus; secondary DI is associated
with lesions in the hypothalamus either in the supraoptic and paraventricular nuclei or in their tracts in the medial eminence or upper pituitary stalk. Among the lesions
are tumors (e.g., pituitary adenoma, craniopharyngioma, meningioma), aneurysms, xanthomatosis (Schller-Christian disease), sarcoidosis, trauma, infections, and
vascular disease. Primary DI is rare. Heredity is a factor in some patients. Many different mutations have been found in familial autosomal-dominant DI. Autopsy
studies of a few cases revealed loss of neurons in the supraoptic and paraventricular nuclei. Secondary or symptomatic DI is more frequent but still uncommon. It may
follow head injury and is present in many patients with xanthomatosis and in some patients with tumors or other lesions in the hypothalamic region. The syndrome is
evidence of hypothalamic disease.
Unless complicated by other symptoms associated with the lesion, the symptoms of DI are limited to polyuria and polydipsia. Eight to 20 L or even more of urine are
passed in 24 hours, and there is a comparably high level of water intake. The frequent voiding and excessive water intake may interfere with normal activities and
disturb sleep. Usually, however, general health is maintained if this is an isolated deficiency of the hypothalamus. The symptoms and signs in patients with tumors or
other lesions in the hypothalamic region are those usually associated with these conditions (see Chapter 58). The laboratory findings are normal, except for a low
specific gravity of the urine (1.001 to 1.005) and increased serum osmolality in many patients.
The diagnosis is made, based on polyuria and polydipsia. It is distinguished from DM by the glycosuria and high specific gravity of the urine in DM. A large amount of
urine may be passed by patients with chronic nephritis but not the large volumes (more than 3 L per day) found in DI; the presence of albumin and casts in the urine
and other findings should prevent any confusion in recognizing nephritis. Psychogenic polydipsia must be considered (see below).
A rare cause of DI is failure of the kidneys to respond to vasopressin, a hereditary defect in infant boys.
Absence of vasopressin is difficult to determine in blood by radioimmunoassay. Therefore, the diagnosis is made by clinical tests that include antidiuretic responses to
exogenous vasopressin and dehydration. Administration of five pressor units of aqueous vasopressin rapidly results in a marked decrease in urinary output and an
increase in osmolality (specific gravity greater than 1.011) in a patient with DI; there is no response in nephrogenic disease. Psychogenic polydipsia, however, may
also show a limited response. In contrast to DI, however, there is a normal response to dehydration in psychogenic polydipsia, although the time required for an
increase in urinary concentration may be 12 to 18 hours. Normal subjects dehydrated for 6 to 8 hours reduce urinary volume and concentrate urinary osmolality to
roughly twice that of plasma (specific gravity greater than 1.015). Patients with severe DI do not respond and should be observed closely, with care taken to prevent
loss of more than 3% of body weight during the test; otherwise, patients may become severely dehydrated. A useful clinical test, devised by Moses and Miller, that
combines dehydration with the response to exogenous vasopressin distinguishes these disorders and also partial DI.
The diagnosis of DI carries with it the necessity of determining the cause. This means a thorough neurologic examination with particular attention to visual acuity and
visual fields. MRI is essential. In DI, the normally bright spot outlining the posterior pituitary gland on MRI may be absent or displaced more proximally in the
hypothalamic infundibular stalk (ectopic) ( Fig. 146.5). MRI may also show craniopharyngioma, hamartoma, dysgerminoma, or histiocytosis X.
FIG. 146.5. Hypothalamic hypopituitarism. On MRI, the bright-spot (arrow) appearance of the posterior pituitary gland is missing from its normal location in the sella
turcica. Instead, it is located in the lower hypothalamus and upper pituitary stalk in this child with congenital GH and TSH deficiency. Damage to the stalk interrupts
the hypophyseal portal system and vasopressin fibers. These fibers regenerate, forming a new, usually smaller, posterior pituitary in this location (ectopic). Such
patients may recover from or have partial DI. More proximal lesions in the hypothalamic nuclei and tracts to the vasopressin system do not regenerate. Interruption of
the releasing-factor pathways and the portal system results in anterior pituitary deficiencies. (From Zimmerman, 1998; with permission.)
Primary DI may persist for years. DI caused by known lesions in the hypothalamus may also be permanent, but complete remission with reversal of symptoms is not
infrequent.
Treatment of DI associated with tumors or other remediable hypothalamic lesions is that appropriate to the lesion (surgical removal or radiation therapy). Symptomatic
therapy of the DI, if it persists in these cases and in syndromes of unknown cause, is directed toward suppression of diuresis. No effort is made to limit fluid intake.
Aqueous vasopressin (Pitressin) can be administered subcutaneously in five pressor-unit doses one to four times daily; it may also be sprayed transnasally in the
form of lysine vasopressin or placed high in the nasopharynx on cotton pledgets. Vasopressin tannate in oil injected intramuscularly is slowly absorbed and may be
effective for several days.
The drug of choice is now the synthetic analog of vasopressin, 1-deamino-8-D-arginine vasopressin (DDAVP). DDAVP has no smooth muscle effects and has no
pressor or cardiac complications. It also avoids the nasal irritation associated with administration of lysine vasopressin nasal spray. It is given by nasal instillation or
spray and provides good control for about 8 hours. An oral form is also now available; the usual dose is 300 to 600 g per day in divided doses. Partial DI may require
no therapy or may be ameliorated by oral administration of clofibrate or chlorpropamide. Chlorpropamide occasionally causes hypoglycemia and, rarely, water
intoxication.
Excessive Secretion of Antidiuretic Hormone
Inappropriate secretion of antidiuretic hormone may occur with injury to the hypothalamohypophyseal system by head injury, infections, tumors, and other causes. It
has been reported in association with lung carcinoma and, occasionally, with other tumors that elaborate vasopressin. It may also be associated with lung diseases
that may overstimulate afferent pathways to the hypothalamus or with drugs that cause excess secretion of vasopressin, such as carbamazepine (Tegretol). Other
drugs associated with the syndrome include vasopressin and its oxytocin analog, nonsteroidal antiinflammatory medications, antipsychotics, thiazides, and selective
serotonin-reuptake inhibitors.
Hyponatremia and natriuresis in patients with intracranial disease may also be due to cerebral salt wasting, which is now recognized as different from inappropriate
secretion of antidiuretic hormones, as it is associated with the loss of salt and hypovolemia and responds to their replacement.
The salient features of the syndrome are hyponatremia and hypotonicity of body fluids, excessive urinary excretion of sodium despite hyponatremia, normal renal and
adrenal function, absence of edema, hypotension, azotemia or dehydration, and improvement of the electrolyte disturbance and clinical symptoms on restriction of
fluid intake. Evidence of cerebral dysfunction includes headache, confusion, somnolence, coma, seizures, transient focal neurologic signs, and an abnormal
electroencephalogram (EEG). Mild forms clear with simple fluid restriction. Severe cases with seizures or coma are treated with furosemide (Lasix) diuresis and
electrolyte replacement (3% sodium chloride). Caution should be used in rapid correction of hyponatremia to avoid central pontine demyelination. Intravenous urea
and normal saline have also been used for rapid correction. In the near future, vasopressin antagonists may be useful in diagnosing and treating this condition.
THYROID
Hypothyroidism
Thyroid hormone is important in early growth and development, and the neurologic consequences of hypothyroidism depend on the age of the patient when the
deficiency begins. Severe thyroid deficiency in utero or early life results in delayed physical and mental development or cretinism. Soon after birth, subcutaneous
tissue thickens, the infant's cry becomes hoarse, the tongue enlarges, and the infant has widely spaced eyes, a potbelly, and an umbilical hernia. Anomalies of the
cardiac and gastrointestinal system commonly accompany congenital hypothyroidism. If treatment is not prompt, dwarfism and mental deficiency result. Despite early
treatment, mild hearing and vestibular dysfunction may persist.
Juvenile myxedema is similar to cretinism, with variations that depend on age at onset of thyroid deficiency. The severity of physical and mental retardation is usually
less than in infantile myxedema. Precocious puberty also occurs in juvenile hypothyroidism. Enlargement of the sella turcica has been seen in juvenile myxedema and
other forms of long-standing hypothyroidism, which can be associated with hyperprolactinemia. Adult myxedema is characterized by lethargy; weakness; slowness of
speech; nonpitting edema of the subcutaneous tissues; coarse, pale skin; dry, brittle hair; thick lips; macroglossia; and increased sensitivity to cold environmental
temperatures.
The neurologic complications of hypothyroidism include headache, disorders of the cranial and peripheral nerves, sensorimotor abnormalities, and changes in
cognition and level of consciousness. Cranial nerve abnormalities, other than visual and acoustic nerve problems, are unusual. Decreased vision and hearing loss
may occur, and vertigo and tinnitus may be present. Visual and auditory evoked potentials have been reported to be abnormal and respond to treatment. The cause of
headache is uncertain. Pseudotumor cerebri has been reported in hypothyroidism in children receiving thyroid replacement therapy.
Encephalopathy has recently been associated with euthyroid patients with Hashimoto thyroiditis. Two types of presentations have been noted: a strokelike pattern
with mild cognitive impairment and a diffuse progressive type with seizures, psychotic episodes, and dementia. Some patients responded to steroids.
A mild polyneuritis is a rare complication characterized mainly by paresthesia in the hands and feet. Entrapment neuropathy of the median nerve (carpal tunnel
syndrome) is attributed to the accumulation of acid mucopolysaccharides in the nerve and surrounding tissues. Neuromuscular findings include slowing of voluntary
movements and slow relaxation of tendon reflexes, particularly the ankle jerks. Electrically silent mounding of muscles on direct percussion is called myoidema. There
may be myopathic weakness. Enlargement of muscles is the Hoffmann syndrome. Neuromuscular symptoms improve with thyroid replacement.
In hypothyroid infants, a remarkable generalized enlargement or hypertrophy of muscles constitutes the Kocher-Debr-Smlaigne syndrome, creating an infant
Hercules (Fig. 146.6); the muscles decrease in size with replacement therapy.
FIG. 146.6. Enlargement of muscles in Kocher-Debr-Smlaigne syndrome. (Courtesy of Dr. Arnold Gold.)
Cerebellar syndromes may occur in adults, manifestly ataxic gait. In children, cell loss has been detected in the vermis.
Mental status changes may be prominent, with decreased attentiveness, poor concentration, lethargy, and dementia. Psychiatric symptomsdelirium, depression, or
frank psychosis (myxedema madness)may appear, depending on the severity and duration of thyroid deficiency. Myxedema coma may be accompanied by
hypothermia, hypotension, and respiratory and metabolic disturbances, and, if untreated, has a high mortality rate.
Severe hypothyroidism or myxedema is primarily associated with thyroid failure as opposed to hypothalamicpituitary disease. The characteristic findings are low
circulating T 4 and T3, elevated TSH, and low radioiodine uptake by the thyroid. The CSF protein content increases; values greater than 100 mg/mL are not
exceptional. EEG abnormalities include slowing and generalized decrease in amplitude.
The treatment of hypothyroidism depends on the severity of the deficiency. Myxedema coma should be treated rapidly with intravenous administration of
levothyroxine. In other patients, gradually increasing doses of oral levothyroxine are recommended. Angina pectoris or heart failure can be precipitated by too rapid
replacement in adults. In secondary hypothyroidism, thyroid replacement should not be started without concomitant corticosteroid replacement. Prophylactic treatment
of cretinism is important in goiter districts, where iodine should be given to all pregnant women.
Hyperthyroidism
Hyperthyroidism or thyrotoxicosis is associated with an increased metabolic rate, abnormal cardiovascular and autonomic functions, tremor, and myopathy. It may
present as atrial fibrillation in older adults. Mental disturbances range from mild irritability to psychosis. When hyperthyroidism is associated with diffuse goiter,
ophthalmopathy, and dermopathy, it is termed Graves disease, which is an autoimmune disorder. Immunologic mechanisms probably play an important role in the
thyroid, eye, and skin manifestations. Hyperthyroidism may be subtle in older patients, with apathy, myopathy, and cardiovascular disease as the most prominent
symptoms.
Ocular symptoms are common in thyrotoxicosis. These may be present as infrequent blinking, lid lag, or weakness of convergence and are distinct from the infiltrative
ophthalmopathy associated with thyroid disease known as Graves ophthalmopathy. The relationship of the eye disorder to thyroid status is unclear; it may appear in
hyperthyroid patients, in euthyroid patients after thyroidectomy, or in euthyroid patients with no history of hyperthyroidism.
The pathologic changes are confined to the orbit. There is an increase in the orbital contents with edema, hypertrophy, infiltration, and fibrosis of the extraocular
muscles (Fig. 146.7). Onset of symptoms is gradual; exophthalmos is often accompanied by diplopia secondary to paresis of one or more ocular muscles. Both eyes
may be simultaneously involved, or the exophthalmos in one eye may precede the other by several months. With advance of the exophthalmos, paresis of the
extrinsic muscles of the eye increases until, finally, the eyeball is almost totally fixed. Papilledema sometimes occurs, and ulcerations of the cornea may develop
secondary to failure of the lid to protect the eye. The paralysis may involve all of the eye muscles concerned with the movement of the eyes in a particular plane. The
symptoms progress rapidly for a few months and may lead to complete ophthalmoplegia. Occasionally, spontaneous improvement occurs; as a rule, the symptoms
persist unchanged throughout a patient's life, unless relieved by therapy.
FIG. 146.7. Graves disease. Coronal T1-weighted (A) and axial T2-weighted fat-suppressed (B) MR images of the orbits show bilateral proptosis with enlargement of
the medial rectus muscles (left greater than right), the left lateral and inferior rectus muscles, and the right superior rectus muscle. Although the most common pattern
of extraocular muscle enlargement is symmetric, asymmetric involvement is not uncommon in Graves disease. This patient had known hyperthyroidism secondary to
Graves disease. (Courtesy of Dr. S. Chan.)
Treatment of thyroid ophthalmopathy is controversial. Radiation therapy of the pituitary or thyroid has no effect; neither does surgical removal of the thyroid. Surgical
decompression of the orbit is of disputed benefit. Methylcellulose drops, shields, or partial suturing of the lids is recommended to protect the eye. Prednisone is
favored by some clinicians.
Limb myopathy is common with hyperthyroidism. Thyrotoxic myopathy is characterized by weakness and wasting of the muscles of the pelvic girdle, particularly the
iliopsoas, and, to a lesser extent, the muscles of the shoulder girdle. Tendon reflexes are normal or hyperactive, and sensation is normal. Fasciculations or myokymia
may be noted. Thyrotoxic myopathy needs to be distinguished from myasthenia gravis (MG), which may accompany hyperthyroidism. Improvement of the myopathy
follows effective treatment of the hyperthyroidism.
The occurrence of hyperthyroidism and periodic paralysis seems more common in people of Asian ancestry. Thyrotoxic periodic paralysis is similar to hypokalemic
periodic paralysis in terms of precipitants and treatment. Propranolol may temporarily reduce the number of attacks. Symptoms disappear when the treated patient
becomes euthyroid.
There is an association between hyperthyroidism and MG. About 5% of patients with MG have hyperthyroidism. In most patients, MG precedes or occurs
simultaneously with the hyperthyroidism. Differential diagnosis between thyrotoxic myopathy and MG is primarily made on the clinical features, response to
edrophonium chloride, and electrophysiologic abnormalities of MG. If there are cranial symptoms (dysarthria, dysphagia, ptosis) in a hyperthyroid patient, MG should
be suspected. Interpretation of ocular signs may be complicated by thyrotoxic ophthalmopathy, but even with exophthalmos, the presence of ptosis suggests
concomitant MG, which may respond to edrophonium.
PARATHYROID
Hypoparathyroidism
Hypoparathyroidism results in a disturbance of calcium and phosphorus metabolism that is manifested especially by tetany. Hypoparathyroidism may be due to
primary deficiency of parathyroid hormone or from lack of peripheral responses as a result of defective action at cellular hormone receptors. Hypoparathyroidism may
follow thyroidectomy or may be part of an idiopathic autoimmune syndrome, which sometimes includes primary adrenal failure.
In pseudohypoparathyroidism, symptoms of hypocalcemia result from the ineffective action of parathyroid hormone at cellular receptors. Patients have a characteristic
habitus, with short stature, stocky physique, rounded face, and shortening of the metacarpal and metatarsal bones. Common clinical features of hypoparathyroidism
and pseudohypoparathyroidism include mental deficiency, cataracts, tetany, and seizures ( Table 146.2). Lesions of ectodermally derived tissue include scaly skin,
alopecia, or atrophic changes in the nails. Other neurologic manifestations are directly related to the effects of hypocalcemia on the nervous system.
TABLE 146.2. INCIDENCE OF SIGNS AND SYMPTOMS IN PSEUDOHYPOPARATHYROIDISM
Tetany is the most distinctive sign that may be manifested by carpopedal spasm. Latent tetany can be demonstrated by contracture of the facial muscles on tapping
the facial nerve in front of the ear ( Chvostek sign), evoking carpal spasm by inducing ischemia in the arm with an inflated blood pressure cuff ( Trousseau sign), or
demonstrating the lowered threshold of electrical excitability of the nerve ( Erb sign).
Convulsions are a symptom of hypocalcemia regardless of cause. Seizures are usually generalized, tend to be frequent, and respond poorly to anticonvulsant drugs.
EEG changes are nonspecific and typically revert to normal with correction of the serum calcium levels. Although hypoparathyroidism is a rare cause of seizures, the
diagnosis should be considered when seizures are frequent or bizarre and difficult to control with medication.
Intracranial calcifications are common in hypoparathyroidism ( Fig. 146.8). The basal ganglia are the predominant site for calcium deposition, but other regions may be
affected. The calcifications are usually not associated with symptoms, but a variety of hypokinetic and hyperkinetic movement disorders have been seen in
hypoparathyroidism. Symptoms may be reversible with appropriate treatment.
FIG. 146.8. Pseudohypoparathyroidism. A: Dense areas of calcification are evident in the head of the caudate nucleus (anterior putamen and globus pallidus (middle
pair) and pulvinar (posterior). The fine densities in the occipital horns are calcifications in the choroid plexus. B: Calcification is also seen in subcortical areas of the
cerebellar hemispheres. (Courtesy of Dr. S.K. Hilal and Dr. M. Mawad.)
Increased intracranial pressure with papilledema has been reported with hypoparathyroidism. The mechanism is unexplained. CSF pressure returns to normal with
correction of serum calcium values. Hypoparathyroid myopathy may be accompanied by high values of serum creatine kinase. The diagnosis of hypoparathyroidism is
made based on clinical symptoms, hypocalcemia, and low or undetectable plasma parathyroid hormone levels. In pseudohypoparathyroidism, parathyroid hormone
levels are elevated. Hypocalcemia may be associated with electrocardiogram changes, including prolongation of the QT interval and T-wave changes.
Vitamin D and calcium supplements are the primary therapy for most forms of hypoparathyroidism. They are effective in relieving tetany and in restoring the serum
calcium and phosphorus values to normal. Dosage needs to be adjusted to the needs of the patient.
Hyperparathyroidism
Primary hyperparathyroidism is most commonly due to the oversecretion of parathyroid hormone by a solitary adenoma of the parathyroid glands. The classic
syndrome of hyperparathyroidism is hypercalcemia with a combination of renal lithiasis, osteitis, and peptic ulcer disease ( Table 146.3). Modern-day
hyperparathyroidism, however, is frequently seen with minimal symptoms.
TABLE 146.3. CLUES TO THE DIAGNOSIS OF HYPERPARATHYROIDISM IN THE FIRST 343 CASES AT THE MASSACHUSETTS GENERAL HOSPITAL
Neuromuscular symptoms include symmetric proximal limb weakness and muscle wasting. Tendon reflexes may be normal or hyperactive. Abnormal movements of
the tongue may be seen. Electromyography and muscle biopsy may show evidence of neuropathic disease. Mental status changes include memory loss, irritability,
and depression, which improve with return to normal of serum calcium levels.
The diagnosis of hyperparathyroidism is now often made by automated blood chemistry tests in routine examinations, before there are clinical signs. Calcium levels
are not as elevated as in the past, and the classic neuromuscular symptoms and signs are less frequently observed. Limb weakness, paresthesia, and muscle cramps
may be seen. Neurologic abnormalities are now uncommon.
Differential diagnosis includes the conditions that cause hypercalcemia, including secondary hyperparathyroidism.
PANCREAS
Hypoglycemia
The central nervous system (CNS) depends almost entirely on glucose for its metabolism; dysfunction develops rapidly when the amount of glucose in the blood falls
below critical levels. Hypoglycemia may be associated with an overdose of insulin in the treatment of DM. Spontaneous hypoglycemia is usually the result of
pancreatic hyperinsulinism. Hypersecretion of insulin by the pancreas may be due to a tumor of the islet cells or functional overactivity of these cells. Hypoglycemia
may also occur when liver function is impaired or when there is severe damage to the pituitary or adrenal glands.
The symptoms of hyperinsulinism are paroxysmal, tending to occur when the blood glucose could be expected to be low (in the morning before breakfast, after a fast,
or after heavy exercise). Occasionally, symptoms follow a meal. The duration of symptoms varies from minutes to hours. The severity also varies. There may be only
nervousness, anxiety, or tremulousness, which is relieved by the ingestion of food. Severe attacks last for hours, during which the patient may perform automatic
activity with complete amnesia for the entire period or seizures may be followed by coma. The frequency of attacks varies from several per day to infrequent episodes.
Spontaneous hypoglycemia is occasionally seen in infants. Risk factors include immaturity, low birthweight, or severe illness. Infants of diabetic mothers may exhibit
hyperinsulinism. A host of genetic or metabolic defects may cause hypoglycemia, including galactosemia, fructose intolerance, or leucine sensitivity. The symptoms of
infantile hypoglycemia are muscular twitching, myoclonic jerks, and seizures. Mental retardation results if the condition is not recognized and adequately treated.
Hypoglycemic symptoms can be divided into two groups: autonomic and cerebral. Sympathetic symptoms are present in most patients at the onset of hypoglycemia,
usually preceding the more serious cerebral manifestations. Autonomic symptoms include lightheadedness, sweating, nausea, vomiting, pallor, palpitations, precordial
oppression, headache, abdominal pain, and hunger.
Cerebral symptoms usually occur with the sympathetic phenomena but may be the only manifestations. The most common manifestations are paresthesia, diplopia,
and blurred vision, which may be followed by tremor, focal neurologic abnormalities, abnormal behavior, or convulsions. After prolonged, severe hypoglycemia, coma
may ensue. Episodic confusion and abnormal behavior may simulate complex partial epilepsy. Although generalized or partial seizures may be a common
manifestation of hypoglycemia, hyperinsulinism only rarely causes epilepsy.
The neurologic examination is usually normal, except during attacks of hypoglycemia when there may be findings as described. The diagnosis is established by
documentation of hypoglycemia during a symptomatic episode, but the timing of the specimen is important because homeostatic mechanisms may return the blood
glucose level to normal. The level of blood glucose at which symptoms appear varies from person to person. The EEG shows focal or widespread dysrhythmia during
an attack of hypoglycemia and, in some patients, even in the interval between attacks.
The diagnosis of hyperinsulinism is made by the paroxysmal appearance of signs of autonomic and cerebral dysfunction in association with a low blood glucose level
and an inappropriately high circulating insulin level. Factitious hypoglycemia may be caused by self-administration of insulin or inappropriate use of oral hypoglycemic
agents. If it is not possible to obtain a blood specimen during an attack, a diagnostic fast should be considered. After 12 to 14 hours, 80% of patients with islet cell
tumors have low glucose and high insulin levels. Longer fasts may be needed. The diagnosis of islet cell adenoma can be difficult; additional endocrine tests and
imaging studies may be needed. Hypoglycemia associated with diseases of the liver, adrenal, or pituitary can usually be distinguished by other signs and symptoms of
disease in these organs.
Early, intensive treatment of acute hypoglycemia is important to prevent CNS damage. Sugar can be given orally in conscious patients. Comatose patients should be
given glucose intravenously. Functional hyperinsulinism is treated by diet modifications to avoid excessive insulin secretion by the pancreas. Long-term management
of hyperinsulinism is directed at identification and correction of the underlying cause.
Diabetes Mellitus
DM is a systemic metabolic disorder characterized by hypoinsulinism or peripheral resistance to the action of insulin. Current classification systems broadly divide DM
into two types defined by clinical characteristics and pattern of insulin deficiency. Insulin-dependent DM usually occurs in young, nonobese people with insulin
deficiency. Noninsulin-dependent DM is generally encountered in older, obese individuals with peripheral resistance to the action of insulin. The neurologic
complications in both types of DM are similar; the presence of neurologic disease is roughly correlated with the duration and severity of the disease and is commonly
associated with other tissue complications of DM, such as retinopathy and nephropathy.
The primary neurologic complication of DM is peripheral neuropathy. This includes mononeuropathies (peripheral and cranial nerves), polyneuropathy, autonomic
neuropathy, radiculopathies, and entrapment neuropathy (median, ulnar, and peroneal) (see Chapter 105). The cause of these neuropathies is uncertain; metabolic,
vascular, and hypoxic mechanisms have been advanced.
Mononeuropathies are attributed to vascular lesions of peripheral nerves. Onset of symptoms is rapid, and pain is common in both mononeuropathies and
radiculopathies caused by DM. Common cranial neuropathies involve the oculomotor and abducens nerves and are also due to vascular lesions. Pupillary sparing is
common but not invariable because of the pattern of vascular damage to the oculomotor nerve. The prognosis for recovery from mononeuropathy or radiculopathy is
good.
Symmetric polyneuropathy of DM is the one most commonly encountered. There is typically a gradual onset of symptoms, the character of the symptoms depending
on the type of peripheral nerve fiber affected. Numbness and burning are common complaints. Rarely, a patient may present with a Charcot joint or skin ulcer if
nociceptive fibers have sustained the predominant damage. Distal sensory loss may be accompanied by weakness; tendon reflexes are usually lost. Diagnosis of
diabetic polyneuropathy is aided by nerve conduction studies that show an axonal neuropathy. CSF protein content is usually elevated but may be normal.
Autonomic neuropathy may be prominent in DM. Cardiovascular symptoms include arrhythmias or orthostatic hypotension. These may complicate diagnosis and
treatment of concurrent myocardial disease. Gastrointestinal motility problems can produce nausea, vomiting, or diarrhea, depending on the severity and distribution
of the autonomic neuropathy. Diabetic neuropathy may lead to bladder dysfunction or erectile and ejaculatory failure in men.
CNS complications of DM are primarily due to the metabolic derangements of hypoinsulinism and hypoglycemia that may follow administration of insulin.
Cerebrovascular disease is an important problem in diabetics because of accelerated atherosclerosis of cerebral blood vessels and related cardiovascular disorders
of heart failure, hypertension, and coagulation abnormalities. Hypoinsulinism or insulin resistance may also be a secondary feature of other neurologic disorders (e.g.,
Friedreich ataxia) and may share common etiologic features with some genetic or familial diseases.
ADRENAL
The adrenal gland is composed of two distinct parts: the mesodermally derived cortex and the neuroectodermally derived medulla. The cortex synthesizes and
secretes steroid hormones, including mineralocorticoids, glucocorticoids, progestins, estrogens, and androgens. Aldosterone is the principal mineralocorticoid and is
involved in sodium and potassium homeostasis by the kidney. Glucocorticoids play an important role in metabolic and immunologic processes. Under normal
circumstances, sex steroid production by the adrenal plays a relatively minor role compared with the contribution by the gonads. The adrenal medulla contains
chromaffin cells, the most important source of circulating catecholamines. These catecholamines, epinephrine and norepinephrine, have important cardiovascular,
metabolic, and neural effects.
Hypoadrenalism
Hypofunction of the adrenal cortex is usually due to atrophy of the gland of unknown cause. The gland may be destroyed by tuberculosis, neoplasms, amyloidosis,
hemochromatosis, or fungal or human immunodeficiency virus infection. Addison disease, or chronic insufficiency of the adrenal cortex, is characterized by weakness,
weight loss, increased pigmentation of the skin, hypotension, behavioral changes, and hypoglycemia. Chronic adrenal insufficiency may be an autoimmune disorder,
occasionally in association with other autoimmune disorders, such as MG. It may also be a feature of the abnormal metabolism of long-chain fatty acids in X-linked
adrenoleukodystrophy. It may be the only clinical expression in about 10% of cases, including both the cerebral and adrenomyelopathic forms of the disease. In one
study, one-third of young males diagnosed with primary adrenal failure (Addison disease) were found to have adrenoleukodystrophy after measurement of long-chain
fatty acids. Secondary adrenal insufficiency follows pituitary failure, in which symptoms are less severe because of the relative preservation of mineralocorticoid
function, which is not regulated by ACTH.
CNS manifestations of Addison disease are common, primarily in cognition and behavior. Psychotic symptoms are rare. Elevated CSF pressure is sometimes
accompanied by cerebral edema. Autopsy studies of the brain in Addison disease indicate that glucocorticoids play an important trophic function in the CNS,
sustaining the granule cells of the hippocampus. (The loss of hippocampal neurons with adrenocortical hormone receptors in aging is accelerated in Alzheimer
disease and appears to be associated with hypercortisolism.)
Diagnosis is suggested by the clinical features and is confirmed by low plasma levels of cortisol with elevated ACTH levels (in primary adrenal failure), decreased
excretion of 17-hydroxycorticosteroids, and failure of the adrenal cortex to respond to ACTH. Treatment is based on administration of a glucocorticoid preparation and
replacement of mineralocorticoids with sodium. The latter may not be needed if the pituitary is the source of adrenal insufficiency.
Hyperadrenalism
Hyperfunction of the adrenal cortex produces Cushing syndrome, which was attributed by Cushing to a basophilic adenoma of the pituitary. The clinical symptoms of
Cushing disease can be reproduced by the administration of corticosteroids. Mental status changes, including difficulties with memory, and myopathy are two of the
more common neurologic symptoms. The syndrome of idiopathic intracranial hypertension with headache, nausea, vomiting, and papilledema may occur with
reduction or withdrawal of corticosteroids being used as therapy. Symptoms resolve with reinstatement of steroid dosage, and withdrawal is accomplished more
gradually.
The differential diagnosis of Cushing syndrome may be difficult because there are several potential sources of hyperadrenalism (pituitary, adrenal, or ectopic source
of ACTH production) and also because of the effects of common clinical conditions, such as obesity and depression, on the production and suppressibility of
corticosteroids. These conditions may make interpretation of diagnostic tests challenging ( Table 146.4). Treatment is directed at control of corticosteroid secretion
and the underlying pathology.
TABLE 146.4. EVALUATION OF HYPERCORTISOLISM (CUSHING SYNDROME)
Primary Hyperaldosteronism
In 1955, Conn described a syndrome caused by production of aldosterone from a tumor of the adrenal cortex. The clinical manifestations include recurrent attacks of
muscular weakness simulating periodic paralysis, tetany, polyuria, hypertension, and a striking imbalance of electrolytes with hypokalemia, hypernatremia, and
alkalosis. Paresthesia may occur as a result of the alkalosis. Diagnosis is made by finding increased aldosterone secretion and excretion, with reduced activity of
plasma renin. Treatment involves removal of the adrenal tumor coupled with use of an aldosterone inhibitor. Familial glucocorticoid-remediable aldosteronism may be
associated with intracranial aneurysms at about the same frequency as in inherited polycystic kidney disease.
Bartter syndrome is a related disorder characterized by hyperreninemia, hyperaldosteronism, and hypokalemic alkalosis without hypertension or peripheral edema.
Hypomagnesemia is often present, and treatment with potassium chloride and magnesium may restore potassium levels. Recent genetic studies have begun to define
the nature of the ion channel defects in these renal tubular disorders of the Bartter-like syndromes, including the Gitelman variant, which also has hypocalciuria.
Pheochromocytoma
Hyperfunction of the adrenal medulla as a result of a tumor of the chromaffin cells is accompanied by increased secretion of catecholamines. The tumor may be
familial, alone or in conjunction with other endocrine tumors. Pheochromocytoma may be seen with neurofibromatosis, von Hippel-Lindau disease,
ataxia-telangiectasia, or Sturge-Weber syndrome, consistent with the neuroectodermal origin of the adrenal medulla. Familial pheochromocytoma is associated with
bilateral adrenal tumors, while sporadic cases are nearly always unilateral.
Hypertension of a moderate or severe degree is characteristic. The hypertension may be paroxysmal or sustained and is associated with palpitations, episodic
hyperhidrosis, headaches, and other nonspecific systemic symptoms, such as nausea, emesis, or diarrhea. Anxiety attacks are common. Death may result from
cerebral hemorrhage, pulmonary edema, or cardiac failure in one of the acute attacks or as a result of one of these complications from sustained hypertension.
Diagnosis and treatment are directed at establishing the increased excretion of catecholamine metabolites in the urine and localization and removal of the tumor. The
tumor may occur in sites other than the adrenal; imaging techniques are helpful in localization.
GONADS
Neurologic disorders associated with diseases of the ovary or testes are not well-defined. However, the primary secretions of the gonadsestrogens, progestins, and
androgenshave been reported to influence a variety of neurologic symptoms. Cyclic or phasic fluctuations in gonadal secretion (during the menstrual cycle or
pregnancy) have been linked to common problems such as migraine headache and epilepsy and to less common disorders such as porphyria. Therapeutic use of
estrogenprogestin preparations in oral contraceptives poses potential risks for neurologic complications, notably cerebrovascular disease.
Although migraine has been frequently reported in association with menstrual periods, the true incidence of catamenial migraine is difficult to determine. Somerville
(1975) demonstrated that some women have headaches precipitated by the rapid decline in circulating estradiol during the late-luteal phase and that these
headaches can be prevented by administration of estrogen, but not progesterone. The mechanism of action is not clear, but the role of estrogens in catamenial
migraine may explain the onset and variation of headaches during pregnancy or with the use of oral contraceptives. Although long-term estrogen treatment is said to
be useful in catamenial migraine, this is not practical for most women. Premenstrual administration of prostaglandin inhibitors may be helpful. Discontinuation of
estrogen-containing oral contraceptives usually relieves the symptoms.
The relation of oral contraceptive use and the occurrence of stroke has been a controversial topic. Numerous epidemiologic studies indicate that age greater than 35
years and cigarette smoking increase the risk of ischemic and hemorrhagic stroke in women using oral contraceptives. Contraceptive preparations with lower doses of
synthetic estrogens are thought to be safest. Hypercoagulability associated with estrogens is thought to be an important etiologic factor in arterial strokes, as well as
in the syndromes of cerebral venous thrombosis that may complicate pregnancy or contraceptive use.
Direct effects of sex steroids on the CNS may explain the effects of estrogens (epileptogenic) and progestins (anticonvulsant) on seizure frequency in epilepsy. Oral
contraceptives or pregnancy may unmask latent chorea (chorea gravidarum), and menstrual cyclicity or exogenous administration of estrogen has been reported to be
associated with functional changes in parkinsonism, myoclonus, and other movement disorders. Sex steroid receptors on CNS neoplasms may influence growth
characteristics of the tumor. Clinically evident enlargement of meningioma may be seen with pregnancy.
The developmental effects of estrogens and androgens on the brain are extensive. Many behavioral characteristics, sexual and otherwise, may be directed by the
influence of these hormones on the morphology of neurons and the creation of neural networks. Studies of cognitive function in hypothalamic hypogonadism
emphasize the linkages between endocrine and neural function. Clinical interventions may be forthcoming.
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CHAPTER 147. HEMATOLOGIC AND RELATED DISEASES
MERRITTS NEUROLOGY
CHAPTER 147. HEMATOLOGIC AND RELATED DISEASES

KYRIAKOS P. PAPADOPOULOS AND CASILDA M. BALMACEDA
Erythrocyte Disorders
Platelet Disorders
Blood Cell Dyscrasias
Coagulation Disorders
Cerebrovascular Complications of Cancer
Other Disorders
Suggested Readings
ERYTHROCYTE DISORDERS
Sickle Cell Disease
Sickle hemoglobin (HbS) is characterized by an abnormal b-globin chain in which the sixth amino acid valine is substituted by glutamic acid. The disorder is prevalent
in blacks of African descent. Individuals with sickle cell anemia are homozygous for HbS (SS); their hemoglobin contains two normal alpha chains and two abnormal
beta chains. In the deoxygenated condition, the hemoglobin tetramer polarizes and the cell shape becomes distorted, resulting in rigid red blood cells. Cell damage
leads to hemolytic anemia and to occlusion of vessels in the kidney, bone, lung, liver, heart, spleen, peripheral nerves, and brain. Other common sickle genotypes
having neurologic sequelae include sickle cell-hemoglobin C (SC) disease and the sickle-b-thalassemia syndromes.
Stroke is the second leading cause of death after infection, occurring in 7% to 15% of homozygous children. According to the Cooperative Study of Sickle Cell
Disease, the incidence of first cerebrovascular accident is 0.6 per 100 patient years for SS, 0.15 per 100 patient years for SC, and 0.08 per 100 patient years for
sickle-b-thalassemia. Isolated case reports describe patients with sickle cell trait as having otherwise unexplained strokes, particularly with subcortical infarction. In
large series, however, the incidence of cerebrovascular disease in these patients was the same as for the general African-American population.
The risk of stroke in children with sickle cell disease is 250 to 400 times more than in the general population. The cumulative risk of stroke by age 45 is about 24% for
SS patients and 10% for SC patients. About 60% of strokes are ischemic; the others are hemorrhagic. Mean age at development of cerebral infarcts is 8 years, but
they also occur in older patients, whereas hemorrhage is most frequent in patients between ages 20 and 29 years.
Most strokes do not occur at the time of painful crisis, dehydration, fever, or infection. Preceding transient ischemic attacks (TIAs) are uncommon. Low hemoglobin
concentration and high leukocyte count are risk factors for hemorrhagic stroke.
In ischemic stroke, the primary vascular lesion is occlusive disease of the intracranial portion of the distal internal carotid, proximal middle cerebral, or anterior
cerebral artery. Vascular damage includes segmental thickening caused by intimal proliferation of fibroblasts and smooth muscle. Both large and small vessels are
affected.
Many infarcts occur in watershed distributions, attributed to large vessel disease compounded by anemia and hemodynamic insufficiency or hypoperfusion in the
border zone. Cerebral blood flow studies show hyperemia, but the vessels fail to dilate further with hypercapneic stimulation. The vessels may be maximally dilated,
and a drop in perfusion cannot be compensated by further vasodilatation. Therefore, damage is attributed to a combination of both perfusion failure and intraarterial
embolization. Strokes occur when the hypoperfusion exceeds adaptive mechanisms and further vasodilatation is not possible. The second mechanism of stroke is the
resistance to the passage of sickle cells in the small distal penetrating arterioles, with rigid red cell sludge and stasis. Small vessels in the distal fields are the most
vulnerable because the cells adhere and are trapped in the areas of already decreased perfusion. In large vessels, damage from the abnormal red cells leads to large
vessel hyperplasia and thrombus formation at the bifurcation.
Subarachnoid hemorrhage is more common in children, whereas intraparenchymal hemorrhage is seen in adults. The causes of hemorrhage include aneurysmal
dilatation of large vessels, moyamoya-like disease with fragile collateral circulation, and hemorrhage into infarcted tissue. Aneurysms are found at the bifurcation
points of large vessels, which are also the sites of endothelial hyperplasia. The chronically abnormal rheology is thought to weaken the mural integrity of the blood
vessel walls, leading to aneurysmal dilatation and rupture.
Magnetic resonance imaging (MRI) shows infarcts, often asymptomatic, in small vessel territory in 28% and large vessel territory in 72%. Angiography shows a high
incidence of large vessel pathology, but intraarterial injections increase the risk of stroke or sickle cell crisis. Preparation for angiography includes transfusions to
reduce the HbS concentration to less than 30%. An 11% incidence of stenosis has been shown by MR angiography in children younger than 4 years. Carotid and
transcranial Doppler studies are sensitive in detecting arterial vasculopathy. Positron emission tomography shows higher regional blood flow in sickle cell patients
than in age-matched control subjects.
The incidence of stroke recurrence is lower in patients who receive transfusions regularly. In those who receive chronic transfusion therapy, 10% have recurrent
stroke; without transfusions, stroke recurrence is 46% to 90% usually within 3 years of the first event. The goal of transfusion with HbA cells is an HbS concentration
less than 30% of the total hemoglobin. The transfusion regimen is maintained for 2 to 4 years; some advocate long-term transfusion indefinitely.
Younger patients with strokes tend to have residual symptoms, and survivors may be neuropsychologically impaired. Cognitive abnormalities occur even in the
absence of MRI abnormalities or clinical stroke, and the IQ may be lower than in asymptomatic carriers.
Transcranial Doppler ultrasonography identifies SS children at risk of stroke. Elevated time-averaged mean blood flow velocity in the intracranial internal carotid or
middle cerebral artery is associated with a 46% risk of cerebral infarction in 39 months. The randomized Stroke Prevention Trial in Sickle Cell Anemia of prophylactic
transfusion for prevention of first stroke in patients with abnormal transcranial Doppler ultrasonography showed a 92% decrease in stroke occurrence. Ultimately, the
benefits of long-term transfusion in preventing a first or recurrent stroke must be weighed against the complications of transfusions, including alloimmunization,
infection, and iron overload. Other therapies include efforts to increase the concentration of fetal hemoglobin with butyric acid and hydroxyurea and bone marrow
transplantation.
The incidence of seizures varies from 6% to 12%. Seizures may accompany strokes or meningitis and may be precipitated by dehydration or by commonly used
medications such as meperidine. Computed tomography (CT) or MRI only rarely shows a lesion responsible for the seizures. Infections are common for several
reasons: splenic infarction, local tissue hypoxia, or abnormalities in complement activation. Bacterial meningitis, most commonly caused by streptococcus pneumonia,
cerebral abscesses, and tuberculomas, have all been seen.
Headache is reported in 28% of children. It is often not associated with sickle cell crisis, intracerebral hemorrhage, skull infarction, or osteomyelitis. An acute or
chronic progressive encephalopathy may be seen. In individuals with SC disease, visual disturbances due to retinopathy is seen in 58% and hearing loss is more
common than with SS disease.
Myelopathy is rare but may follow spinal cord infarction or spinal cord compression by extramedullary hematopoiesis. Peripheral neuropathy is also unusual but may
manifest as an acute mononeuropathy affecting the mental, peroneal, or multiple cranial nerves.
Thalassemia
b-Thalassemia is an inherited hemolytic anemia resulting from defective b-globin chain synthesis. It usually occurs in individuals of Mediterranean or Asian extraction
and is characterized by hepatosplenomegaly, skin changes, and growth retardation. Transient dizziness and visual blurring are seen in up to 20%. The transient
symptoms characteristically occur between transfusions and improve when the anemia is ameliorated. Other manifestations are headaches (13%) and seizures
(13%). Twenty percent develop a mild peripheral, mainly motor, neuropathy in the second decade of life. A syndrome consisting of myalgia, paroxysmal muscle
weakness, and myopathic electromyography changes has also been reported. Stroke is rare, seen in those receiving multiple transfusions and attributed to
thrombocytosis after splenectomy or to intravascular hemolysis. Spinal cord and cauda equina compression resulting from extramedullary hematopoiesis responds to
transfusion and radiation therapy. Skull x-ray films show characteristic abnormalities ( Fig. 147.1).
FIG. 147.1. Skull in chronic hemolytic anemia (thalassemia). A: Thickening of vault. B: Magnified view of hair-on-end appearance as a result of extramedullary
hematopoiesis in the widened diploic space. (Courtesy of Dr. William H. McAlister.)
Polycythemia
Polycythemia, an abnormal increase in the number of circulating erythrocytes, occurs with the myeloproliferative disorder polycythemia vera or may be secondary to
pulmonary hypoventilation or high altitude. Rarely, cerebellar hemangioblastoma or hepatoma causes polycythemia by elaborating erythropoietin. Blood viscosity
increases and may cause headache. Other symptoms, occurring in 50% to 80% of patients, include dizziness, tinnitus, visual disturbances, and cognitive impairment.
These symptoms respond to reduction in the red blood cell count by phlebotomy or chemotherapy. Circulation returns to normal as the hematocrit is reduced to 40%
to 45% and blood viscosity is lowered.
Hyperviscosity also predisposes to large and small vessel cerebral infarction and may accelerate atherosclerosis. In polycythemia vera, transient ischemic attacks and
ischemic stroke account for 70% of arterial thromboses. Aseptic cavernous sinus thrombosis is rare. Both thrombocytosis and a platelet disorder that leads to a
hemorrhagic diathesis may be seen. Cerebral thrombosis is fatal in 15% and cerebral hemorrhage in 3% of patients with this condition. Patients may complain of limb
pain or paresthesias that are attributed to ischemia and often recede promptly with phlebotomy. Peripheral neuropathy, predominantly sensory axonal, occurs in up to
46% of patients.
PLATELET DISORDERS
Essential Thrombocytosis (Thrombocythemia)
Essential thrombocytosis is an acquired myeloproliferative disorder characterized by splenomegaly, elevated platelet count, platelet dysfunction, and a predisposition
to both hemorrhage and thrombosis involving the arterial and venous circulation. The Polycythemia Vera Study Group established specific criteria for diagnosis:
persistent thrombocytosis (platelet count greater than 600,000/mm 3), megakaryocytic hyperplasia in the bone marrow, absence of the Philadelphia chromosome,
marrow fibrosis or myeloid metaplasia, and absence of increased erythrocyte mass in the presence of normal iron stores. Other causes of secondary thrombocytosis,
such as underlying systemic illness, iron deficiency, and neoplasia, must be excluded. Onset is in the sixth or seventh decade of life, and the mean platelet count at
diagnosis is 1 10 6/mm3. Neurologic episodes occur in about 30% of patients. The most common neurologic manifestation is headache, followed by paresthesias,
TIAs, cerebral infarction, and seizures. Bleeding complications are mild, primarily gastrointestinal, and rarely of neurologic consequence.
It is not known whether the qualitative platelet abnormalities or the thrombocytosis is responsible for symptoms. Most neurologic episodes occur at onset or with
hematologic relapse. Microvasculature occlusion may be responsible. Some authorities recommend treatment with aspirin or dipyridamole in asymptomatic patients.
After serious thromboembolic events, urgent platelet pheresis is recommended. Hydroxyurea and anagralide are effective in reducing the platelet count. The clinician
should check the platelet count in all patients with ischemic episodes and in those with headaches, visual symptoms, or paresthesias.
Thrombotic Thrombocytopenic Purpura
Thrombotic thrombocytopenic purpura (TTP) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, fever, nephropathy, and neurologic
manifestations. The mean age at onset is 40 years as an acute process that causes damage by microvasculature occlusion, with anoxic injury, in kidney and brain.
Seventy percent of the patients have neurologic symptoms, most commonly as hemiparesis in 25% or an organic mental syndrome in 50%. Aphasia, hemisensory
loss, seizures, ataxia, and field defects are less common. The symptoms are transient, usually lasting less than 48 hours. Permanent neurologic symptoms occur in a
few patients. Hemiparesis tends to improve more readily than mental status changes.
Neuropathologic changes may or may not be symptomatic. Hyaline thrombotic occlusion of arterioles and capillaries without inflammation results in small infarcts and
petechial hemorrhages, usually in the gray matter ( Fig. 147.2). Rarely, there is large vessel occlusion or subarachnoid or subdural hemorrhage. Symptoms are
attributed to episodes of focal ischemia. The majority of cases of TTP are associated with an acquired IgG inhibitor of von Willebrand factor cleaving protease.
Ticlopidine therapy has been associated with TTP.
FIG. 147.2. Thrombotic thrombocytopenic purpura. Occlusion of small cerebral vessels by amorphous hyaline material. (Courtesy of Dr. Abner Wolf.)
Normal findings on CT suggest the possibility of full clinical recovery in 70% of the patients. If CT findings are abnormal, death or permanent neurologic disorder
follows in 80% of the patients. Cerebrospinal fluid (CSF) is usually normal except for elevated protein content.
Treatment includes chemotherapy, steroids, or plasma exchange, leading to remission in 75%. Dialysis is used to treat the renal dysfunction, and heparin may be
used but may cause cerebral hemorrhage. Death from neurologic complications in TTP is not as common as from other organ failure. Malaria may be mimicked by
TTP.
Heparin-induced Thrombocytopenia
Heparin-induced thrombocytopenia is an immune-mediated disorder typically occurring 5 or more days after initiation of therapy in a patient not previously exposed to
heparin. The pathogenic IgG immunoglobulin binds a heparin/platelet factor 4 complex, causing platelet activation. This prothrombotic state is characterized by a 50%
or greater decrease in platelet count, and up to 50% of patients develop thrombotic complications, including cerebral infarction in 3% to 4% of all patients. Heparin
therapy should be discontinued immediately, and warfarin withheld until platelets recover to avoid venous limb gangrene. Danaparoid, a heparinoid mixture of
anticoagulant glycosaminoglycans, is an effective therapy.
BLOOD CELL DYSCRASIAS
Leukemia
All forms of leukemia may lead indirectly to neurologic symptoms because of complications of therapy, especially hemorrhage due to thrombocytopenia or infection
due to low white blood cell counts. With markedly elevated white blood counts (greater than 150,000/mm 3), leukostasis may occlude cerebral blood vessels.
Furthermore, leukemic blasts can infiltrate the arteriole endothelial walls to cause hemorrhage. Patients at risk for central nervous system (CNS) leukostasis are
treated with emergency leukapheresis to lower the blast count. Leukemic nodules may also predispose to intracerebral hemorrhage, which may be fatal.
Direct CNS manifestations of leukemia depend on the specific cell type involved. In acute myelogenous leukemias, CNS involvement is uncommonly the first
manifestation. Patients at risk for CNS symptoms include those with high circulating blast counts and the monocytic M4 subtype. The M4 Eo variant in particular, with
eosinophilia and the inv(16)(p13q22) inversion of chromosome 16, is commonly associated with leptomeningeal and intracerebral lesions. Cranial nerve palsies due
to infiltration are rare in acute myelogenous leukemias, mostly involving the fifth and seventh nerves. Unless CNS symptoms require therapy, lumbar puncture is
deferred until the peripheral blood is cleared of blast cells to avoid possible CNS seeding. Acute myelogenous leukemias may affect the CNS in the form of a
chloroma (or granulocytic sarcoma), a local collection of blast cells that appears green because of a high myeloperoxidase content. Chloromas may be seen 1 year
before the overt onset of acute leukemia, originating in subperiosteal sites in bone and characteristically causing unilateral or bilateral exophthalmos simulating orbital
lymphoma. Other sites include the cranial and facial bones, commonly causing facial palsy, and the spinal epidural space, causing paraplegia.
Acute lymphocytic leukemia involves the CNS in 5% to 10% of patients at time of diagnosis, often without symptoms. Risk factors for CNS leukemia include a high
lymphocyte count, T-ALL phenotype, and L3 (Burkitt) morphology. Without prophylactic chemotherapy directed at the CNS, the CNS relapse rate is up to 50%.
Leukemic cells invade the meninges; tumor spreads from the bone marrow centripetally along arachnoid veins, giving rise to leptomeningeal metastases. The infiltrate
spreads along the arachnoid into the Virchow-Robin spaces, secondarily affecting the adventitia of arterioles. With leptomeningeal seeding, the CSF cytology is
invariably abnormal. As with meningeal involvement by carcinoma, all levels of the CNS are affected, with cranial nerve signs (IIIrd, IVth, VIth, and VIIth), seizures,
cognitive deficit, or hydrocephalus. Uncommon syndromes with leukemic infiltration include hypothalamic infiltration with hyperphagia and obesity or diabetes
insipidus.
The prognosis for acute leukemia was poor before therapy directed at eradication of leptomeningeal metastasis was introduced in the early 1960s. The CNS is a
sanctuary because most systemic antileukemic chemotherapy does not achieve adequate therapeutic CSF levels to eradicate tumor cells. Surviving leukemia cells in
the CSF may reenter the marrow and reestablish the disease. With combined craniospinal radiation and intrathecal chemotherapy (methotrexate or cytosine
arabinoside), the incidence of CNS relapse has declined dramatically, with improved quality of life and survival. Although cranial irradiation is neurotoxic (see Chapter
71), intrathecal chemotherapy is less satisfactory. Current protocols attempt to eliminate spinal radiation, reduce the cranial dose, and treat more intensively with
intrathecal medications. Bone marrow transplantation in patients with leukemia may be complicated by posttransplant leukoencephalopathy.
In contrast, chronic leukemia rarely affects the CNS. When chronic myelogenous leukemia enters into blast crisis, leptomeningeal metastases may occur. Chronic
lymphocytic leukemia is common but only exceptionally invades the meninges or brain, most often with late-stage disease.
Plasma Cell Dyscrasias
Several conditions, both neoplastic and nonneoplastic, are characterized by the appearance of monoclonal gamma globulins (M protein) in the serum. The
monoclonal proteins are produced by cells of B-cell lineage, and the associated plasma cell dyscrasias include multiple myeloma, Waldenstrm macroglobulinemia
(with IgM paraprotein), and amyloidosis.
If monoclonal gammopathy is the only manifestation, this is termed monoclonal gammopathy of unknown significance (MGUS). MGUS may persist in asymptomatic
people for years or decades. In 20% of patients, a plasma cell dyscrasia or one of the lymphoproliferative diseases (chronic lymphocytic leukemia [CLL], lymphoma)
later appears. Differentiation of MGUS from more serious disease depends on bone marrow examination, urinary excretion of light chains (Bence-Jones protein), and
survey for bone lesions.
Peripheral neuropathy is a common neurologic manifestation of MGUS. In most cases the paraprotein is IgM and less commonly IgG or IgA. In about half of the
patients with IgM neuropathy, the monoclonal protein has antibody activity against myelin-associated glycoprotein and results in a demyelinating peripheral
neuropathy. These patients show large-fiber sensory loss and late-onset distal limb weakness. Some patients with a sensory axonal neuropathy have IgM antibodies
that recognize axonal sulfatides or chondroitin sulfate. The role of the M protein in the pathogenesis of these syndromes is debated, but experimentally antibodies to
myelin-associated glycoprotein can induce peripheral nerve demyelination.
In myeloma, the most frequent neurologic complication is thoracic or lumbosacral radiculopathy, resulting from nerve compression by a vertebral lesion or collapsed
bone. A syndrome of spinal cord compression may appear when there are epidural myeloma masses within the spinal canal. The intraspinal lesions are treated with
combinations of radiotherapy or chemotherapy. Intracranial plasmacytomas are usually extensions of myeloma skull lesions. Characteristic multiple osteolytic lesions
are seen on radiographs of the skull and other bones ( Fig. 147.3). Leptomeningeal invasion is also seen with myeloma. Peripheral neuropathy is uncommon and
usually associated with axonal degeneration and amyloidosis. One unusual multisystem disease is POEMS ( p olyneuropathy, o rganomegaly, e ndocrinopathy, M
protein, and s kin changes), which is associated with osteosclerotic myeloma or plasmacytoma. The M protein is usually IgG or IgA, invariably associated with a
lambda light chain. Surgical removal of the plasmacytoma may reverse the neuropathy.
FIG. 147.3. Multiple myeloma. Myriads of osteolytic lesions. (Courtesy of Dr. Lowell G. Lubic.)
The peripheral neuropathy in Waldenstrm macroglobulinemia is similar to the demyelinating neuropathy of MGUS. Leukoencephalopathy with macroglobulinemia is
called the Bing-Neel syndrome; there may be plasma cell invasion of perivascular spaces, but there is no cerebral mass lesion. A hyperviscosity syndrome with IgM
paraproteinemia is associated with headache, blurred vision, tinnitus, vertigo, and ataxia. Serum viscosity can be reduced by chemotherapy or by plasmapheresis to
lower the paraprotein concentration.
The neuropathies are treated with immunosuppressive drugs, intravenous immunoglobulin therapy, or plasmapheresis.
Myelofibrosis
Extramedullary hematopoiesis often accompanies myelofibrosis or polycythemia vera and may cause extradural spinal cord compression, cerebral compression by
calvarial-based intracranial masses, or orbital lesions with exophthalmos. The neurologic signs are usually painless and develop insidiously. The syndrome occurs
more frequently after splenectomy and responds to radiotherapy.
COAGULATION DISORDERS
Hematologic disorders or coagulopathies may be responsible for stroke in 4% to 17% of young patients and 1% of all patients with ischemic stroke. The role of
prothrombotic disorders in older stroke patients is not known. Most prothrombotic disorders are associated with venous thrombosis in unusual sites (mesentery,
sagittal sinus), but arterial thrombosis, mainly in the carotid artery, has been described. Women with hereditary prothrombotic conditions using oral contraception are
at a three- to fourfold risk of cerebral sinus thrombosis. Cerebral thrombosis can occur without systemic manifestations. A hematologic abnormality is attributed a
causal role in stroke if the abnormality persists months after the event or is seen in other family members.
Antithrombin III Deficiency
Antithrombin III (ATIII) is a plasma glycoprotein synthesized by the liver and endothelial cells. It binds to endogenous heparan on the surface of endothelial cells or to
exogenous heparin. ATIII is required for the anticoagulant action of heparin, increasing its ability to inhibit thrombin and other activated clotting factors. The activity of
ATIII can be measured by its ability to inactivate factor Xa or thrombin. Heparin accelerates this interaction.
Deficiency of ATIII is inherited or acquired, with a prevalence of 1:2,000 to 1:5,000 in the general population. There are two types of familial ATIII deficiency. Type I
accounts for about 90% of inherited cases; both antigen level and functional activity of ATIII are decreased. In type II, levels are normal, but there is dysfunction of
ATIII. The disease is inherited in an autosomal dominant fashion, affecting both sexes equally. Penetrance is variable. The most common manifestation is leg
thrombosis and pulmonary embolus. In heterozygote individuals, symptomatic thrombosis increases after the age of 15, and by age 55 it is estimated to occur in 85%
of gene carriers. More than half of the thrombotic episodes occur with triggering events: pregnancy, surgery, or infection. It is an isolated event in 42%. Cerebral
venous thrombosis is more common, but arterial thrombosis may occur. For homozygotes, venous thrombosis is usually seen during the first year of life. Clues to
diagnosis are family history of thromboembolism, thrombosis during pregnancy, resistance to heparin therapy, or unusual sites of thrombosis (brain, mesentery).
There are several causes of acquired ATIII deficiency. Decreased synthesis is seen with liver cirrhosis. Drug-induced ATIII deficiency occurs with L-asparaginase,
heparin, or oral contraceptives containing estrogen. Increased excretion in protein-losing enteropathy, inflammatory bowel disease, or nephrotic syndrome results in
low ATIII levels. Accelerated consumption in disseminated intravascular coagulopathy (DIC) or after major surgery can lead to ATIII deficiency.
ATIII deficiency is resistant to anticoagulation with heparin. ATIII concentrate is given to deficient patients with a thrombotic event or at times of maximal risk, such as
surgery or delivery. After a thrombotic event, lifelong warfarin therapy is indicated. The value of prophylactic anticoagulation for all carriers during high-risk events is
debated.
Protein S Deficiency
Protein S is a vitamin K-dependent plasma protein synthesized in the liver. It facilitates the binding of protein C to the platelet membrane, acting as a nonenzymatic
cofactor for the anticoagulant activity of activated protein C. Only 40% of protein S is in a free form; the rest is in an inactive form, bound to C4-binding protein.
C4-binding protein levels are elevated during acute inflammation or stress, increasing the inactivation of protein S and thus the risk of thrombosis. The complex of
proteins C and S inhibits the clotting cascade. Protein S deficiency can be acquired or congenital, inherited as autosomal dominant with partial expressivity. Acquired
deficiency is caused by liver dysfunction, vitamin K deficiency, warfarin therapy, nephrotic syndrome, oral contraceptives, or chemotherapy.
Up to 20% of patients with stroke have protein S deficiency, but the significance of this figure has been challenged by case-control studies. Thrombosis, both cerebral
venous and arterial system, has been described. In evaluating protein S deficiency, it is necessary to determine both the free and the total protein S levels. Most
patients with protein S deficiency and stroke are given anticoagulation therapy for a predetermined period. Prophylactic anticoagulation is not advocated for
asymptomatic protein S deficiency.
Protein C Deficiency
Protein C is a serine protease and an important inhibitor of plasma coagulation. Similar to protein S, its synthesis by the liver depends on vitamin K. Protein C in the
plasma is inactive; it is activated by a thrombinthrombomodulin complex when clotting is initiated at the endothelial surface. Protein S enhances the activity of protein
C. Once activated, protein C inactivates factors Va and VIIIa, inhibiting coagulation and enhancing fibrinolytic activity. Deficiency can be inherited or acquired. The
trait is autosomal dominant with incomplete penetrance. Homozygous individuals develop purpura fulminans and severe thrombotic complications in the neonatal
period. Heterozygotes have recurrent thrombosis in early adult years. Members of the family may have subnormal protein C levels but may be asymptomatic.
Additional risk factors for thromboembolism, such as smoking or oral contraceptives, may be contributory. Acquired protein C deficiency may occur with vitamin K
malabsorption or warfarin therapy or with malignancy or chemotherapy. Either quantitative or qualitative protein C deficiency can lead to cerebral thrombosis.
Protein C deficiency is found in 6% to 8% of patients who have a stroke before age 40. Strokes are usually attributed to venous thrombosis. Occlusion of the cerebral
arteries is rare, as is cerebral sinus thrombosis.
Anticoagulation with heparin or warfarin is recommended only for clinical thrombosis and not for those with subnormal levels. Warfarin necrosis of skin and
subcutaneous tissues, particularly breast and adipose tissue, may be seen in patients 2 to 5 days into treatment and has been attributed to loading doses. Protein C
deficiency may be associated with homocysteinemia, which itself can lead to thrombosis.
Factor V Leiden and Prothrombin G20210A Mutations
Factor V Leiden is the most common known genetic risk factor for thrombosis. A mutation of the factor V gene causing replacement of arginine 506 by glycine results
in factor Va resistance to degradation by activated protein C. The resultant imbalance between pro- and anticoagulant factors predisposes to venous thrombosis. The
incidence of heterozygous factor V Leiden is 2% to 8.5%, depending on the ethnicity and geographic location of the population studied. Heterozygosity for the factor V
mutation alone does not appear to increase the risk for ischemic stroke.
There is conflicting data as to whether the prothrombin G20210A mutation, which is associated with thrombosis, confers an increased risk of ischemic stroke in young
patients heterozygous for this mutation. Spinal cord infarction in young women smokers on oral contraception having the prothrombin G20210A mutation has been
described.
Recent data suggest that the frequent coexistence of factor V Leiden; the prothrombin 20210A allele; and hereditary deficiencies of ATIII, protein C, and protein S
may significantly contribute to the risk of thrombotic events.
Hereditary Abnormalities of Fibrinolysis
There are four inherited abnormalities of fibrinolysis. Plasminogen deficiency is autosomal dominant, with patients predisposed to venous thrombosis, including
cortical vein thrombosis. Tissue plasminogen activator deficiency has been associated with venous thrombosis but not stroke. Patients with dysfibrinogenemia can
have strokes rarely. Those with factor XII deficiency have elevated activated partial thromboplastin time, and some have had strokes.
Autoantibodies
Antiphospholipid antibodies, encompassing the lupus anticoagulant and anticardiolipin antibodies, are the most common acquired defects associated with thrombosis.
IgG anticardiolipin antibodies have been associated with ischemic stroke, often recurrent, particularly in young adults. Other neurologic presentations in patients with
antiphospholipid antibodies include cerebral venous sinus thrombosis, dementia, and chorea. The presence of a lupus anticoagulant should be suspected if the
activated partial thromboplastin time (and prothrombin time in some cases) is prolonged and fails to correct with mixing studies.
Paroxysmal Nocturnal Hemoglobinuria
This clonal myelodysplastic syndrome is characterized by the absence of glycosylphosphatidylinositol, which anchors proteins to the cell surface. Patients are prone
to hepatic vein and sagittal sinus thrombosis and may have hemolytic anemia, cytopenia, and headache.
Hemophilia
Twenty-five percent of hemorrhagic deaths in hemophiliacs are due to intracranial bleeding, often without precedent trauma. Bleeding can be subdural, epidural,
intracerebral, or infrequently intraspinal. In a study of 2,500 patients followed for 10 years, the incidence of intracranial bleeding was 3%, with a 34% mortality rate
and 47% of survivors having residual mental retardation, motor impairment, or seizures. Treatment with factor concentrate should not be delayed for diagnostic
procedures if there is a clinical suspicion of intracranial bleeding. Peripheral neuropathies may follow intaneural bleeding or nerve compression by hematomas.
CEREBROVASCULAR COMPLICATIONS OF CANCER
At autopsy, as many as 15% of patients with systemic malignancy have evidence of cerebrovascular disease. Cancers cause vascular complications by several
indirect or direct mechanisms.
Nonbacterial thrombotic endocarditis with sterile platelet-fibrin heart valve vegetations is the most common cause of cerebral infarction in patients with systemic
malignancy. Most patients have disseminated malignancy and have multiple strokes, with ischemic or hemorrhagic infarctions in different vascular territories, often
preceded by TIAs. The lesions are differentiated from brain metastases by CT or MRI. The most common tumors are lymphomas and adenocarcinomas, particularly
mucin-producing adenocarcinomas. Emboli to other organs (pulmonary embolism, limb arterial emboli, or myocardial infarction) may call attention to the diagnosis,
especially in patients with neurologic symptoms. There is thought to be a coagulopathy, but this has not been clarified. Therapy is directed toward eradication of the
primary tumor; the role of anticoagulation is unsettled.
Tumor emboli uncommonly cause cerebral infarction, usually with atrial myxoma or lung carcinoma. Neoplastic angioendotheliomatosis was formerly attributed to
tumor emboli or diffuse spread of endothelial cells with strokelike symptoms, but neoplastic angioendotheliomatosis is a systemic lymphoma with intravascular
dissemination (see Chapter 56).
Coagulation disorders may be due to the underlying tumor, chemotherapy, or radiotherapy. Coagulopathy is often seen with hepatic metastases and depletion of
coagulation factors. Many chemotherapeutic agents depress stem cell function to cause thrombocytopenia. Colony-stimulating factors stimulate leukocyte production
and permit more intensive chemotherapy, but thrombocytopenia may require platelet transfusions. Spontaneous intraparenchymal or subarachnoid hemorrhage may
occur when the platelet count is less than 20,000/mm 3, a common problem in the cancer patient with sepsis. The combination of coagulopathy and thrombocytopenia,
often seen with leukemia, predisposes to cerebral hemorrhage. In contrast, subdural hemorrhage is less common than parenchymal or subarachnoid hemorrhage in
patients with coagulopathy or thrombocytopenia and occurs more frequently in the presence of dural metastases from carcinoma of breast, lung, or prostate.
Even with normal coagulation and platelet function, some metastatic tumors (melanomas, lung carcinomas, choriocarcinomas, and hypernephromas) are likely to
cause hemorrhage into a tumor. With gliomas, the likelihood of intratumor hemorrhage increases with increasing grade of malignancy. To avert intratumor
hemorrhage, patients with known primary or metastatic brain tumors should receive platelet transfusions if the count falls below 20,000/mm 3, and coagulation
functions should be maintained with transfusions of fresh frozen plasma. Intracranial or subarachnoid hemorrhage may result from rupture of a neoplastic (oncotic)
aneurysm caused by atrial myxomas or direct destruction of arterial walls as a result of invasion by a metastatic lung carcinoma or choriocarcinoma or glioblastoma.
DIC is readily detected in its acute fulminant form when patients bleed profusely after venipuncture and have intracranial hemorrhage. Acute promyelocytic leukemia
is associated with fulminant DIC, probably secondary to release of granules from leukemic cells. A more indolent form of DIC may also cause neurologic
manifestations. Autopsy examinations reveal evidence of thrombosis in situ, intravascular coagulation. In contrast to nonbacterial thrombotic endocarditis, in which
multifocal neurologic signs predominate, the main neurologic manifestation of DIC is diffuse encephalopathy. The diagnosis of chronic DIC is difficult but should be
considered if the level of fibrin split products is elevated. Heparin anticoagulation is a logical but unproven therapy.
Occlusion of the superior sagittal sinus may follow direct spread of tumor to the dura. The cardinal symptoms of venous sinus thrombosis include headache secondary
to increased intracranial pressure and seizures. It may also be a nonmetastatic complication, presumably caused by coagulopathy. The diagnosis is made by MRI,
which shows loss of the typical signal flow void in the superior sagittal sinus at the site of the thrombosis. Heparin therapy is frequently beneficial but must be
monitored, particularly if there is hemorrhagic cortical infarction. Leptomeningeal metastasis infrequently produces TIA or infarction by compromising vessels near the
meningeal infiltrate.
Radiation-induced vasculopathy of the carotid artery may be delayed for years after radiation therapy for tumors of the head or neck. Symptoms of TIAs or infarction
point to the involved vessel, and angiography reveals intimal irregularity. Radiotherapy may accelerate atherosclerosis, and appropriate patients benefit from
endarterectomy.
OTHER DISORDERS
Hypereosinophilic Syndrome
Hypereosinophilia has been associated with a number of disorders, including allergies, parasitic infections, Hodgkin and T-cell lymphomas, and some forms of
vasculitis. When eosinophilia (greater than 1,500/mm 3) persists for more than 6 months without an apparent underlying cause, with evidence of tissue damage by
eosinophils, the disorder is termed the hypereosinophilic syndrome. The pathogenesis may be related to T-cell overexpression of cytokines, particularly interleukin-5.
Eosinophils contain a number of granule proteins that damage tissue, including the eosinophil-derived neurotoxin that can cause Purkinje cell degeneration, ataxia,
and paralysis in experimental animals. Multiple organs are affected, including the heart (endomyocardial fibrosis), lungs, liver, spleen, and skin. The CNS is affected
in 15% of cases as encephalopathy, TIA, embolic infarction, or peripheral neuropathy. Behavioral changes, confusion, memory loss, ataxia, and upper motor neuron
signs may be the first manifestation. Cerebral embolism is attributed to the cardiac disorder and responds poorly to anticoagulation. Patients with hypereosinophilia
and peripheral neuropathy raise the possibility of the Churg-Strauss syndrome. Steroids and hydroxyurea are the mainstay of therapy for the eosinophilic syndrome.
Langerhans Cell Histiocytosis
Histiocytes include the antigen-presenting dendritic cells and antigen-processing phagocytic cells. Disorders of dendritic cells, previously called histiocytosis X, are
now termed Langerhans cell histiocytosis. They may arise from clonal proliferation of cells but malignant histiocytosis, a true neoplasm, is rare. A localized form is the
eosinophilic granuloma (Fig. 147.4); a multifocal form is the Hand-Schller-Christian disease, and a disseminated disease in children under age 2 is the Letterer-Siwe
disease. The diagnosis of Langerhans cell histiocytosis is made by biopsy of affected tissues and immunohistochemical analysis with surface markers that are
expressed by Langerhans cells.
FIG. 147.4. Eosinophilic granuloma of optic chiasm. A: T1-weighted coronal magnetic resonance (MR) image shows enlargement of optic chiasm. B and C:
T1-weighted coronal and sagittal MR images after gadolinium enhancement demonstrate focal enhancing nodule involving optic chiasm and hypothalamus, consistent
with known eosinophilic granuloma. Incidentally noted are several small enhancing lesions in left temporal lobe (an unusual site for eosinophilic granuloma).
(Courtesy of Drs. S. Chan and S.K. Hilal.)
Eosinophilic granuloma is a painless destructive bone lesion that frequently involves the calvarium but is detected on CT performed for other reasons. Excision and
local radiation therapy are often curative.
Hand-Schller-Christian disease is characterized by the triad of calvarial lesions, exophthalmos, and diabetes insipidus. Otitis media and constitutional symptoms of
fever or weight loss may occur. The hypothalamus is likely to be affected, most often with diabetes insipidus, especially in children and young adults. CT or MRI
reveals both gray and white matter contrast and noncontrast-enhancing intraparenchymal lesions that are not specific; biopsy is needed unless tissue diagnosis can
be obtained from a calvarial lesion. Therapy consists of localized irradiation and corticosteroids. Chemotherapy is given for those with resistant disease.
Letterer-Siwe disease causes a granulomatous rash, lymphadenopathy, hepatosplenomegaly, fever, and weight loss, usually without neurologic involvement. The
prognosis for this form is quite poor; cytotoxic chemotherapy has been recommended.
Neurolymphomatosis
In 1934, Lhermitte and Trelles described lymphomatous infiltration of peripheral nerves or neurolymphomatosis. Of more than 40 histologically proven cases reported
subsequently, most have had non-Hodgkin lymphoma with progressive sensorimotor peripheral neuropathy. Some also had cranial neuropathy (45%), bowel or
bladder incontinence (25%), gait ataxia (18%), or mental change (13%). The CSF protein content was above 100 mg/dL in 57% of patients, and 70% had lymphocytic
CSF pleocytosis. CSF cytology was abnormal in 33%. Electrodiagnostic studies show axonal neuropathy, mixed, or pure demyelinating neuropathy. Sural nerve
biopsy shows equal numbers of patients with purely axonal degeneration or demyelinating lesions. MRI may be useful in identifying appropriate biopsy sites. At
postmortem examination, there is often B-lymphocytic infiltration of leptomeninges, dorsal root ganglia, and spinal roots. The histopathologic pattern is
indistinguishable from that of primary leptomeningeal lymphoma. Neurolymphomatosis is readily discernible from the polyclonal T-cell infiltration in human
immunodeficiency virus-associated diffuse infiltrative lymphocytosis syndrome. The neurologic disorder sometimes improves with corticosteroids, chemotherapy, or
radiation therapy.
Angiocentric Immunoproliferative Lesions
These disorders are discussed in Chapter 56.
Chediak-Higashi Syndrome
This rare autosomal recessive disorder is characterized by partial oculocutaneous albinism, immunologic defects, a bleeding diathesis, and progressive neurologic
dysfunction. Mutation of the CHS1 gene on chromosome 1q42-q44 appears to result in defective transport of intracellular proteins, producing giant lysosomal
granules in granule-containing cells, including neutrophils, monocytes, hepatocytes, and renal tubular cells. The granules are easily recognized on a peripheral blood
smear. Impaired neutrophil function and defective T-cell and natural killer cell cytotoxicity predisposes to infections that lead to death, usually within the first decade of
life. Neurologic syndromes include a spinocerebellar disorder and peripheral neuropathy. The neurologic symptoms may be associated with neuronal or Schwann cell
inclusions or by lymphohistiocytic infiltration of peripheral nerves. CT brain findings include diffuse atrophy and decreased periventricular density. Bone marrow
transplant is a potentially curative avenue for therapy.
SUGGESTED READINGS
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Essential Thrombocytosis (Thrombocythemia)
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Martin EA, Lavin PJ, Thompson AJ. Painful extremities and neurological disorder in essential thrombocythaemia. J R Soc Med 1984;77:372374.
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Tardy B, Page Y, Convers P, et al. Thrombotic thrombocytopenic purpura: MR findings. AJNR 1993;14:489490.
Tsai HM, Lian EC. Antibodies to von Willebrand factor-cleaving protease in acute thrombotic thrombocytopenic purpura. N Engl J Med 1998;339:15851594.
Heparin-induced Thrombocytopenia
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Magnani HN. Heparin-induced thrombocytopenia (HIT): an overview of 230 patients treated with Organan (Org 10172). Thromb Haemost 1993;70:554561.
Warkentin TE, Kelton JG. A 14-year study of heparin-induced thrombocytopenia. Am J Med 1996;101:502507.
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Rice GPA, Assis LJP, Barr RM, et al. Extramedullary hematopoiesis and spinal cord compression complicating polycythemia rubra vera. Ann Neurol 1980;7:8184.
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Balis FM, Savitch JL, Bleyer WA, et al. Remission induction of meningeal leukemia with high-dose intravenous methotrexate. J Clin Oncol 1985;3:485489.
Cramer SC, Glaspy JA, Efird JT, Louis DN. Chronic lymphocytic leukemia and the central nervous system: a clinical and pathological study. Neurology 1996;46:1925.
Dekker AW, Elderson A, Punt K, Sixma JJ. Meningeal involvement in patients with acute nonlymphocytic leukemia. Incidence, management, and predictive factors. Cancer 1985;56:20782082.
Freeman AI, Weinberg V, Breecher ML, et al. Comparison of intermediate-dose methotrexate with cranial irradiation for the post-induction treatment of acute lymphocytic leukemia in children. N Engl
J Med 1983;308:477484.
Holmes R, Keating MJ, Cork A, et al. A unique pattern of central nervous system leukemia in acute myelomonocytic leukemia associated with inv(16)(p13q22). Blood 1985;65:10711078.
McCarthy LJ. Leukostasis thrombi. JAMA 1985;254:613.
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Steinherz PG, Miller LP, Ghavimi F, et al. Dural sinus thrombosis in children with acute lymphoblastic leukemia. JAMA 1981;246:28372839.
Plasma Cell Dyscrasias
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Kelly JJ Jr, Kyle RA, Miles JM, et al. Osteosclerotic myeloma and peripheral neuropathy. Neurology 1983;33:202210.
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West SG, Pittman DL, Coggin JT. Intracranial plasma cell granuloma. Cancer 1980;46:330335.
Disorders of Coagulation
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Grewal RP, Goldberg MA. Stroke in protein C deficiency. Am J Med 1990;89:538539.

Harris M, Exner T, Rickard K, et al. Multiple cerebral thrombosis in Fletcher factor (prekallikrein) deficiency: a case report. Am J Hematol 1985;19:387393.
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Amico L, Caplan LR, Thomas C. Cerebrovascular complications of mucinous cancers. Neurology 1989;39:522526.
Atkinson JL, Sundt TM, Dale AJD, et al. Radiation associated atheromatous disease of the cervical carotid artery: report of seven cases and review of the literature. Neurosurgery 1989;24:171.
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CHAPTER 148. HEPATIC DISEASE
MERRITTS NEUROLOGY
CHAPTER 148. HEPATIC DISEASE

NEIL H. RASKIN AND LEWIS P. ROWLAND
Clinical Features
Pathophysiology
Treatment
Neurologic Complications of Liver Transplantation
Suggested Readings
The terms hepatic coma and encephalopathy have led to imprecision of both clinical and pathophysiologic concepts. The often fatal comatose state associated with
acute hepatic necrosis is usually attended by striking elevation of serum ammonia content; coma is usually a single event of rapid onset and fulminant course that is
characterized by delirium, convulsions, and, occasionally, decerebrate rigidity. The mechanism of this encephalopathy is not clear.
Hepatic encephalopathy usually develops in patients with chronic liver disease when portal hypertension induces an extensive portal collateral circulation; portal
venous blood bypasses the detoxification site, which is the liver, and drains directly into the systemic circulation to produce the cerebral intoxication that is properly
termed portal-systemic encephalopathy. Several examples of portal-systemic encephalopathy have been reported in which the hepatic parenchyma was normal,
underlining the anatomic importance of bypassing the liver as the mechanism. The offending nitrogenous substance arising in the intestine has not been identified
with precision, but ammonia is the prime suspect.
The clinical syndrome resulting from shunting is an episodic encephalopathy comprising admixtures of ataxia, action tremor, dysarthria, sensorial clouding, and
asterixis. The episodes are usually reversible, although they may recur. Cerebral morphologic changes are few except for an increase in large Alzheimer type II
astrocytes. In a few patients with this disorder, a relentlessly progressing neurologic disorder occurs in addition to the fluctuating intoxication syndrome, including
dementia, ataxia, dysarthria, intention tremor, and a choreoathetotic movement. The brains of these patients show zones of pseudolaminar necrosis in cerebral and
cerebellar cortex, cavitation and neuronal loss in the basal ganglia and cerebellum, and glycogen-staining inclusions in enlarged astrocytes. This irreversible disorder
has been termed acquired chronic hepatocerebral degeneration, but it is probably the ultimate morphologic destruction that may result from the chronic metabolic
defect that attends portal-systemic shunting.
CLINICAL FEATURES
Thought processes are usually compromised insidiously, although an acute agitated delirium may occasionally usher in the syndrome. Mental dullness and
drowsiness are usually the first symptoms; patients yawn frequently and drift off to sleep easily yet remain arousable. Cognitive defects eventually appear. Asterixis
almost always accompanies these modest changes of consciousness. As encephalopathy progresses, bilateral paratonia appears, and the stretch reflexes become
brisk; bilateral Babinski signs are usually found when obtundation becomes profound. Convulsions are decidedly uncommon in this disorder, in contrast to uremic
encephalopathy. Spastic paraparesis may be seen. Decerebrate and decorticate postures and diffuse spasticity of the limbs frequently accompany deeper stages of
coma.
In the patient with overt hepatocellular failure with jaundice or ascites, the diagnosis of this disorder is not difficult. When parenchymal liver disease is mild or
nonexistent, however, an elevated serum ammonia level or an elevation of cerebrospinal fluid glutamine content has high diagnostic sensitivity. The cerebrospinal
fluid is otherwise bland. The ultimate diagnostic test is clinical responsiveness to ammonium loading; the risks of this procedure in patients with intact hepatocellular
function are minimal. Ten grams of ammonium chloride is given in daily divided doses for 3 days; the appearance or worsening of asterixis, dysarthria, or ataxia or a
further slowing of the electroencephalogram is diagnostic. Early in the course of encephalopathy, when the only evidence is seen on neuropsychologic tests,
computed tomography may show cortical atrophy, cerebral edema, or normal patterns. Magnetic resonance imaging usually shows increased signal in the globus
pallidus in T1-weighted studies. Manganese deposition may account for this. Sometimes there is calcification, and there may be abnormalities in the mesencephalon
and pons. Cerebral edema is more common in chronic encephalopathy than once believed.
PATHOPHYSIOLOGY
Several substances have been considered the putative neurotoxin in portal-systemic encephalopathy. These include methionine, other amino acids, short-chain fatty
acids, biogenic amines, indoles and skatoles, and ammonia. None of these has succeeded in explaining the condition better than ammonia.
Ammonia, a highly neurotoxic substance, is ordinarily converted to urea by the liver; when this detoxification mechanism is bypassed, levels of ammonia in the brain
and blood increase. Occasionally, blood ammonia levels are normal or only slightly elevated in the face of full-blown coma. This has been used as a powerful
argument against the implication of ammonia in this disorder; however, at physiologic pH, almost all serum ammonia in the NH 4+ NH 3 + H+ system is in the form of
NH4+, with only traces of NH 3 present. NH 3 crosses membranes with facility and is far more toxic than NH 4+; thus, it is possible that when methods become available to
measure circulating free ammonia levels in portal-systemic encephalopathy, they will be strikingly consistently elevated. Ammonia is detoxified in brain astrocytes by
conversion to the nontoxic glutamine.
Following up on the observation that levodopa benefited patients in hepatic coma, Fischer and Baldessarini (1971) proposed the false neurotransmitter hypothesis to
explain the mechanism of this effect and other features of the disorder. They suggested that amines such as octopamine (or their aromatic amino acid precursors
tyrosine and phenylalanine), which are derived from protein by gut bacterial action, might escape oxidation by the liver and flood the systemic and cerebral
circulations. Octopamine could then replace norepinephrine and dopamine in nerve endings and act as a false neurotransmitter; the accumulation of false
neurotransmitters might then account for the encephalopathy, and the amelioration could be achieved by restoring true neurotransmitters through an elevation of
tissue dopamine levels. L-Dopa administration, however, has a powerful peripheral effect, inducing the renal excretion of ammonia and urea; this probably accounts
for the beneficial effects of L-dopa in some encephalopathic patients. Further, octopamine concentration in rat brain has been elevated more than 20,000-fold, along
with depletion of both norepinephrine and dopamine, without any detectable alteration of consciousness. Although false neurotransmitters do accumulate in
portal-systemic encephalopathy, there is little reason to hold them responsible for the encephalopathy. It has also been suggested that increased sensitivity to
inhibitory neurotransmitters such as GABA and glycine may underlie the encephalopathy.
DIFFERENTIAL DIAGNOSIS
Among the numerous causes of encephalopathy, several affect abusers of alcohol, including acute ethanolic intoxication and delerium tremens, Wernicke
encephalopathy, Korsakoff syndrome, drug intoxication, other metabolic disorders (uremia, hyponatremia), and consequences of head injury, such as subdural
hematoma. Another consideration is Wilson disease.
TREATMENT
Administration of antibiotics (especially neomycin or metronidazole) decreases the population of intestinal organisms to decrease production of ammonia and other
cerebrotoxins. Lactulose is also beneficial for reasons that are not clear, but it lowers colonic pH, increases incorporation of ammonia into bacterial protein, and is a
cathartic. The effects of neomycin and lactulose, given together, seem better than the effects either gives alone.
Although recovery is expected in patients with mild acute encephalopathy, cerebral edema occurs in about 75% of patients in acute coma and may be the cause of
death. Intracranial pressure monitoring is often carried out in transplantation centers despite the risk of bleeding. If cerebral perfusion pressure is less than 40 mm Hg
and does not respond to mannitol therapy, transplantation is deemed futile. In some cases of fulminant hepatic failure, emergency hepatectomy has been performed,
followed by support with an extracorporeal bioartificial liver and then orthoptic liver transplantation.
NEUROLOGIC COMPLICATIONS OF LIVER TRANSPLANTATION
Neurologic problems arise in 8% to 47% of liver transplant recipients. The complications range from mild encephalopathy to akinetic mutism or coma. Psychiatric
syndromes range from mild anxiety or depression to hallucinatory psychosis. Other syndromes include seizures, myoclonus, tremor, cortical blindness, brachial
plexopathy, and peripheral neuropathy ( Table 148.1). Cerebral hemorrhage is sometimes responsible. Recovery from these disorders is often excellent and has no
effect on survival, which is the same for those with or without neurologic syndromes. The acute leukoencephalopathy caused by tacrolimus (FK506) is reversed
promptly on withdrawal of drug.
TABLE 148.1. NEUROLOGIC COMPLICATIONS OF LIVER TRANSPLANTATION
The necessary immunosuppression may lead to the opportunistic infections, and cyclosporine itself is held responsible for some cerebral disorders, possibly including
central pontine myelinosis and leukoencephalopathy. Instead of the intravenous administration of cyclosporine, use of an oral formulation has reduced the severity of
neurotoxicity. Both cyclosporine and OKT3 may cause seizures, and OKT3 may cause aseptic meningitis.
Epileptiform activity in the electroencephalogram is seen much more often in patients who die than in those who survive. In an autopsy study of 21 patients who had
seizures, Estol et al. (1989) found combinations of ischemic or hemorrhagic strokes in 18, central pontine myelinosis in 5, and central nervous system infections in 5.
Metabolic abnormalities were also responsible for the seizures in these patients. Graft-versus-host reactions may include polyneuropathy, myasthenia gravis, and
polymyositis. Infected donor tissue may transmit cytomegalovirus or Creutzfeldt-Jakob disease.
SUGGESTED READINGS
Hepatic Encephalopathy
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Victor M, Adams RD, Cole M. The acquired (non-Wilsonian) type of chronic hepatocerebral degeneration. Medicine (Baltimore) 1965;44:345396.
Zieve L, Doizai M, Derr RF. Reversal of ammonia coma in rats by L-dopa: a peripheral effect. Gut 1979;20:2832.
Liver Transplantation
Bird GLA, Meadows J, Goka J, et al. Cyclosporin-associated akinetic mutism and extrapyramidal syndrome after liver transplantation. J Neurol Neurosurg Psychiatry 1990;53:10681071.
Campellone JV, Lacomis D, Kramer DJ, Van Cott AC, Giuliani MJ. Acute myopathy after liver transplantation. Neurology 1998;50:4553.
De Groen PC, Aksamit AJ, Rakela J, et al. Central nervous system toxicity after liver transplantation: role of cyclosporin and cholesterol. N Engl J Med 1987;317:861866.
Estol CJ, Faris AA, Martinez AJ, et al. Central pontine myelinosis after liver transplantation. Neurology 1989;39:493498.
Estol CJ, Lopez O, Brenner RP, et al. Seizures after liver transplantation: a clinicopathologic study. Neurology 1989;39:12971301.
Fisher NC, Ruban E, Carey M et al. Late-onset fatal acure leukoencephalopathy in liver transplant recipient. Lancet 1997;349:18841885.
Garg BP, Walsh LE, Pescovitz MD, et al. Neurologic complications of pediatric liver transplantation. Pediatr Neurol 1993;9:4448.
Martin MA, Massanari RM, Ngheim DD, et al. Nosocomial aseptic meningitis associated with administration of OKT3. JAMA 1988;259:20022005.
Small SL, Fukui MB, Bramblett GT, et al. Immunosuppression-induced leukoencephalopathy from Tacrolimus (FK506). Ann Neurol 1996;40:575580.
Stein DP, Lederman RJ, Vogt DP, et al. Neurological complications following liver transplantation. Ann Neurol 1992;31:644649.
Torocsik HV, Curless RG, Post J, et al. FK506-induced leukoencephalopathy in children with organ transplants. Neurology 1999;52:14971500.
Truwit CL, Denaro CP, Lake JR, et al. MRI of reversible cyclosporin A-induced neurotoxicity. AJNR 1991;12:651659.
Wijdicks EFM, Dahlke LJ, Wiesner RH. Oral cyclosporine decreases severity of neurotoxicity in liver transplant recipients. Neurology 1999;52:17081710.
Wijdicks EFM, Wiesner RH, Krom RAF. Neurotoxicity in liver transplant recipients with cyclosporine immunosuppression. Neurology 1995;45:19621964.
Wszolek ZK, Aksamit AJ, Ellingson RJ, et al. Epileptiform EEG abnormalities in liver transplant recipients. Ann Neurol 1991;130:3741.
CHAPTER 149. CEREBRAL COMPLICATIONS OF CARDIAC SURGERY
MERRITTS NEUROLOGY
CHAPTER 149. CEREBRAL COMPLICATIONS OF CARDIAC SURGERY

ERIC J. HEYER AND LEWIS P. ROWLAND
Magnitude of the Problem

Disorders of Cognition
Other Complications of Open-Heart Surgery
Interventional Cardiac Procedures
Suggested Readings
MAGNITUDE OF THE PROBLEM
In one series of 1,487 cardiac operations performed between 1984 and 1989, the mortality rate was 8.54%. Additionally, 16 patients (1.1%) had major neurologic
syndromes of four types: unresponsive after surgery, awoke with signs of cerebral infarction, initially intact but had a stroke later, or dementia without focal signs.
Among those who were unresponsive in the postoperative period, half died or remained comatose. The problems were attributed to atheromatous embolism,
perioperative hypotension, or air embolism. In another series, up to 4% had cerebral symptoms if reactions included chronic anxiety and depression. Clinically
detectable encephalopathy results in 3% to 12% of operations, but permanent cognitive disability is less common.
DISORDERS OF COGNITION
In the early days of heart surgery, intellectual decline seemed inordinately common after operations performed with cardiopulmonary bypass support, even when the
procedure seemed to be uncomplicated. In prospective studies, cognitive problems were seen in up to 70% of survivors, depending on the criteria used;
neuropsychologic testing is most sensitive. Six months after surgery, Shaw et al. (1987) found that 3 of 259 (2%) patients seemed seriously disabled and were
dependent on family members.
The pathogenesis of this disorder is probably influenced by more than one of the following during cardiopulmonary bypass: type of oxygenator, type of
cardiopulmonary bypass circuit, body temperature, arterial blood gas management, and use of arterial line filters.
Before 1985, cardiopulmonary bypass was achieved with bubble oxygenators that produced particulate or gaseous bubbles, which could have occluded small
cerebral vessels. Capillary membrane oxygenators were substituted to avoid this complication, and the frequency of serious intellectual loss occurs less often. Also,
hypothermia is maintained as a protective measure, but there is uncertainty about the exact temperature (mild, 32 to 34C, versus moderate, 28 to 32C) to be
used, although normothermia (37C) is potentially harmful. Solid emboli are held responsible for the cerebral injury. Arterial line filters, however, reduce the number of
emboli from the cardiopulmonary bypass system. The fraction of cardiac output going to the brain also determines the fraction of the embolic load reaching the brain.
Maintaining cerebral blood flow by supporting autoregulation would provide sufficient but not excessive flow to support cerebral metabolism. To maintain
autoregulation during cardiopulmonary bypass, blood gas values must be kept near normal when measured at 37C even though the patient may actually be colder. In
contrast, correcting the blood gases for the lower temperature would lead to the addition of carbon dioxide to the cardiopulmonary bypass system to normalize the
blood gas values at the patient's hypothermic temperature; under those conditions, autoregulation would be lost. If heparin is bonded to the cardiopulmonary bypass
circuit there is considerably less activation of platelets, white cells, and endothelial cells, resulting in attenuation of coagulation and the inflammatory response.
Consequently, less anticoagulation may be required and blood loss decreases. The incidence of cerebral dysfunction may also decrease.
Despite these precautions, however, some patients note forgetfulness, mental slowing, or difficulty concentrating. Performance on neuropsychologic tests is worst in
the first week or so after surgery; months later, most patients have returned to preoperative levels.
Moody et al. (1990) found many focal dilatations or small aneurysms in 90% of patients who died after cardiac surgery on bypass. The dilated areas were empty and
were therefore assumed to have been sites of gas bubbles or fat emboli. In living patients, continuous transcranial or carotid Doppler measurements have detected
emboli in operations performed with either membrane or bubble oxygenators. With either membrane or bubble oxygenators, emboli also arise when the aortic cannula
is inserted and when the aorta is unclamped. Emboli also arise during bypass when the bubble oxygenator is used.
In coronary artery bypass graft (CABG) operations, carotid Doppler studies demonstrated a mean of 62 emboli for each operation. In open-chamber cardiac
operations, carotid and transcranial Doppler studies demonstrated even more cerebrally directed emboli. Times of danger included removal of the aortic side clamp,
aortic cannulation, onset of cardiopulmonary bypass, and resumption of ventricular contraction. Emboli and cerebral injuries are even more numerous with aortic
disease.
Other monitoring systems have not been successful. Quantitative electroencephalogram does not detect impending brain damage, partly because cerebral
hypothermia reduces the electroencephalogram amplitude. Infrared detection of cerebral oxygenation is beset by technical problems, including contamination of the
signal with extracranial blood.
OTHER COMPLICATIONS OF OPEN-HEART SURGERY
Patients with active infective endocarditis and those having a second cardiac operation are at high risk for stroke or other cerebral complications. Risk factors include
impaired left ventricular function, low cardiac output, sepsis, toxemia, and impaired hemostasis. Use of aprotinin for hemostasis may decrease morbidity.
Heparin-bonded cardiopulmonary bypass circuits may circumvent this issue. Controversy exists about the advantages of pulsatile or nonpulsatile perfusion during
bypass.
INTERVENTIONAL CARDIAC PROCEDURES
Cardiac Catheterization
Strokes or transient ischemic attacks after cardiac catheterization are rare, encountered in 0.1% to 1.0% of procedures. The posterior circulation is affected more than
the carotid territory. Cerebral blindness and visual field defects result. About half of those with occipital symptoms have a confusional state or memory problems that
are attributed to temporal lobe ischemia. Carotid syndromes of hemiparesis, with or without language disorders, occur in 30% to 40%. About half of the syndromes
abate within 48 hours. The episodes are attributed to emboli released by the guidewire or in flushing the catheter in the ascending aorta. Systemic hypotension may
be responsible for some.
Showers of cholesterol emboli after catheterization or cardiac surgery can cause peripheral occlusive vascular disease, with gangrene and peripheral neuropathy
(cholesterol emboli syndrome).
Coronary Angioplasty
Transient ischemic attacks occur in about 0.2% of these procedures, presumably embolic in origin.
Valvuloplasty
Percutaneous balloon valvuloplasty is used to treat stenosis of pulmonary, mitral, and aortic valves. In one series, embolic stroke occurred in 3 of 26 aortic valve
procedures and none of 6 mitral procedures.
Coronary Artery Bypass Graft
Stroke is the major complication of CABG, and although the rate has declined, it is still reported in 1% to 5% of operations, affecting 1,000 to 3,000 people annually in
the United States. Many of these patients are elderly. More than half of the episodes are transient or mild, but that leaves many with serious disability. The major
recognized factors are cardiac arrhythmia during surgery, carotid artery disease, and air embolism from the left ventricle.
Attention has focused on the carotid arteries, assuming that hypotension during surgery in the presence of arterial narrowing induces focal cerebral ischemia. Many
strokes, however, occur in people with normal carotids or after, not during, surgery. There seems to be no advantage to defer CABG for prophylactic endarterectomy.
In one series, stroke occurred in 1 of 90 patients with 50% to 90% asymptomatic carotid stenosis and 1 of 16 with 90% stenosis. Even symptomatic carotid stenosis
does not seem to increase the risk prohibitively, but conclusive data are not available.
A history of stroke increases the likelihood of a second stroke as a complication of CABG. Among 127 CABG patients with a history of stroke, 17 (13.4%) had a new
one with surgery; 3.2% were deemed serious. Many were thought to be embolic because of atrial fibrillation. Postoperative cardiac arrhythmia is a common problem
even in patients who have not had prior stroke.
Persistent postoperative coma is encountered in 1% of patients. In half the cases, the cause is not apparent. The others are attributed to global ischemia or hypoxia,
major hemisphere infarction with herniation, or multiple infarcts.
Cardiac Transplantation
In the early days of heart transplantation, neurologic complications were seen in 54% of the cases, and 20% were fatal. With time, both figures have been much
reduced. Because the patients have advanced atherosclerosis, stroke is still a major risk, occurring in up to 9%. Other problems include reversible encephalopathy
and seizures. Cerebral hemorrhage is rare, linked to anticoagulation or uncontrolled hypertension. Vascular headache is common.
Encephalopathy occurs in about 10% of cases and is attributed to renal or hepatic failure or sepsis. Later, because of the necessary immunosuppression,
opportunistic infection is the most common cause of neurologic disorder; with new antibiotics, the rate has dropped from 15% to 5%. Aspergillus, toxoplasma, and
other uncommon organisms are encountered. Cytomegalovirus and herpes zoster may cause problems. Aseptic meningitis may have no detectable cause. The
incidence of primary central nervous system lymphoma is increased. Osteoporosis and other complications of steroid therapy are common, and cyclosporine may
cause tremor, seizures, and confusional states.
SUGGESTED READINGS
Aldea GS, O'Gara P, Shapira OM, et al. Effect of anticoagulation protocol on outcome in patients undergoing CABG with heparin-bonded cardiopulmonary bypass circuits. Ann Thorac Surg
1998;65:425433.
Barbut D, Lo YW, Hartman GS, et al. Aortic atheroma is related to outcome but not numbers of emboli during coronary bypass. Ann Thorac Surg 1997;64:454459.
Bendixen BH, Younger DS, Hair LS, et al. Cholesterol emboli neuropathy. Neurology 1992;42:428430.
Fessatidis I, Prapas S, Havas A, et al. Prevention of perioperative neurological dysfunction: six year prospective study of cardiac surgery. J Cardiovasc Surg 1991;32:570574.
Furlan AJ, Sila CA, Chimowitz MI, et al. Neurologic complications related to cardiac surgery. Neurol Clin 1992;10:145166.
Grote CL, Shanahan PT, Salmon P, et al. Cognitive outcome after cardiac operations. J Thorac Cardiovasc Surg 1992;104:14051409.
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Kirkham FJ. Recognition and prevention of neurological complications in pediatric cardiac surgery. Pediatr Cardiol 1998;19:331345.
Kosmororsky G, Hanson MR, Tomsak RL. Neuro-ophthalmic complications of cardiac catheterization. Neurology 1988;38:483485.
Lane RJM, Roche SW, Leung AAW, et al. Cyclosporine neurotoxicity in cardiac transplant recipients. J Neurol Neurosurg Psychiatry 1988;51:14341437.
Montero C, Martinez AJ. Neuropathology of heart transplantation. Neurology 1986;36:11491156.
Moody DM, Bell MA, Challa VA, et al. Brain microemboli during cardiac surgery or aortography. Ann Neurol 1990;28:477486.
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1996;11:307317.
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CHAPTER 150. BONE DISEASE
MERRITTS NEUROLOGY
CHAPTER 150. BONE DISEASE

ROGER N. ROSENBERG
Osteitis Deformans (Paget Disease)

Fibrous Dysplasia
Achondroplasia
Ankylosing Spondylitis
Atlantoaxial Dislocation
Suggested Readings
OSTEITIS DEFORMANS (PAGET DISEASE)
This chronic disease of the adult skeleton is characterized by bowing and irregular flattening of the bones. Any or all skeletal bones may be affected, but the tibia,
skull, and pelvis are the most frequent sites. Except for the skeletal deformities and pain, the disease causes disability only when the skull or spine is involved.
Pathology
In affected bones, there is an imbalance between formation and resorption of bone. In most cases, there is a mixture of excessive bone formation and bone
destruction. The areas of bone destruction are filled with hyperplastic vascular connective tissue. New bone formation may occur in the destroyed areas in an irregular
disorganized manner. The metabolic disturbance is unknown.
Incidence
There is a postmortem incidence of 3% in patients over 40 years of age. Men and women are equally affected. The common age at onset is in the fourth to sixth
decades; it is rare before age 30.
Symptoms and Signs
Two types of neurologic symptoms appear: those due to the abnormalities in bone and those due to arteriosclerosis, a common accompaniment. The cerebral
manifestations that occur with arteriosclerosis are identical to those seen in patients with arteriosclerosis in the absence of Paget disease.
The neurologic defects of osteitis deformans are usually related to pressure on the central nervous system or the nerve roots by the overgrowth of bone. Convulsive
seizures, generalized or neuralgic head pain, cranial nerve palsies, and paraplegia occur in a few cases. Deafness caused by pressure on the auditory nerves is the
most common symptom; unilateral facial palsy is the next most common symptom. Loss of vision in one eye, visual field defects, or exophthalmos may occur when the
sphenoid bone is affected. Compression of the spinal cord is more common than compression of the cerebral substance, which is extremely rare except when there is
sarcomatous degeneration of the lesions. Platybasia may occur in advanced cases. Paget disease has been described in a patient with basilar impression and
Arnold-Chiari type 1 malformation.
Laboratory Data
The serum calcium content is normal, and the serum phosphorus is normal or only slightly increased. Serum alkaline phosphatase activity is increased; the level
varies with the extent and activity of the process. It may be only slightly elevated when the disease is localized to one or two bones.
Diagnosis
The diagnosis of Paget disease is made from the patient's appearance and the characteristic radiographic changes. Involvement of the skull in advanced cases is
manifested by a generalized enlargement of the calvarium, anteroflexion of the head, and depression of the chin on the chest. When the spine is involved, the
patient's stature is shortened; the spine is flexed forward and its mobility is greatly reduced.
Radiographically, the skull shows areas of increased bone density with loss of normal architecture, mingled with areas in which the density of the bone is decreased
(Fig. 150.1). The margins of the bones are fuzzy and indistinct. The general appearance is that of an enormous skull with the bones of the vault covered with cotton
wool. In advanced cases, there may be a flattening of the base of the skull on the cervical vertebrae ( platybasia) with signs of damage to the lower cranial nerves,
medulla, or cerebellum. Both computed tomography (CT) and magnetic resonance imaging (MRI) aid diagnosis ( Fig. 150.2).
FIG. 150.1. Osteitis deformans (Paget disease) of the skull. (Courtesy of Dr. Juan Taveras.)
FIG. 150.2. Paget disease. Basilar invagination. A: Using bone windows, axial computed tomography shows the foramen magnum projected within the posterior fossa.
Intradiploic calcific density with cotton wool appearance is typical of Paget disease. B: Higher section, using soft tissue windows, demonstrates obliteration of basal
cisterns and brainstem compression caused by basilar invagination. C: Axial T2-weighted magnetic resonance image shows prominent mottled signal in the diploic
space. D: Sagittal T1-weighted magnetic resonance image confirms impingement of brainstem by dens. (Courtesy of Drs. J.A. Bello and S.K. Hilal.)
Diagnosis may be difficult if the clinical symptoms are mainly neurologic. In these instances, radiographs of the pelvis and legs or a general survey of the entire
skeleton may establish the diagnosis. Rarely, it may be impossible to distinguish monophasic Paget disease of the skull from osteoblastic metastases. Search for a
primary neoplasm, particularly in the prostate or biopsy of one of the lesions in the skull may be necessary in those cases.
Course
The course is variable but usually extends over decades. The neurologic lesions seldom lead to serious disability other than deafness, convulsive seizures, or
compression of the spinal cord.
Treatment
There is no specific therapy. Calcitonin is given to inhibit the osteolytic process. Salmon calcitonin is given in subcutaneous injections of 50 to 100 units daily.
Improvement of osteolytic lesions and reversal of neurologic manifestations have been noted with long-term therapy. About 25% of the patients develop serum
antibodies to salmon calcitonin, sometimes in titers high enough to make the person resistant to the hormonal action of calcitonin; under these circumstances, human
calcitonin may be effective.
An alternate therapy is disodium editronate in a dosage of 5.0 mg/kg body weight daily for 6 months. The value of either medical therapy can be evaluated by
reduction of serum levels of alkaline phosphatase measured at 4-month intervals and annual radiographs of specific lesions.
Decompression of the spinal cord may be indicated for myelopathy secondary to stenosis created by the enlarged vertebrae. Similarly, platybasia may lead to
decompression of the posterior fossa.
FIBROUS DYSPLASIA
The skull and the bones in other parts of the body are occasionally involved by a process characterized by small areas of bone destruction or massive sclerotic
overgrowth. The clinical picture of fibrous dysplasia is related to the site and extent of the bone overgrowth. Sassin and Rosenberg (1968) described involvement of
bones of the skull in 50 cases as follows: frontal, 28; sphenoid, 24; frontal and sphenoid, 18; temporal, 8; facial, 15; parietal, 6; and occipital, 8. Diffuse involvement of
the entire skull produces leontiasis ossea, with exophthalmos, optic atrophy, and cranial nerve palsies ( Fig. 150.3).
FIG. 150.3. Fibrous dysplasia. Computed tomographies. A: Axial contrast-enhanced scan shows proptosis on right with abnormal soft tissue enhancement within orbit
and middle cranial fossa. B: Bone window depicts pronounced thickening of sphenoid bone. (Courtesy of Dr. T.L. Chi.)
In addition to the disfiguration of the skull in the polyostotic form, symptoms of the monostotic form of the disease include headache, convulsions, exophthalmos, optic
atrophy, and deafness. Symptoms may begin at any age, but onset usually occurs in early adult life. The family history is negative, and there is no racial or sexual
predominance.
A polyostotic form of the disease is characterized by cafe-au-lait spots, endocrine dysfunction with precocious puberty in girls, and involvement of the femur
(shepherd's crook deformity). Mutations in the Arg201 codon of the Ys G protein subunit have been described in patients with fibrous dysplasia. These Ys G as
mutations may be seen in monostotic or polyostotic patients and in the McCune-Albright syndrome that includes multiple endocrinopathies and cafe-au-lait lesions
with fibrous dysplasia.
ACHONDROPLASIA
Achondroplasia (chondrodystrophy) is the most frequent form of skeletal dysplasia causing dwarfism. It is characterized by short arms and legs, lumbar lordosis, and
enlargement of the head caused by mutations in the fibroblast growth factor receptor 3 gene (FGFR3). The disease is rare and is estimated to occur in 15 of 1 million
births in the United States. It is usually inherited as an autosomal dominant trait.
Symptoms of involvement of the nervous system sometimes develop as a result of hydrocephalus, compression of the medulla and cervical cord at the level of the
foramen magnum, compression of the spinal cord by ruptured intervertebral disk, and bone compression of the lower thoracic or lumbar cord. Convulsive seizures,
ataxia, and paraplegia are the most common symptoms. Mental development is usually normal.
The diagnosis is made from the characteristic body configuration of short arms and legs, normal-size trunk, enlargement of the head, and changes in the radiographs
of the skeleton (Fig. 150.4). Many affected infants die in the perinatal period, although a normal lifespan is possible for patients with less severe involvement of the
bones.
FIG. 150.4. Skull radiograph showing typical malformation of achondroplasia. The clivus is shortened.
Shunting procedures may be needed for hydrocephalus caused by involvement of the bones at the base of the skull. Laminectomy is indicated for signs of cord
compression.
The mutations described in 1994 in the FGFR3 gene at 4p are usually new mutations and result in autosomal dominant inheritance. The gene product is expressed in
cartilage. A frequent FGFR3 mutation is a G1138A codon mutation with GGG to AGG or CGG substitutions, resulting in an exchange of glycine at position 380 in the
FGFR3 protein to arginine. As a result of this mutation, a gain of negative function results, producing an inactive fibroblast growth factor receptor and resultant
dwarfism.
ANKYLOSING SPONDYLITIS
This inflammatory disorder affects ligamentous insertions into bones; at first, it usually affects the sacroiliac joints and lumbar spine. In some patients, the entire spine
is involved, with ossification of the ligaments and fusion of the vertebra. The spine becomes rigid and susceptible to a variety of disorders that may affect the spinal
cord, including fractures and dislocations, atlantooccipital dislocation, and spinal stenosis. The condition is common, affecting an estimated 1.4% of the general
population. It only rarely, however, causes symptoms and signs of myelopathy.
A cauda equina syndrome may appear in patients with long-standing spondylitis. Signs and symptoms are symmetric, with weakness, wasting, and sensory loss in
lumbosacral myotomes. Bladder and bowel are commonly affected, and pain may be severe. The mechanism is not clear.
Although concomitant arachnoiditis has been suspected as the cause, the syndrome appears late, when there is little evidence that the underlying spondylitis is
active. Moreover, there is little inflammation at postmortem examination, which is likely to show chronic fibrosis. There is erosion of posterior bone elements, and, in
earlier days, myelography showed enlargement of the caudal sac and prominent diverticulae of the arachnoid. CT shows similar pathology, but MRI is more
illuminating, showing nerve root thickening and sometimes enhancement of dura and nerve roots; that pattern suggests inflammation of the arachnoid structures,
supporting the earlier theory. Surgery is generally ineffective and has sometimes been deleterious, although there have been rare reports of some relief. Steroid
therapy has been similarly without benefit.
ATLANTOAXIAL DISLOCATION
Subluxation of C-1 on C-2 occurs in many conditions that render the odontoid process of C-2 ineffective as a stabilizing post. This occurs most often as a complication
of cervical trauma but also occurs as a congenital malformation (alone or in combination with other anomalies of the cervical spine or cranium) and is seen with
disproportionate frequency with Down syndrome, ankylosing spondylitis, and rheumatoid arthritis. It can be demonstrated with plain spine films, CT, or MRI. There is
risk of cervical myelopathy or medullary compression, and sudden death has been reported. For symptomatic cases, surgical stabilization is indicated. For
asymptomatic cases, there has to be consideration of the risks of surgery against uncertain risks of no surgery. A general recommendation is to consider stabilization
or decompression if imaging shows deformation of the neuroaxis, symptomatic or not. A closed reduction and brace immobilization was successfully applied to a
patient with traumatic bilateral rotatory dislocation of the atlantoaxial joints.
SUGGESTED READINGS
Osteitis Deformans (Paget Disease)
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Fibrous Dysplasia
Albright F. Polyostotic fibrous dysplasia: a defense of the entity. J Clin Endocrinol Metab 1947;7:307324.
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Achondroplasia
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Ankylosing Spondylitis
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Atlantoaxial Dislocation
Crockard HA, Heiman AE, Stevens JM. Progressive myelopathy secondary to odontoid fractures: clinical, radiological, and surgical features. J Neurosurg 1993;78:579586.
Elliott S, Morton RE, Whitelaw RA. Atlantoaxial instability and abnormalities of the odontoid in Down's syndrome. Arch Dis Child 1988;63:14841489.
Floyd AS, Learmouth ID, Mody G, et al. Atlantoaxial instability and neurologic indicators in rheumatoid arthritis. Clin Orthop 1989;241:177182.
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CHAPTER 151. RENAL DISEASE
MERRITTS NEUROLOGY
CHAPTER 151. RENAL DISEASE

NEIL H. RASKIN
Uremic Encephalopathy
Uremic Neuropathy
Dialysis Dysequilibrium Syndrome
Dialysis Dementia
Pseudotumor Cerebri
Neurologic Complications of Renal Transplantation
Suggested Readings
Uremia is a term used to describe a constellation of signs and symptoms in patients with severe azotemia caused by acute or chronic renal failure; symptomatic renal
failure is an acceptable definition. The clinical features of the neurologic consequences of renal failure do not correlate well with any single biochemical abnormality
but seem to be related to the rate of development of renal failure. This chapter summarizes the features of uremic encephalopathy and neuropathy and the distinctive
neurologic complications of dialysis and renal transplantation.
UREMIC ENCEPHALOPATHY
In uremia, as in other metabolic encephalopathies, there is a continuum of signs of neurologic dysfunction, including dysarthria, instability of gait, asterixis, action
tremor, multifocal myoclonus, and sensorial clouding. One or more of these signs may predominate, but fluctuation of clinical signs from day to day is characteristic.
The earliest most reliable indication of uremic encephalopathy is sensorial clouding. Patients appear fatigued, preoccupied, and apathetic; they have difficulty
concentrating. Obtundation becomes more apparent as perceptual errors, defective memory, and mild confusion become evident. Illusions and perceptions
sometimes progress to frank visual hallucinations.
Asterixis is almost always present once sensorial clouding appears: It is most effectively elicited by having the patient hold the arms outstretched in fixed
hyperextension at the elbow and wrist, with the fingers spread apart. After a latency of up to 30 seconds, flexion-extension (flapping) of the fingers at the
metacarpophalangeal joints and at the wrist appears arrhythmically and at irregular intervals.
Multifocal myoclonus refers to visible twitching of muscles that is sudden, arrhythmic, and asymmetric, involving muscles first in one locus and then in another and
affecting chiefly the face and proximal limbs. It is a strong indication of a severe metabolic disturbance and usually does not appear until stupor or coma has
supervened. In uremia, asterixis and myoclonus may be so intense that muscles appear to fasciculate, giving rise to the term uremic twitching. This form of myoclonus
probably signifies cortical irritability; it is, at times, difficult to distinguish from a multifocal seizure. Tetany is commonly associated with myoclonus and other signs of
encephalopathy. It may be overt, with spontaneous carpopedal spasms, or latent, manifested by a Trousseau sign. The spasms originate in abnormal peripheral nerve
discharges. In uremic patients, tetany does not usually respond to injections of calcium and occurs despite metabolic acidosis (which inhibits hypocalcemic tetany).
The restless-legs syndrome occurs in 40% of uremic patients and probably is an encephalopathic symptom. This syndrome comprises creeping, crawling, prickling,
and pruritic sensations deep within the legs. These sensations are almost always worse in the evening; they are relieved by movement of the limbs. Clonazepam,
levodopa, dopamine agonists, opioids, and some anticonvulsants are effective in terminating this syndrome.
Alterations in limb tone appear as encephalopathy progresses and brainstem function is compromised. Muscle tone is usually heightened and is sometimes
asymmetric. Eventually, decorticate posturing may appear in preference to decerebrate attitudes. Focal motor signs are present in about 20% of patients; these signs
often clear after hemodialysis.
Convulsions are usually a late manifestation of uremic encephalopathy. In the older literature, convulsions were thought to occur far more often than is now reported;
this may have been the result of failing to distinguish hypertensive encephalopathy from uremia, which may coexist. Hypertensive retinopathy and papilledema are
major signs that distinguish the two conditions; further, focal signs such as aphasia or cortical blindness are much more common in hypertensive brain disease than in
uremia. The treatment of recurring uremic convulsions is not straightforward because the pharmacokinetics of phenytoin are altered in uremic patients. In uremia,
plasma protein binding of phenytoin is decreased so much that the unbound fraction of the drug is two to three times more than that found in normal plasma. In uremic
patients, however, the volume of distribution of the drug is larger, and there is an increased rate of conversion of phenytoin to hydroxylated derivatives, resulting in
lower total serum concentrations of the drug for any given dose. This combination of factors allows the physician to administer the usual dosage of phenytoin (300 to
400 mg daily) to a uremic patient and attain therapeutic unbound levels of the drug despite lower total serum levels (i.e., 5 to 10 mg/L rather than 10 to 20 mg/L).
Meningeal signs occur in about 35% of uremic patients; half of those affected have cerebrospinal fluid (CSF) pleocytosis. CSF protein elevations greater than 60
mg/dL occur in 60% of uremic patients; in 20%, the CSF protein exceeds 100 mg/dL. CSF protein content may return to normal in the immediate posthemodialysis
period. The increase in CSF protein is caused by an alteration in the permeability properties of the brain's capillary endothelial cells adjacent to the CSF, which have
tight intercellular junctions.
There are no specific pathologic alterations of brain in uremic encephalopathy; cerebral use of oxygen is depressed, as it is in other metabolic encephalopathies,
because of a primary interference with synaptic transmission. Depressed cerebral metabolic rate and clinical state usually change together but are probably
independent reflections of generally impaired neuronal functions. The profundity of uremic encephalopathy correlates only in a general way, and sometimes poorly,
with biochemical abnormalities in the blood. Cerebral acidosis has been suggested as a possible mechanism, but CSF pH is usually normal. Brain calcium is
increased by 50% and seems to be due to excess circulating parathyroid hormone, which is nondialyzable. It is not clear whether calcium changes are related to the
cerebral dysfunction.
The rapid clearing of uremic encephalopathy after dialysis suggests that small to moderately sized water-soluble molecules are responsible for the encephalopathy.
Excessive accumulation of toxic organic acids overwhelms the normal mechanisms for excluding such compounds from the brain and may be important. These
organic acids may block transport systems of the choroid plexus and of glia that normally remove metabolites of some neurotransmitters in brain. Furthermore, there is
a nonspecific increase in cerebral membrane permeability in uremia, and this may permit greater entry into brain of uremic toxins such as the organic acids, which
further derange cerebral function.
Erythropoietin is often given to patients on long-term dialysis to correct the anemia. In the process, cognitive functions may improve.
UREMIC NEUROPATHY
Peripheral neuropathy is the most common neurologic consequence of chronic renal failure. It is a distal, symmetric, mixed sensorimotor neuropathy affecting the legs
more than the arms. It is clinically indistinguishable from the neuropathies of chronic alcohol abuse or diabetes mellitus. The rate of progression, severity, prominence
of motor or sensory signs, and prevalence of dysesthesia vary. It is several times more common in men than in women. The symptom of burning feet was considered
a common feature of uremic neuropathy but probably resulted from removal of water-soluble thiamine by hemodialysis, and with near universal B vitamin replacement,
this syndrome is now rare.
The rate of progression of uremic neuropathy varies widely; in general, it evolves over several months but may be fulminant. Among most patients who enter chronic
hemodialysis programs, the neuropathy stabilizes or improves slowly. Patients with mild neuropathy often recover completely, but those who begin dialysis with
severe neuropathy rarely recover even after several years. Lack of improvement or progression of symptoms while on hemodialysis may suggest an alternative
diagnosis, such as chronic inflammatory demyelinating polyneuropathy. Patients in chronic renal failure are also more susceptible to drugs that are normally excreted
in the urine; for this reason, there may be prolonged paralysis after administration of neuromuscular blocking agents as an aid to endotracheal intubation, and the
prolonged paralysis may be mistaken for peripheral neuropathy. An accelerated neuropathy of renal failure may progress so rapidly that it is mistaken for the
Guillain-Barr syndrome.
Successful renal transplantation has a clear, predictable, and beneficial effect on uremic neuropathy. Motor nerve conduction velocities increase within days of
transplantation. There is progressive improvement for 6 to 12 months, often with complete recovery, even in patients with severe neuropathy before transplantation.
Pathologically, this neuropathy is usually a primary axonal degeneration with secondary segmental demyelination, probably as a result of a metabolic failure of the
perikaryon; there is also a predominantly demyelinative type. Because uremic neuropathy improves with hemodialysis, it seems evident that the neuropathy results
from the accumulation of dialyzable metabolite. These substances may be in the middle molecule (300 to 2,000 Da) range; compounds of this size cross dialysis
membranes more slowly than smaller molecules such as creatinine and urea, which are the usual measures of chemical control of uremia. Supporting this contention
are observations that control of neuropathy in some patients depends on increased hours of dialysis each week (beyond that necessary for chemical control of
uremia) and that peritoneal dialysis seems to be associated with a lower incidence of neuropathy. The peritoneal membrane seems to permit passage of some
molecules more readily and selectively than the cellophane membrane used in hemodialysis. The transplanted kidney deals effectively with substances of different
molecular size; the resulting elimination of middle molecules could explain the invariable improvement of the neuropathy after transplantation.
There is a parathormone-induced increase in calcium in peripheral nerves in experimental uremia, which causes slowed nerve conduction velocity; these changes can
be prevented by prior parathyroidectomy. In human uremic patients, circulating parathormone levels correlate inversely with nerve conduction velocities. It seems
unlikely, however, that parathormone is involved in uremic neuropathy because the hormone is nondialyzable, and hyperparathyroidism itself is not usually associated
with neuropathy.
DIALYSIS DYSEQUILIBRIUM SYNDROME
Headache, nausea, and muscle cramps attend hemodialysis in more than 50% of patients; in somewhat over 5%, obtundation, convulsions, or delirium may occur.
The cerebral sequelae are usually seen with rapid dialysis at the outset of a dialysis program; symptoms usually appear toward the third or fourth hour of a dialysis
run but occasionally appear 8 to 24 hours later. The syndrome is usually self-limited, subsiding in hours, but delirium may persist for several days. Some patients
become exophthalmic because of increased intraocular pressure at the height of the syndrome. Other clinical correlates include increased intracranial pressure,
papilledema, and generalized electroencephalographic slowing.
Shift of water into brain is probably the proximate cause of dysequilibrium. Rapid reduction of blood solute content cannot be paralleled by brain solutes because of
the bloodbrain barrier. An osmotic gradient is produced between blood and brain causing movement of water into brain, which results in encephalopathy, cerebral
edema, and increased intracranial pressure. The osmotically active substances retained in brain have not yet been identified.
DIALYSIS DEMENTIA
A distinctive, progressive, usually fatal encephalopathy may occur in patients who are chronically dialyzed for periods that exceed 3 years. The first symptom is
usually a stammering, hesitancy of speech, and, at times, speech arrest. The speech disorder is intensified during and immediately after dialysis and at first may be
seen only during these periods. A thought disturbance is usually evident, and there is a consistent electroencephalogram abnormality, with bursts of high-voltage
slowing in the frontal leads. As the disorder progresses, speech becomes more dysarthric and aphasic; dementia and myoclonic jerks usually become apparent ( Table
151.1) at this time. The other elements of the encephalopathy include delusional thinking, convulsions, asterixis, and occasionally focal neurologic abnormalities.
Early in the course, diazepam is effective in lessening myoclonus and seizures and in improving speech; it becomes less effective later. The CSF is unremarkable.
Increased dialysis time and renal transplantation do not seem to alter the course of the disease. No distinctive abnormalities have been found in brain at autopsy.
TABLE 151.1. CLINICAL FEATURES OF DIALYSIS DEMENTIA
The geographic variation in the incidence of dialysis dementia suggests a neurotoxin. Aluminum content is consistently elevated in the cerebral gray matter of patients
who die from this condition. Municipal water supplies heavily contaminated with aluminum have been linked to the syndrome in epidemiologic studies. Another
possible source is absorption of aluminum from orally administered phosphate-binding agents that are given to uremic patients. Plasma protein binding of aluminum
retards the removal of aluminum during dialysis even when an aluminum-free dialysate is used. Nevertheless, there have been several reports of remission of dialysis
dementia when deferoxamine was used to remove aluminum from the diet, from the dialysate, or from the patient. Cerebral aluminum intoxication, still an unconfirmed
hypothesis, seems to be the most likely possibility at this time. Brain GABA levels are reduced in numerous regions, but the meaning of this finding is not clear.
PSEUDOTUMOR CEREBRI
Patients in chronic renal failure may be at increased risk for benign intracranial hypertension. There has been no formal epidemiologic study, but several cases have
been reported. In the experience of Guy et al. (1990), patients in renal failure seem more likely to lose vision, but fenestration of the optic nerve sheath was effective
in improving vision in several of them.
NEUROLOGIC COMPLICATIONS OF RENAL TRANSPLANTATION
A curious vulnerability to certain brain tumors and unusual infections of the nervous system occur in patients who have undergone transplantation; however, cerebral
infarction is the most common neurologic complication.
The risk that a lymphoma will develop after a transplant is about 35 times greater than normal; this increased risk depends almost entirely on the increased incidence
of primary central nervous system lymphoma. Brain tumors appear between 5 and 46 months after transplantation. The resulting clinical syndromes include increased
intracranial pressure, rapidly evolving focal neurologic signs, or combinations of these. Convulsions are rare. A remarkable characteristic of primary lymphomas is the
response to radiotherapy; survivals of 3 to 5 years are not unusual.
Systemic fungal infections are found at autopsy in about 45% of patients who have been treated with renal transplantation and immunosuppression; brain abscess
formation occurs in about 35% of these patients. In almost all cases, the primary source of infection is in the lung. Chest radiographs and the presence of fever aid in
differentiating fungal brain abscess from brain tumor in recipients of transplants. Aspergillus has a unique predilection for dissemination to brain and accounts for
most fungal brain abscesses; candida, nocardia, and histoplasma are found in the others. The clinical syndrome resulting from these infections is usually delirium
accompanied by seizures. Headache, stiff neck, and focal signs also occur but not commonly. The CSF is often remarkably bland, and brain biopsy may be the only
reliable way to establish a diagnosis. The distinction of fungal brain abscess from possibly radiosensitive brain tumor makes it important to consider this procedure.
SUGGESTED READINGS
Adams HP, Dawson G, Coffman TJ, Corry RI. Stroke in renal transplant recipients. Arch Neurol 1986;43:113115.
Altmann P, Al-Salihi F, Butter K, et al. Serum aluminum levels and erythrocyte dihydropteridine reductase activity in patients on hemodialysis. N Engl J Med 1987;317:8084.
Babb AL, Ahmad S, Bergstrom J, Scribner BH. The middle molecule hypothesis in perspective. Am J Kidney Dis 1981;1:4650.
Bolton CF, Young GB. Neurological complications of renal disease. London: Butterworths, 1990.
Bucher SF, Seelos KC, Oertel WH, et al. Cerebral generators involved in the pathogenesis of the restless legs syndrome. Ann Neurol 1997;41:639645.
Guy J, Johnston PK, Corbett JJ, et al. Treatment of visual loss in pseudotumor cerebri with uremia. Neurology 1990;40:2832.
Hamed LM, Winward KE, Glaser JS, et al. Optic neuropathy in uremia. Am J Ophthalmol 1989;108:3035.
Healton EB, Brust JCM, Feinfeld DA, Thomson GE. Hypertensive encephalopathy and the neurologic manifestations of malignant hypertension. Neurology 1982;32:127132.
Lederman RJ, Henry CF. Progressive dialysis encephalopathy. Ann Neurol 1978;4:199204.
Mattana J, Effiong C, Gooneratne R, Singhal PC. Outcome of stroke in patients undergoing hemodialysis. Arch Intern Med 1998;158:537541.
McCarthy JT, Milliner DS, Johnson WJ. Clinical experience with desferrioxamine in dialysis patients with aluminum toxicity. Q J Med 1990;74:257276.
Nissenson AR, Nimer SD, Wolcott DL. Recombinant human erythropoietin and renal anemia: molecular biology, clinical efficacy, and nervous system effects. Ann Intern Med 1991;114:402416.
Pastan S, Bailey J. Dialysis therapy. N Engl J Med 1998;338:14281437.
Patchell RA. Neurological complications of organ transplantation. Ann Neurol 1994;36:688703.
Raskin NH, Fishman RA. Neurologic disorders in renal failure. N Engl J Med 1976;294:143148, 204210.
Ropper AH. Accelerated neuropathy of renal failure. Arch Neurol 1993;50:536539.
Russo LS, Beale G, Sandroni S, et al. Aluminum intoxication in undialyzed adults with chronic renal failure. J Neurol Neurosurg Psychiatry 1992;55:697700.
Said G, Boudier L, Selva J, et al. Patterns of uremic polyneuropathy. Neurology 1983;33:567574.
Sidhom OA, Odeh YK, Krumlovsky FA, et al. Low-dose prazosin in patients with muscle cramps during hemodialysis. Clin Pharm Ther 1994;56:445451.
Wills MR, Savory J. Aluminum and chronic renal failure; sources, absorption, transport, and toxicity. Crit Rev Clin Lab Sci 1989;27:59107.
CHAPTER 152. RESPIRATORY CARE: DIAGNOSIS AND MANAGEMENT
MERRITTS NEUROLOGY
CHAPTER 152. RESPIRATORY CARE: DIAGNOSIS AND MANAGEMENT

STEPHAN A. MAYER AND MATTHEW E.FINK
Respiratory Physiology
Neurologic Diseases with Primary Respiratory Dysfunction
Management of Respiratory Failure in Neurologic Diseases
Suggested Readings
Many different problems are encountered in a neurologic intensive care unit (ICU); all patients share a common need for meticulous nursing care and
cardiorespiratory monitoring to prevent a life-threatening complication. Diagnosis is rarely a problem; the major concern in the ICU is treatment of neurologic disease
and the medical complications that determine survival and recovery. Neurologic patients who require ICU treatment frequently have a depressed level of
consciousness, impaired airway protection due to depressed cough and gag reflexes, immobilization and paralysis, or oropharyngeal and respiratory muscle
weakness, all of which predispose to pulmonary complications and respiratory failure. In fact, respiratory monitoring and support is the most common reason for
admission of neurologic patients to the ICU.
RESPIRATORY PHYSIOLOGY
Respiratory failure occurs when gas exchange is impaired. The diagnosis of respiratory failure depends on arterial blood gas analysis. PaO 2 less than 60 mm Hg or
PaCO 2 greater than 50 mm Hg unequivocally defines respiratory failure. There are warning signs, however, of deteriorating ventilatory function before respiratory
failure is overt. Patients with neurologic disease often do not complain of dyspnea. The premonitory signs of mild respiratory failure include restlessness, insomnia,
confusion, tachycardia, tachypnea, diaphoresis, asterixis, and headache. When muscle weakness is the problem, use of accessory muscles, dysynchronous
breathing, and paradoxical respirations (inward movement of the abdomen with inspiration) may be observed. Advanced respiratory failure leads to cyanosis,
hypotension, and coma. It is impossible to predict PaO 2 and PaCO2 from clinical signs; measurement of arterial blood gases is essential. Normal PaO 2 is a function of
age. A healthy 20 year old has a PaO 2 of 90 to 95 mm Hg. With each decade, PaO 2 decreases by 3 mm Hg. Normal PaCO2 is 37 to 43 mm Hg and is not affected by
age.
Hypoxemia is caused by five conditions: a low inspired oxygen concentration, alveolar hypoventilation, ventilation-perfusion mismatch, intracardiac right-to-left
shunting, and impaired diffusion. Accurate interpretation of PaO 2 requires calculation of the alveolar-arterial (A-a) oxygen tension difference, or A-a gradient.
Alveolar oxygen tension (PaO 2) can be calculated from the equation PaO 2 5 (FiO2 2 713) 2 (PaCO 2/0.8), where FiO2 is the inspired fraction of oxygen (0.21 in room
air) and Paco 2 is the arterial carbon dioxide tension.
An A-a gradient exceeding 20 mm Hg usually results from ventilation-perfusion mismatching, which in turn comes in two forms. Dead space ventilation occurs when
ventilated lung segments do not come in contact with pulmonary capillary blood flow; this occurs when the alveolar-capillary interface is destroyed (e.g., emphysema)
or when blood flow is reduced (e.g., pulmonary embolism). Intrapulmonary shunting occurs when perfused lung segments do not come in contact with ventilated
alveoli; this occurs when small airways are occluded (e.g., asthma, chronic bronchitis), when alveoli are filled with fluid (e.g., pulmonary edema, pneumonia), or when
alveoli collapse (atelectasis). In most conditions, these two processes occur in combination. Hypoxemia with an A-a gradient less than 20 mm Hg strongly suggests an
extrapulmonary cause of hypoxemia (hypoventilation or a low inspired oxygen concentration).
Hypercapnia is caused by three conditions: increased CO 2 production or inhalation, alveolar hypoventilation, and ventilation-perfusion mismatching with dead space
ventilation. Hypoventilation is identified by high PaCO 2 with a normal A-a gradient. Acute hypercapnia leads to acidosis and cerebral vasodilation, which in turn can
cause depressed level of consciousness (CO 2 narcosis), aggravation of elevated intracranial pressure, and blunted respiratory drive leading to further
hypoventilation.
Pulmonary function testing is the simplest and most reliable way to evaluate respiratory function in patients with neuromuscular respiratory failure ( Table 152.1).
Arterial blood gases are also important to monitor, but abnormalities (hypoxia and hypercarbia) usually develop late in the cycle of respiratory decompensation and
thus are not sensitive for detecting early ventilatory failure. Vital capacity, the volume of exhaled air after maximal inspiration, normally ranges from 40 to 70 mL/kg.
Reduction of vital capacity to 30 mL/kg is associated with a weak cough, accumulation of oropharyngeal secretions, atelectasis, and hypoxemia. A vital capacity of 15
mL/kg (1 L in a 70-kg person) is generally considered the level at which intubation is required ( Table 152.2). Negative inspiratory pressure, normally more than 80 cm
H 2O, measures the strength of the diaphragm and other muscles of inspiration and generally reflects the ability to maintain normal lung expansion and avoid
atelectasis. Positive expiratory force, normally more than 140 cm H 2O, measures the strength of the muscles of expiration and correlates with strength of cough and
the ability to clear secretions from the airway.
TABLE 152.1. PULMONARY FUNCTION TESTS IN NEUROMUSCULAR RESPIRATORY FAILURE
TABLE 152.2. CRITERIA FOR INTUBATION AND MECHANICAL VENTILATION
The pathophysiology of neuromuscular respiratory failure resembles a vicious cycle. Mild hypoxemia usually precedes hypercapnia because atelectasis (and mild
intrapulmonary shunting) is an early development. As weakness progresses, inability to maintain normal lung expansion results in reduced lung compliance and an
increase in the work of breathing, which is often further aggravated by a weak cough and inability to clear secretions from the airway. As vital capacity approaches 15
mL/kg, rapid shallow breathing and hypercapnia develop. At this stage, the situation can rapidly and unexpectedly deteriorate once muscle fatigue develops and the
patient can no longer compensate with increased respiratory effort.
NEUROLOGIC DISEASES WITH PRIMARY RESPIRATORY DYSFUNCTION
Brainstem Disease
Reticular formation neurons, sensitive to hypoxemia and hypercarbia, are located in the brainstem and may be affected by ischemia, hemorrhage, inflammation, or
neoplasms. The medullary center is responsible for initiation and maintenance of spontaneous respirations, whereas the pontine pneumotaxic center helps to
coordinate cyclic respirations. Forebrain damage, often from metabolic causes, can lead to Cheyne-Stokes respirations (regular, cyclic crescendo-decrescendo
respiratory pattern with intervening apnea), as respiratory drive becomes dependent on changes in PCO 2. Hypothalamic or midbrain damage, particularly in the
setting of brainstem herniation, may cause central neurogenic hyperventilation (low PCO 2 with normal A-a gradient). Lower pontine tegmental damage may lead to
apneustic (inspiratory breath holding) or cluster breathing (irregular bursts of rapid breathing alternating with apneic periods). Medullary damage may cause ataxic
breathing (irregular pattern with hypoxemia and hypercarbia), gasping, or apnea.
Documentation of total apnea in the face of a hypercarbic stimulus is an essential component in the diagnosis of brain death. Formal apnea testing requires
preoxygenating the patient with 100% oxygen and normalizing the PCO 2 to 40 mm Hg, turning off the ventilator, and allowing the PCO 2 to rise above 55 mm Hg (the
PCO2 will rise 3 to 6 mm Hg/min). Arterial blood gases are checked at both the beginning and end of the test to confirm the eventual extent of hypercarbia. The
physician must stand at the bedside during the apnea test to observe the chest wall and diaphragm to confirm the absence of respiratory muscle movement.
In addition to abnormalities in respiratory rate and pattern and synchronization of diaphragm and intercostal muscles, brainstem damage often alters consciousness
and causes paralysis of pharyngeal and laryngeal musculature, predisposing to aspiration pneumonitis. Patients with severe brainstem dysfunction should have
nasotracheal or orotracheal intubation, electively, to prevent respiratory complications.
Brainstem respiratory centers may be depressed (lose responsiveness to CO 2 or O2) by narcotics or barbiturates, metabolic abnormalities such as hypothyroidism,
and by starvation or metabolic alkalosis. Idiopathic primary alveolar hypoventilation and central sleep apnea syndrome are due to brainstem malfunction. These
disorders are easily distinguished from structural brainstem pathology by the lack of associated neurologic signs.
Spinal Cord Disease
The respiratory system is affected depending on the segmental level and severity of the spinal injury. In spinal cord trauma, the most common cause of death is acute
respiratory failure due to apnea, aspiration pneumonia, or pulmonary embolism. The long-term care of a quadraplegic patient heavily depends on the degree of
respiratory impairment.
A lesion at C-3 abolishes both diaphragmatic and intercostal muscle activity, leaving only accessory muscle function. The result is severe hypercapnic respiratory
failure. Acute spinal cord lesions at the C-5 to C-6 level produce an immediate fall in vital capacity to 30% of normal. Several months after injury, however, the vital
capacity will increase to 50% to 60% of normal. High thoracic lesions will compromise intercostal and abdominal muscles, causing a limitation of inspiratory capacity
and active expiration. Midthoracic lesions have little impact on respiratory muscle function because only the abdominal muscles are affected.
Most spinal cord diseases cause respiratory impairment by interrupting the suprasegmental impulses that drive the diaphragm and intercostal muscles. There are two
notable exceptions, however, strychnine poisoning and tetanus. Both of these toxins block the inhibitory interneurons within the spinal cord, causing simultaneous
increases in the activity of muscles that are normally antagonists. Apnea and respiratory failure can result from intense muscle spasms of the upper airway muscles,
diaphragm, and intercostal muscles. In rare cases, severe generalized dystonia can lead to a similar picture.
Motor Neuron Diseases
Amyotrophic lateral sclerosis is the main form of motor neuron disease that causes respiratory failure (see Chapter 117). Respiratory failure usually develops late in
course of amyotrophic lateral sclerosis, as the respiratory muscles and strength of cough progressively weaken. If symptoms begin with limb weakness, the disorder
may progress to respiratory failure in 2 to 5 years. If oropharyngeal symptoms appear first, respiratory complications may be caused by recurrent aspiration
pneumonitis. Frequent pulmonary function testing can identify patients at risk for respiratory complications. The earliest changes are decreases in maximum
inspiratory and expiratory muscle pressures, followed by reduced vital capacity. When vital capacity falls below 30 mL/kg, the ability to cough and maintain lung
expansion is impaired, increasing the risk of aspiration pneumonia. Blood gases remain normal until the patient is near respiratory arrest.
Peripheral Neuropathies
The Guillain-Barr syndrome, or acute inflammatory demyelinating polyneuropathy, is the prototype neuropathy with respiratory complications (see Chapter 105). Of
patients with this syndrome, 20% require tracheal intubation and mechanical ventilation. There is a 5% mortality rate with the best possible treatment. Most deaths are
due to pulmonary embolism, severe pneumonia, or other medical complications. Some degree of respiratory insufficiency must be expected in all patients with severe
disease; therefore, during the 2- to 4-week period of progression, there should be frequent measurements of inspiratory and expiratory pressures and vital capacity.
Intubation is usually required when the vital capacity falls below 15 mL/kg. Plasmapheresis or intravenous immunoglobulin therapy should be initiated as soon as
possible in all Guillain-Barr patients with respiratory muscle weakness.
Critical illness neuropathy is an acquired axonal neuropathy that usually presents as failure to wean from mechanical ventilation. Sepsis and multisystem organ failure
are risk factors. Neurologic examination reveals flaccid, areflexic quadraparesis, or quadraplegia. Recovery occurs gradually over months, if the patient's underlying
medical problems are stabilized.
Disorders of Neuromuscular Transmission
Myasthenia gravis, botulism, and neuromuscular blocking drugs may affect respiratory muscles. Myasthenia gravis almost always affects cranial muscles, causing
ptosis, weakness in the ocular and oropharyngeal muscles, and symmetric facial weakness (see Chapter 120). As in Guillain-Barr syndrome and other
neuromuscular diseases, blood gas abnormalities are a late manifestation of respiratory failure. Frequent measurement of inspiratory and expiratory pressures and
vital capacity is essential; tracheal intubation is carried out if the vital capacity is less than 15 mL/kg. Myasthenia gravis is a treacherous disease because fluctuations
may be sudden and unpredictable. Patients with severe dysarthria and dysphagia are at greatest risk.
Myasthenic crisis is defined an exacerbation of weakness that requires mechanical ventilation. It occurs in 15% to 20% of patients overall, and one-third of these will
experience two or more episodes of crisis. As with Guillain-Barr syndrome, mortality is approximately 5%. Infection (usually pneumonia or viral upper respiratory
infection) is the most common precipitant (40%), followed by no obvious cause (30%) and aspiration (10%). As a general rule, 25% of patients in crisis can be
extubated after 1 week, 50% after 2 weeks, and 75% after 1 month. Plasmapheresis leads to short-term improvement of weakness in 75% of patients and should be
performed in all patients unless otherwise contraindicated, although its efficacy for reducing the duration of crisis has not been tested in a randomized controlled trial.
Muscle Disease
Muscular dystrophies, myotonic disorders, inflammatory myopathies, periodic paralyses, metabolic myopathies (especially acid maltase deficiency), endocrine
disorders, infectious myopathies, mitochondrial myopathies, toxic myopathies, myoglobinuria, critical illness myopathy, and electrolyte disorders may cause
widespread skeletal muscle weakness. Respiratory failure may appear in acute fulminant attacks or after a period of progression. Rarely, respiratory failure may be
the first manifestation of a generalized myopathy.
MANAGEMENT OF RESPIRATORY FAILURE IN NEUROLOGIC DISEASES
Examination
The initial management of the patient with impending neuromuscular respiratory failure is directed toward assessing the adequacy of ventilation and possible need for
immediate intubation. The patient's overall comfort level and the rapidity with which the dyspnea has developed are both important. Rapid shallow breathing, with
inability to generate adequate tidal volumes, is a danger sign of significant respiratory muscle fatigue. Diaphragmatic strength can be estimated by palpating for
normal outward movement of the abdomen with inspiration; with severe weakness, inspiration is associated with spontaneous inward movement of the diaphragm
(paradoxical respirations). Ventilatory reserve can be assessed by checking the patient's ability to count from 1 to 25 in a single breath. The strength of the patient's
cough should be observed. A wet gurgled voice and pooled oropharyngeal secretions are the best clinical signs of significant dysphagia. When severe, weakness of
the glottic and oropharyngeal muscles can lead to stridor, which is indicative of potentially life-threatening upper airway obstruction. Dysphagia is best screened for by
asking the patient to sip 3 ounces of water; coughing is diagnostic of aspiration, and if present, oral feedings should be held until swallowing can be formally
assessed.
Mechanical Ventilation
Mechanical ventilation may be positive pressure or negative pressure. Until the mid-1950s, all mechanical ventilation was negative pressure. The most common
device was the Drinker tank respirator (iron lung), which created a cyclical subatmospheric pressure around the patient's chest, causing chest expansion. Today,
there are several types of negative-pressure devices, cuirass ventilators, that can be used on a long-term basis to assist the patient's own respiratory efforts without
tracheal intubation. Patients with motor neuron disease and chronic myopathies are sometimes able to live at home with these devices.
Small suitcase-sized portable and battery-powered volume-cycled ventilators are also available for ambulatory use. Ventilator-dependent patients may go home and
remain mobile.
Mechanical ventilation is the primary treatment for respiratory failure. The trachea may be intubated orally or nasally; a soft air-filled cuff is then inflated in the trachea
to prevent leakage of air around the tube. Indications for endotracheal intubation include physiologic parameters ( Table 152.2) and the rate of respiratory
deterioration and the patient's overall comfort level. In some cases, positive-pressure ventilation can be delivered for short periods (e.g., overnight) with the use of a
tight-fitting face mask.
Positive pressure ventilation may be pressure cycled or volume cycled; the latter mode is usually preferred because it delivers a precise tidal volume over a wide
range of pressures. Synchronous intermittent mandatory ventilation is the initial mode of ventilation in most patients. With this mode, a predetermined number of
volume-cycled positive pressure breaths are delivered per minute. The patient can initiate a spontaneous breath at any time and receive either a volume-assisted
breath or an unsupported breath, depending on the phase of the ventilator cycle. Initially, the tidal volume is set at 10 mL/kg with a respiratory rate of 8 to 12
breaths/min, and 3 to 5 cm H2O of positive end-expiratory pressure is maintained to prevent atelectasis. The fraction of inspired air is gradually adjusted downward
from 100% until the Pao2 is 70 to 90 mm Hg.
Weaning from the ventilator can be considered when pulmonary function tests show improvement and there are no significant medical complications ( Table 152.3).
Weaning can be accomplished in three ways: a gradual reduction of the rate of intermittent mandatory ventilation, enabling the patient to take over the spontaneous
respirations; pressure support weaning with continuous positive airway pressure; and complete removal of the patient from the respirator, allowing free breathing for
short periods with oxygen supplementation alone (weaning with a T-tube). Breathing through a ventilator circuit can sometimes increase the work of breathing
because of the internal resistance of the machine. Thus, some patients with respiratory muscle weakness wean more easily on a T-tube. Pressure support is a preset
level of airway pressure delivered with each inspiratory effort, which reduces the overall work of breathing; the level (usually 5 to 15 cm H 2O) should be adjusted to
attain spontaneous tidal volumes of 300 to 500 mL and a comfortable breathing pattern. Whatever the mode of weaning, an increasing respiratory rate with
decreasing tidal volumes indicates tiring, at which point the weaning trial should be stopped and the patient returned to synchronous intermittent mandatory ventilation
for rest overnight. The ability of the patient to tolerate a T-tube or continuous positive airway pressure with minimal pressure support (5 cm H 2O) for extended periods
of time, while maintaining a ratio of respiratory rate (breaths/min) to tidal volume (L) below 100, is probably the single best predictor of successful extubation.
TABLE 152.3. CRITERIA FOR WEANING FROM MECHANICAL VENTILATION
Most clinicians perform a tracheostomy if mechanical ventilation is required for more that 2 weeks. Tracheostomy has several advantages over long-term
endotracheal intubation, including increased comfort, reduced risk of permanent tracheolaryngeal injury, increased ease of weaning from the ventilator (reduced dead
space and less resistance to flow from the endotracheal tube), and improved ability to manage and suction secretions. The latter two considerations are of particular
importance when weaning patients with neuromuscular respiratory failure from mechanical ventilation. If some patients with severe persistent oropharyngeal muscle
weakness, a tracheostomy is necessary to manage secretions and prevent aspiration, even though respiratory muscle function is adequate.
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CHAPTER 153. PARANEOPLASTIC SYNDROMES
MERRITTS NEUROLOGY
CHAPTER 153. PARANEOPLASTIC SYNDROMES

LEWIS P. ROWLAND
Definition
Epidemiology
Pathogenesis
Clinical Syndromes
Laboratory Data
Treatment
Suggested Readings
DEFINITION
A paraneoplastic syndrome is one that occurs more frequently than expected by chance in association with neoplasm, most often a malignant tumor. It is called
paraneoplastic because the neurologic disorder is not the result of tumor invasion or metastasis, chemotherapy, radiotherapy, malnutrition, or coincidental infection.
EPIDEMIOLOGY
If only clinically symptomatic syndromes are considered (and not, say, subclinical peripheral neuropathy determined by nerve conduction studies), all syndromes are
rare. For instance, all syndromes together occur in less than 1% of all patients with small cell lung cancer. Conversely, among patients diagnosed with a recognized
paraneoplastic syndrome, 10% to 60% prove to have a tumor ( Table 153.1). The possible presence of a tumor cannot be totally eliminated without postmortem
examination.
TABLE 153.1. FREQUENCY OF ASSOCIATED TUMOR WITH CLINICAL SYNDROMES THAT ARE OFTEN PARANEOPLASTIC
PATHOGENESIS
The dominant theory holds that most paraneoplastic disorders are autoimmune in origin. This is based primarily on the frequent presence of characteristic antibodies
against neuronal antigens. Presumably, the host mounts an antibody attack against antigens in the tumor and, by a process of molecular mimicry, the immune
response is directed against central or peripheral neural antigens. However, the antibodies have limited specificity and sensitivity. Also, there is no evidence of
complement-mediated autoimmunity. Attention has therefore been directed to the possibility of T-cellmediated neurotoxicity. Because the syndromes are so rare,
genetic susceptibility is thought to play a role.
In contrast to the central nervous system syndromes, antibodies are thought to be pathogenic in the peripheral neuromuscular disorders of the Lambert-Eaton
syndrome with neoplasm and myasthenia gravis with thymoma and the antimyelin-associated glycoprotein (MAG) peripheral neuropathies with lymphoproliferative
disease. These syndromes are discussed in Chapter 103, Chapter 120, and Chapter 121.
Other recognized paraneoplastic mechanisms include hormones secreted by a tumor, such as corticotropin, resulting in Cushing syndrome, or parathyroid
hormone-related protein, causing hypercalcemic encephalopathy. Carcinoid tumors may compete with tryptophan to cause a pellagra-like encephalopathy.
Immunodeficiency may lead to opportunistic infection, especially by the JC virus in progressive multifocal leukoencephalopathy.
CLINICAL SYNDROMES
Paraneoplastic Cerebellar Degeneration
Symptoms and signs are dominated by cerebellar pathways: ataxia of gait and limbs, dysarthria, nystagmus, and oscillopsia. Other manifestations are encountered in
half the cases, with hearing loss, bulbar syndromes, corticospinal tract signs, dementia, and peripheral neuropathy. Computed tomography (CT) and magnetic
resonance imaging (MRI) show no specific lesions. Cerebrospinal fluid (CSF) abnormalities may include modest pleocytosis and high protein content, sometimes with
high IgG and oligoclonal bands. Associated antibodies may be anti-Yo (with cancer of the ovary), anti-Hu (with small cell lung cancer), Hodgkin antibody with Hodgkin
disease, or anti-Ri with cancer of the breast. The differential diagnosis includes viral encephalitis, multiple sclerosis, Creutzfeldt-Jakob disease, alcoholic cerebellar
degeneration, and hereditary spinocerebellar atrophy. Treatment is not satisfactory.
Subacute Sensory Neuropathy/Encephalitis
Among patients with idiopathic sensory neuropathy, at least one-third prove to have an associated malignant tumor. Neurologic symptoms usually precede those of
the tumor, which is likely to be small. Painful paresthesias are the dominant symptoms and progress for days or weeks on all four limbs, the trunk, and sometimes the
face. Unlike cisplatinum neuropathy, which spares pain and temperature, paraneoplastic neuropathy affects all forms of sensation, resulting in a severe sensory
ataxia. Tendon reflexes are lost and CSF pleocytosis is characteristic. Nerve conduction studies show loss of sensory evoked potentials, with normal motor functions.
Inflammation is seen in the dorsal root ganglia.
Limbic Encephalitis
Personality and mood changes progress rapidly, and within weeks the syndrome is dominated by delirium and dementia with severe memory loss. The disorder may
occur alone or with other signs of encephalitis or sensory neuropathy. Computed tomography and magnetic resonance imaging are usually normal at first, but
enhancing lesions may be seen in the temporal lobes. CSF pleocytosis is characteristic. Pathologic signs of inflammation are limited at first to the limbic and insular
cortex, but other gray matter may be affected. The changes include loss of neurons, perivascular infiltration by leukocytes, and microglial proliferation.
Brainstem Encephalitis
Symptoms of brainstem encephalitis are usually part of a more widespread encephalitis but may be the first manifestations. The manifestations are those of the
cranial nerves or basal ganglia. Common findings are oculomotor disorders, including nystagmus and supranuclear vertical gaze palsy as well as hearing loss,
dysarthria, dysphagia, and abnormal respiration. Movement disorders may be prominent.
Opsoclonus-Myoclonus
This syndrome is seen most often in children with neuroblastoma, which has a favorable prognosis. The term implies constant motion of the eyesarrhytmic, irregular
in direction, or tempo. There may be evidence of encephalomyelitis or cerebellar disorder. The disorder of eye movements is attributed to dysfunction of the
paramedian pontine reticular formation. In adults, opsoclonus may be part of a complex syndrome with cerebellar signs and encephalomyelitis, tumors of several
types, and anti-Ri antibodies.
Myelitis
Spinal cord symptoms evolve in days or weeks with clinical evidence of a level lesion. The CSF may show pleocytosis with high protein content and normal sugar;
oligoclonal bands may be present. Myelitis may occur with or without encephalomyelitis. Acute necrotizing myelopathy may be an extreme form of the inflammatory
demyelinating myelitis.
Motor Neuron Diseases
It is uncertain whether there is a higher frequency of malignant tumor in patients with forms of motor neuron disease. Most epidemiologic studies have shown no such
relation. Yet there have been reports of patients whose neurologic symptoms disappeared with treatment of the tumor. Also, there have been more than 60 reports of
patients with motor neuron diseases and lymphoproliferative disease. Lower motor neuron signs (amyotrophy), including fasciculation, are seen in combination with
paraneoplastic encephalomyelitis. A pure upper motor neuron syndrome (primary lateral sclerosis) has been reported in women with breast cancer, but several
patients also developed lower motor neuron signs (i.e., they developed amyotrophic lateral sclerosis).
Sensorimotor Peripheral Neuropathy
Sensorimotor peripheral neuropathy with or without slow conduction velocity is common after age 50. Among the diverse causes are anti-MAG paraproteinemic
peripheral neuropathy and paraneoplastic neuropathy. Prominent features may include glove-stocking paresthesias and sensory loss, distal limb weakness, or both.
Autonomic failure may be prominent, with disorders of gastrointestinal motility, especially diarrhea or pseudo-obstruction. Cranial symptoms are lacking and the
syndrome is slow in evolution; it may responde to immunotherapy, as described in Chapter 105. Vasculitis is found in some acute neuropathies.
Neuromuscular Disorders
The association of myasthenia gravis with thymoma is described in Chapter 120. There is no known paraneoplastic form of myasthenia with cancers; the
neuromuscular disorder may occur by chance with a malignant tumor. Lambert-Eaton myasthenic syndrome (LEMS) is discussed in Chapter 121. Paraneoplastic
neuromyotonia, as described in Chapter 129 is associated most often with thymoma but also with small cell lung cancer or other tumors. The Moersch-Woltman or
stiff-man syndrome is sometimes associated with cancer of lung or other organs.
Myopathies
About 20% patients with dermatomyositis starting after age 40 have an associated tumor, which can be almost any type. Whether there is a higher than expected
association of tumor with polymyositis has not been proven. These syndromes are described in Chapter 130 and Chapter 131.
LABORATORY DATA
Few laboratory tests point to the diagnosis of a paraneoplastic syndrome. MRI may or may not show abnormalities of white or gray matter; scans are often normal.
Similarly, the CSF may or may not show high CSF protein or pleocytosis, but the CSF sugar content should be normal or some other diagnosis suspected. The
diagnosis of peripheral neuropathy depends in part on the demonstration of conduction abnormalities, and LEMS is virtually defined by the demonstration of an
incrementing response to repetitive nerve stimulation, as described in Chapter 121. Demonstration of a characteristic antibody can accelerate diagnosis of the several
paraneoplastic syndromes.
Antibodies
Anti-amphiphysin is found in nerve terminals. Antibodies are found in diverse syndromes, including LEMS, sensory neuropathy, and limbic encephalitis. The
associated tumors are also diverse, including lung, breast, and ovary.
Anti-Hu was the first antibody to be identified with small cell lung carcinoma. Like several of the others that followed, it was named after the patient who provided the
first serum. It is also called type 1 antineuronal nuclear autoantibody or ANNA-1. In a few patients, the tumor was one other than small cell lung cancer. Specificity
for sensory neuropathy is given as 99%, with a sensitivity of 82%. The clinical syndrome is most often encephalomyelitis or sensory neuropathy, and the neurologic
symptoms usually precede discovery of the tumor.
Anti-Ri is an RNA-binding protein. The clinical syndrome is opsoclonus-myoclonus and the tumors are mostly breast and small cell lung cancer.
In anti-ta, the antigen, Ma2, is a member of a family of proteins in brain, testis, and some tumors. The antibody has been found primarily in patients with testicular
cancer associated with limbic and brainstem encephalitis.
Anti-Tr reacts with Purkinje cells of the cerebellum. The clinical syndrome is primarily a subacute cerebellar disorder, often with dysarthria and nystagmus. The
neoplasm is almost always Hodgkin disease.
Anti-VGCC reacts with voltage-gated calcium channel of muscle and is found in patients with LEMS. The antibody is not found in other types of paraneoplastic
syndromes.
Anti-Yo is a DNA-binding protein, and the antibody is found most often with a cerebellar disorder or brainstem encephalitis in association with a tumor of the ovary,
uterus, or breast.
TREATMENT
The peripheral disorders of sensorimotor polyneuropathy and LEMS often respond to intravenous immunoglobulin therapy or immunosuppressive drug therapy. The
central nervous system syndromes are refractory to treatment. Corticosteroid therapy is often effective for the opsoclonus-myoclonus syndrome in children, and
treatment of the associated tumor may ameliorate the syndrome in adults.
SUGGESTED READINGS
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1999;52:414416.
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Posner JB, Dalmau JO. Paraneoplastic syndromes affecting the central nervous system. Annu Rev Med 1997;48:157166.
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Wakabyashi K, Horikawa Y, Oyake M, Suzuki S, Morita T, Takahashi H. Sporadic motor neuron disease with severe sensory neuronopathy. Acta Neuropathol 1998;95:426430.
CHAPTER 154. NUTRITIONAL DISORDERS: VITAMIN B12 DEFICIENCY, MALABSORPTION, AND MALNUTRITION
MERRITTS NEUROLOGY
CHAPTER 154. NUTRITIONAL DISORDERS: VITAMIN B12 DEFICIENCY, MALABSORPTION, AND

MALNUTRITION
LEWIS P. ROWLAND AND BRADFORD P. WORRALL
Vitamin B12 (Cobalamin) Deficiency

Malnutrition
Malabsorption
Suggested Readings
Many neurologic syndromes are ascribed to lack of vitamins or other essential nutrients. The most common are pernicious anemia (lack of vitamin B 12), malnutrition,
and malabsorption syndromes.
VITAMIN B12 (COBALAMIN) DEFICIENCY
History
Although not the first to describe the disorder, in 1849 Thomas Addison made pernicious anemia well known. By the turn of the century, the diagnostic triad was
recognized: anemia, neurologic symptoms, and atrophy of the epithelial covering of the tongue. In 1900, Russell, Batten, and Collier introduced the term combined
degeneration of the spinal cord. The disease was lethal until 1926, when Minot and Murphy used replacement therapy without knowing what had to be replaced; they
found that supplementing the diet with liver was therapeutic. Castle administered liver extract parenterally, and in 1948 vitamin B 12 completely reversed the symptoms.
Additionally, the automation of blood counts and measurement of blood vitamin B 12 levels has made early diagnosis the rule. As a result, the neurologic disorder is
now rarely seen in major medical centers of industrialized countries. Although the condition was once thought to affect Nordic people primarily, it is seen in all racial
groups. The prevalence of undiagnosed pernicious anemia after age 60 is about 2%.
Physiology
Cobalamin is synthesized only in specific microorganisms, and animal products are the sole dietary sources for humans. Gastric acid is needed for peptic digestion to
release the vitamin from proteins. Achlorhydria of the elderly may suffice to cause B 12 deficiency, but an intrinsic factor is usually missing as well.
The freed B 12 is bound by R proteins (R for rapid movement on electrophoresis) and then by gastric intrinsic factor, a glycoprotein produced by gastric parietal cells,
which is needed for absorption of B 12 and which is absent in people with pernicious anemia. The combined intrinsic factorcobalamin complex is transported across
the terminal ileum and binds to transcobalamin, with a half-life of 6 to 9 minutes. The complex enters cells by endocytosis, and the vitamin enters red blood cells in an
energy-dependent process.
Cobalamin is converted to adenosyl or methyl coenzymes, which are necessary for normal neural metabolism. If they are missing, abnormal fatty acids may
accumulate in myelin or methylating reactions may be defective. A congenital form of methylcobalamin deficiency leads to developmental delay, microcephaly, and
seizures, with delayed myelination. However, the details of B 12 dependency in the mature nervous system are not well known, and it is not clear why the spinal cord
and peripheral nerves are so vulnerable when B 12 levels are low.
Pathogenesis
About 80% of adult-onset pernicious anemia is attributed to lack of gastric intrinsic factor secondary to atrophic gastritis ( Table 154.1). The disorder is thought to be
autoimmune in origin because antibodies to gastric parietal cells are found in 90% and antibodies to intrinsic factor occur in up to 76%. The parietal cell antigen is
gastric H +/K+-ATPase. Supporting the view that autoimmunity is important is the frequent association of pernicious anemia with some other autoimmune disease, such
as myasthenia gravis, Hashimoto thyroiditis, vitiligo, or polyglandular deficiency. A murine model of the immune disorder has been developed. In those with normal
intrinsic factor, the vitamin is not absorbed because of jejunal diverticulosis, tropical sprue, or loss of the stomach or ileum by surgical resection. Rarely, the vitamin
cannot be liberated from dietary animal proteins because peptic digestion is inadequate.
TABLE 154.1. CAUSES OF COBALAMIN DEFICIENCY IN 143 PATIENTS
Pathology
In the spinal cord, white matter is affected more than gray. Symmetric loss of myelin sheaths occurs more often than axonal loss; changes are most prominent in the
posterior and lateral columns ( combined system disease) (Fig. 154.1 and Fig. 154.2). The thoracic cord is affected first and then the process extends in either
direction. Patchy demyelination may be seen in the frontal white matter ( Fig. 154.3).
FIG. 154.1. Subacute combined degeneration. Sections of spinal cord at various levels showing segmental loss of myelin, which is most intense in the dorsal and
lateral columns.
FIG. 154.2. Subacute combined degeneration. Destruction of myelin predominating in the posterior and lateral columns. Swelling of affected myelin sheaths causes
spongy appearance.
FIG. 154.3. Subacute combined degeneration. Partial loss of myelin of white matter of frontal lobe. (Courtesy of Dr. L. Roizin.)
Clinical Features
Today most patients are probably asymptomatic. If the deficiency persists, symptoms may be those of anemia, neurologic disorder, or other problems such as vitiligo,
sore tongue, or prematurely gray hair. Anorexia and weight loss may be prominent.
About 40% of all patients with B 12 deficiency are said to have some neurologic symptoms or signs, and these are often the first or most prominent manifestations of
the disease. Only 20% of patients are younger than age 50; most are over 60. Usually, there are features of both myelopathy and peripheral neuropathy. The most
common symptom, attributed to the neuropathy, is acroparesthesia, burning and painful sensations that affect the hands and feet. There may be sensory ataxia.
Memory loss, visual loss (due to optic neuropathy), orthostatic hypotension, anosmia, impaired taste (dysgeusia), sphincter symptoms, and impotence are other
symptoms.
On examination, there is glove-stocking sensory loss, and almost all patients show loss of vibratory sensation and of position sense. The Romberg sign is often
present; the patient can stand with feet together if the eyes are open but sways and falls on closing the eyes because of the loss of position sense. There may or may
not be weakness of limb muscles; the neuropathy is predominantly sensory, but there are upper motor neuron signs: increased tone, impaired alternating movements,
and hyperactive tendon jerks, with Babinski and Hoffmann signs. Cognitive loss may be evident as florid dementia or may be manifest only on neuropsychologic tests.
Optic atrophy is found in fewer than 1% of patients.
As a measure of the efficacy of modern diagnosis and treatment, even symptomatic patients are usually independent in activities of daily living. Fewer than 10% are
restricted to chair or bed.
Diagnosis
The diagnosis rests on demonstration of blood levels of vitamin B 12 less than 200 pg/mL, but low normal values (200 to 350 pg/mL) may be found in people who
respond to therapy. Some people with low values are not deficient, and additional tests may be useful. Both methylmalonic acid and homocysteine accumulate when
there is impairment of cobalamin-dependent reactions; both metabolites are abnormally increased in serum in more than 99% of patients with true cobalamin
deficiency. The Schilling test, a measure of the absorption of orally ingested labeled B 12, is technically difficult and unreliable because it may be normal in vegetarians
and nitrous oxide abusers. Sometimes a therapeutic trial is the only way to determine whether a neurologic syndrome is in fact due to B 12 deficiency. Magnetic
resonance imaging (MRI) may show increased T2-weighted signal and contrast enhancement of the posterior and lateral columns of the spinal cord, with return to
normal on treatment.
Nerve conduction tests show a sensorimotor neuropathy that may be either axonal or demyelinating. Visual, brainstem, and somatosensory evoked responses may be
normal or abnormal. Computed tomography and MRI may show no abnormality, or there may be cerebral atrophy in patients with dementia.
In patients with neurologic signs, only about 20% show severe anemia. Both the hematocrit and mean corpuscular volume may be normal, although they are the
traditional abnormalities. Bone marrow biopsy, however, reliably shows megaloblastic abnormalities. B 12 deficiency must be considered in any sensorimotor
neuropathy, myelopathy, autonomic neuropathy, dementia, or optic neuropathy. Several of these disorders arise in acquired immunodeficiency syndrome, but a
possible role of B 12 is doubted.
Dentists may be at special risk because recreational abuse of nitrous oxide can interfere with cobalamin metabolism and cause neuropathy or combined system
disease.
Treatment
B12 is given intramuscularly in a dosage of 1,000 g daily for the first week, followed by weekly injections for the first month, and then monthly injections for life. Oral
therapy is less reliable largely because absorption without intrinsic factor is inefficient. After parenteral injection of B 12, hematologic improvement may be evident
within 48 hours, and there is a subjective sense of general improvement. Paresthesias are often the first neurologic symptoms to improve and do so within 2 weeks;
corticospinal abnormalities are slower to respond. If there is no response in 3 months, the condition is probably not due to B 12 deficiency. About half of the patients
are left with some abnormality on examination; the residual disability depends on the duration of symptoms.
MALNUTRITION
Malnutrition is still a serious problem throughout the world. In poor countries, dietary deficiency is common. In industrial countries, nutritional syndromes are more
likely to be seen in alcoholics, in patients with chronic bowel disease, or in patients after some medical treatment that interferes with essential elements of diet ( Table
154.2). Even if the acute disorders are corrected, there may be long-term effects. Maternal malnutrition may affect the fetus and cause mental retardation; on another
level, chronic neurologic syndromes persisted in World War II prisoners long after they had resumed a normal diet.
TABLE 154.2. NEUROLOGIC SYNDROMES ATTRIBUTED TO NUTRITIONAL DEFICIENCY
Dietary therapy may be important in the management of some inborn errors of metabolism to prevent accumulation of some toxic substances (as in phenylketonuria)
or to amplify the activity of a mutant enzyme (as in vitamin B 6-responsive homocystinuria).
Diseases of malnutrition may arise if essential nutrients are not provided because the diet is inadequate. The result may be the same if nutrients are lost by vomiting
or diarrhea, if there is malabsorption, if use of a nutrient is impaired, or if the target organ is unresponsive to a mediating hormone.
Examples of different syndromes are found in other chapters of this book; a simple listing or table is a gross oversimplification for two reasons. First, vitamin
deficiency is likely to be multiple and often accompanied by protein-calorie malnutrition and thus the resulting syndromes are complex. Second, it is possible to
tabulate the major target system of a particular syndrome, although most involve more than one system; spinal cord syndromes and encephalopathy, for example, may
be more prominent than the peripheral neuropathy of pellagra. In contrast, peripheral neuropathy, optic neuropathy, or dementia may be seen in patients with
combined system disease of the spinal cord secondary to vitamin B 12 deficiency. Some neurologic syndromes are attributable to dietary excess ( Table 154.3). For this
reason, too, the syndromes are likely to be complex.
TABLE 154.3. NEUROLOGIC SYNDROMES ATTRIBUTED TO DIETARY EXCESS
A common cause of malnutrition in industrialized countries is anorexia nervosa. In addition to the conventional neuropathy and other syndromes of multiple vitamin
deficiency, there may be a myopathy. Here, however, the nutritional disorder is often complicated by the ingestion of emetine to induce vomiting.
An epidemic of peripheral and optic neuropathy in Cuba was seen in 1991 after the collapse of support from the Soviet Union and enforcement of an embargo by the
United States. As many as 50,000 may have been affected. This combination of disorders had earlier been seen in prisoners of war and other malnourished
populations. In Cuba, some patients had mutations of mitochondrial DNA of the kind seen in Leber hereditary optic neuropathy, which may have made them more
susceptible to dietary deprivation. Many patients improved with supplemental vitamin therapy. Viral infection may have been responsible for some cases.
Only a brief overview is offered of disorders of the stomach and intestine. The major neurologic syndrome of stomach disease results from lack of intrinsic factor and
B12 deficiency. There are no major neurologic consequences of peptic ulcer (other than those that might result from shock after massive hemorrhage), but treatment of
the ulcer may lead to a neurologic disorder. Antacids may cause a partial malabsorption syndrome. Cimetidine therapy avoids these problems but may cause an acute
confusional state. Antacids that contain aluminum or phosphate-binders can cause encephalopathy, especially in the presence of renal disease. Surgical therapy may
cure the ulcer but may also create a neurologic disorder as a result of malabsorption.
MALABSORPTION
Malabsorption syndromes may arise for any of several reasons ( Table 154.4). In patients with these disorders, neurologic abnormalities seem to be disproportionately
frequent. Alone or in combination, there may be evidence of myopathy, sensorimotor peripheral neuropathy, degeneration of corticospinal tracts and posterior
columns, and cerebellar abnormality. Optic neuritis, atypical pigmentary degeneration of the retina, and dementia are less common signs of malabsorption syndromes.
TABLE 154.4. SOME CAUSES OF NEUROLOGIC DISORDER DUE TO MALABSORPTION

There have been three waves of explanation. First, the syndromes were attributed to vitamin B 12 deficiency, which probably accounted for some but not all cases;
many patients had normal serum B12 levels and did not respond to vitamin B 12 therapy. Second, there was considerable interest in the relation of the neurologic
abnormality to osteomalacia, which often appeared in the same patients. Osteomalacia also accompanied similar neurologic syndromes in patients who had dietary
problems other than malabsorption (e.g., lack of sunlight or dietary vitamin D, resistance to vitamin D, renal disease, ingestion of anticonvulsant drugs). Osteomalacia
or vitamin D deficiency, however, was hard to prove in some cases, and there was often no response to vitamin D therapy. Third, now the main culprit is lack of
vitamin E, which can arise in several different ways: fat malabsorption, colestatic liver disease, abetalipoproteinemia, and autosomal recessive absence of the
tocopherol transfer protein. In these disorders, ataxia and sensorimotor polyneuropathy are prominent clinical signs and may improve with vitamin E replacement,
giving up to 4 g daily of alpha tocopherol.
The main bowel diseases associated with neurologic symptoms are celiac disease and inflammatory bowel disease (Crohn disease or ulcerative colitis). Celiac
disease is characterized by the triad of malabsorption, abnormal small bowel mucosa, and intolerance to gluten, a complex of wheat proteins. Gluten sensitivity can be
documented by finding antibodies to gliadin. Neurologic complications arise from osteomalacic myopathy, B 12 deficiency with neuropathy or myelopathy, hypokalemia,
or hypocalcemia. In some patients, severe ataxia of gait has been related to the gluten sensitivity, with changes in peripheral nerves, posterior columns, and
cerebellum.
Both Crohn disease and ulcerative colitis are associated with increased risk of thromboembolism that may affect other parts of the body but includes arteries and veins
of the brain or spinal cord. Neuromuscular disorders are diverse ( Table 154.5). Peripheral neuropathy is found with Crohn disease for reasons that are uncertain;
acute or chronic demyelinating neuropathy is found more often with ulcerative colitis. Myopathy may occur with either disorder, but symptomatic central nervous
system disease is exceptional even though white matter lesions are found by MRI.
TABLE 154.5. NEUROLOGIC SYNDROMES IN 19 PATIENTS WITH INFLAMMATORY BOWEL DISEASE
Another unusual syndrome of malabsorption is episodic abnormality of sleep, thirst, hunger, and mood, a combination that suggests a hypothalamic disorder. Other
manifestations are episodes of weakness, ataxia, slurred speech, confusion, and nausea. This is attributed to bacterial overgrowth with production of D-lactic acid.
D-Lactic acidosis is seen in patients with a short small intestine and an intact colon. Excessive production of d-lactate by abnormal bowel flora overwhelms normal
metabolism of D-lactate and leads to an accumulation of this enantiomer in the blood. The condition may be fatal, but oral antibiotic treatment has abolished the
syndrome in some patients.
Chronic diarrhea from any cause, including malabsorption or abuse of laxatives, may cause hypokalemia with resulting chronic myopathy, acute paralysis, or acute
myoglobinuria. Acute hypophosphatemia may arise in alcohol abusers treated for loss of fluids and electrolytes, after treatment of diabetic ketoacidosis, or after
hyperalimentation. In these circumstances, limb weakness may simulate Guillain-Barr syndrome, or the acute electrolyte disorder may actually precipitate the
neuropathy; seizures and coma may be part of the picture.
In some conditions, diarrhea accompanies but is not thought to cause the neurologic disorder. The combination of diarrhea, orthostatic hypotension, and peripheral
neuropathy suggests the possibility of amyloid disease or diabetes mellitus. The combination of chronic diarrhea, arthritis, and dementia or other cerebral disorder
suggests Whipple disease (see Chapter 34). The disease is often diagnosed only at autopsy because there is no characteristic clinical picture and steatorrhea may be
lacking. An unusual sign is oculomasticatory myorhythmia, a term that describes rhythmic convergence of the eyes and synchronous contractions of the masticatory
muscles. Diagnosis can be made reliably by a polymerase chain reaction test. Recognition is important because Whipple disease can be cured by treatment with
trimethoprim-sulfamethoxazole.
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CHAPTER 155. VASCULITIS SYNDROMES
MERRITTS NEUROLOGY
CHAPTER 155. VASCULITIS SYNDROMES

LEWIS P. ROWLAND
Polyarteritis Nodosa
Temporal Arteritis and Polymyalgia Rheumatica (Giant Cell Arteritis)
Temporal Arteritis
Polymyalgia Rheumatica
Antineuronal Cytoplasmic Autoantibody-Positive Granulomatous Giant Cell Arteritis: Churg-Strauss Syndrome and Wegener Granulomatosis
Granulomatous Angiitis of the Brain
Systemic Lupus Erythematosus
Other Collagen-Vascular Diseases
Suggested Readings
Several syndromes are commonly linked because they are characterized by a combination of arthritis, rash, and visceral disease. Because arthritis is common to all
and fibrinoid degeneration of blood vessels is common, they are called collagen-vascular diseases. Inflammatory lesions of the blood vessels, however, are the
dominant pathologic changes in some syndromes. Periarteritis nodosa was the model vasculitis, but the classification of related syndromes depended on autopsy
evaluation of histologic changes in the arteries, whether large or small vessels were involved, and which organs were most affected. Similar classifications were
applied to clinical diagnosis, but overlap between syndromes and lack of knowledge of pathogenesis obscured the area. Some of these diseases were attributed to
the deposition of circulating immune complexes within vessel walls, and some seemed related to viral infection. With the discovery of antineuronal cytoplasmic
autoantibodies (ANCA) and other antibodies, a new classification was adopted by an international consensus conference in 1994 ( Table 155.1). An older
classification describes syndromes that have characteristic clinical and neurologic manifestations and warrant individual discussion ( Table 155.2). Clinical disorders
of brain, spinal cord, peripheral nerve, and muscle are prominent in these diseases. All these conditions are said to be rare except for temporal arteritis and
polymyalgia rheumatica after age 60 and Kawasaki disease in children.
TABLE 155.1. VASCULITIS SYNDROMES: CHAPEL HILL CONSENSUS CRITERIA
TABLE 155.2. SYNDROMES ASSOCIATED WITH SYSTEMIC VASCULITIS
ANCA tests have had a major impact in clinical practice and in theory, bolstering the view that these diseases are autoimmune in origin. In the United Kingdom, the
annual incidence of systemic vasculitis other than temporal arteritis was 42 per million population, and 50% of patients tested positive for ANCA. They are especially
prevalent in Wegener granulomatosis, microscopic polyangiitis, and the Churg-Strauss syndrome. The test depends on immunofluorescence that gives either of two
patterns, cytoplasmic ANCA or perinuclear ANCA. The cytoplasmic antigen is a proteinase (PR3-ANCA) and the perinuclear antigen is myeloperoxidase
(MPO-ANCA); 90% of patients with Wegener disease have the cytoplasmic PR3-ANCA, and 90% of patients with Churg-Strauss have the perinuclear MPO-ANCA.
However, the missing 10% is important because a negative test does not exclude either diagnosis.
POLYARTERITIS NODOSA
Polyarteritis nodosa is an inflammatory arteritis that affects primarily the medium-sized arteritis. It is characterized by nonspecific symptoms commonly associated with
an infection or signs and symptoms involving abdominal organs, joints, peripheral nerves, muscles, or central nervous system (CNS).
Etiology
The cause of periarteritis is unknown; reactions to bacterial or viral infection have been postulated. Association of the disorder with asthma, serum sickness, or drug
reactions suggests autoimmunity. Rich reproduced the lesions in rabbits by repeated injections of horse serum. Immune complexes may play a role; in some cases,
immune complexes have been found in vessel walls without vasculitis but with chronic aggressive hepatitis attributed to hepatitis B virus.
Pathology
There is widespread panarteritis. The pathology in the nervous system includes infiltrates in the adventitia and vasa vasorum, polymorphonuclear leukocytes, and
eosinophils. Necrosis of the media and elastic membrane occurs and may lead to formation of multiple small aneurysms. As these become fibrotic, they may rupture;
proliferation of intima may lead to thrombosis of vessels. Repair and fibrosis of the aneurysms lead to a characteristic beading appearance caused by the nodules.
Incidence
Polyarteritis nodosa is rare, but when it occurs, the CNS is involved in about 25% of cases. Both sexes are affected. The disease may occur at any age, but more than
50% of the reported cases are in the third or fourth decades of life.
Signs and Symptoms
Onset may be acute or insidious. Fever; malaise; tachycardia; sweating; fleeting edema; weakness; and pains in the joints, muscles, or abdomen are common early
symptoms (Table 155.3 and Table 155.4). Blood pressure may be elevated, and there may be a moderate or severe anemia with leukocytosis.
TABLE 155.3. CLINICAL FEATURES IN PATIENTSa WITH POLYARTERITIS NODOSA
TABLE 155.4. SYMPTOMS AT ONSET IN PATIENTS WITH POLYARTERITIS NODOSA
Visceral lesions occur in most cases. Kidney involvement produces symptoms and signs of acute glomerular nephritis. Cutaneous hemorrhages, erythematous
eruptions, and tender red subcutaneous nodules may appear in the skin of the trunk or limbs. Gastrointestinal, hepatic, renal, or cardiac symptoms may develop.
Peripheral neuropathy is the most common neurologic disorder. Periarteritis is probably one of the most common causes of mononeuritis multiplex, but there may also
be a diffuse sensorimotor peripheral neuropathy. Both forms of neuropathy are attributed to ischemia effected by the arteritis of nutrient vessels.
Damage to cerebral arteries may lead to thrombosis or hemorrhage; spinal syndromes are exceptional. The most common manifestations of cerebral involvement are
headache, convulsions, blurred vision, vertigo, sudden loss of vision in one eye, and confusional states or organic psychosis.
A disorder characterized by keratitis and deafness in nonsyphilitic individuals is called the Cogan syndrome. It occurs predominantly in young adults with negative
blood and cerebrospinal fluid (CSF) tests for syphilis and no stigmata of congenital syphilis. The cause of the keratitis and deafness is not known, but in some cases,
the syndrome was one feature of polyarteritis nodosa. Symptoms begin suddenly, involving the cornea and both divisions of the eighth nerve. The eye and the eighth
nerve are usually involved simultaneously, but there may be weeks or months between the onset of symptoms in the eye and the ear. Involvement of the eighth nerve
is usually signaled by nausea, vomiting, tinnitus, and loss of hearing. With progression of the hearing loss to complete deafness, the vestibular symptoms subside.
Laboratory Data
There is a leukocytosis with an inconstant eosinophilia. Nontreponemal serologic tests for syphilis may be positive, and there may be positive skin and serologic tests
for trichinosis. CSF is normal unless there has been a meningeal hemorrhage.
Diagnosis
Diagnosis of polyarteritis nodosa should be considered in all patients with an obscure febrile illness with systemic symptoms and chronic peripheral neuropathy. The
diagnosis can often be established by biopsy of sural nerve, muscle, or testicle.
Prognosis is poor. Death usually occurs because of lesions of the kidneys, other abdominal viscera, or the heart; occasionally, lesions in the brain or peripheral
nerves may cause death. Duration of life after onset of symptoms varies from a few months to several years. Spontaneous healing of the arteritis may occur and is
followed by remission of all symptoms and signs, including those due to involvement of the peripheral nerves.
Treatment
There is no specific therapy. Treatment is chiefly supportive, including blood transfusions and symptomatic therapy for associated conditions. Corticosteroids may be
of temporary benefit in some cases.
TEMPORAL ARTERITIS AND POLYMYALGIA RHEUMATICA (GIANT CELL ARTERITIS)
Temporal arteritis and polymyalgia rheumatica are inextricably linked because they overlap in clinical features, high erythrocyte sedimentation rate (ESR), pathology
in the temporal artery (giant cell arteritis), course, and response to steroid therapy. Both affect people older than age 50, and dominant features include malaise and
myalgia. The major difference is the prominent headache in temporal arteritis and the threat of visual loss. However, temporal artery biopsy may be positive in patients
who lack the cranial symptoms. It is not clear whether the two syndromes are slightly different manifestations of the same etiology and pathogenesis or there are two
separate conditions with overlapping manifestations. Doppler studies may provide a noninvasive mode of diagnosis, but sensitivity and specificity must be assessed.
The lesions are characterized by the presence of activated CD4+ T cells, macrophages that produce transforming growth factor-b, and absence of B cells. If temporal
artery biopsy samples are implanted in severe combined immunodeficiency mice, patterns suggest that persistence of the transforming growth factor-b macrophages
accounts for the chronicity of disease and that steroid therapy suppresses the function of these cells as assessed by histology and also by interleukin production.
TEMPORAL ARTERITIS
This syndrome was first described by Horton in 1934. The pathology is similar to that of periarteritis nodosa except that the inflammatory reaction is more severe and
there are more multinucleated giant cells in the media ( giant cell arteritis). It is usually restricted to the temporal artery, but other vessels are sometimes affected. The
syndrome occurs after age 50 equally in men and women.
It is said to occur exclusively in whites and primarily those of Nordic descent. In Sweden, the incidence rate was 18.3 cases per 100,000 inhabitants over age 50. In
Italy, the comparable figure was 6.9 per 100,000. The low frequency in blacks parallels the distribution of HLA-DR4.
The pathogenesis is uncertain. Immune complexes are not found consistently, and it is thought that local T cells are activated, many bearing peceptors for
interleukin-2. There is also evidence, however, of depletion of circulating T-suppressor CD8 cells, implying a general abnormality of immune function. Also, the
antigen is unknown.
Symptoms include headache, which is typically centered on the affected temporal artery but may be more generalized. Systemic symptoms include malaise, fever,
anorexia, weight loss, and myalgia. The ESR is almost always above 50 mm/hr. The affected temporal artery may be prominent, nodular, tender, and
noncompressible. Unilateral visual loss, found in 14% to 33% of patients in different series, is attributed to occlusion of the central retinal artery. The disk may appear
pale, normal, or swollen with retinal hemorrhages. Ophthalmoparesis may be prominent, but other cranial nerve palsies are uncommon. Coronary and limb arteries
are sometimes affected. Cerebral symptoms are mostly those of cerebral infarction, which is seen in few cases. However, it is also one of the rare forms of reversible
dementia.
Diagnosis is simple when all typical findings are present. The ESR, however, may not be elevated, and the temporal artery biopsy specimen may be normal in
otherwise typical cases. The diagnosis should be considered whenever a person older than 50 begins to have new headaches, unilateral visual loss, or
ophthalmoparesis. Diagnosis is then made by the high ESR or typical findings on biopsy. Typical abnormalities on temporal artery biopsy are diagnostic because
inflammatory cells are not seen at autopsy of control subjects. If the clinical picture includes headache, jaw claudication, and myalgia with high ESR, it is more likely
that the biopsy will support the diagnosis, but not always. It is difficult to substantiate the diagnosis if clinical manifestations are not typical and the ESR or biopsy is
normal.
It is now difficult to determine the natural history because the threat of visual loss leads to steroid treatment as soon as the diagnosis is made; it is truly emergency
treatment. It is difficult to justify a placebo-controlled trial under these circumstances. However, it is believed that the disease is self-limited, lasting months or a year
or two. In the past, when daily prednisone doses were about 60 mg, few patients could stop steroid therapy. In the 1980s, the dose gradually dropped without losing
efficacy. The adverse effects of steroid therapy are dose and duration dependent; with standard doses, at least a third of the patients had serious adverse effects of
steroids. With maintenance doses of 5 to 10 mg prednisone, the frequency of side effects is much less, and therapy can often be discontinued in 6 to 12 months. In
the past decade, the recommended starting dose has dropped from 60 mg daily to 20 to 40 mg daily.
Taylor and Samanta recommend a starting dose of 40 mg daily if there has been no visual loss. They reduce the dose by 10 mg/day each month for 3 months, then
from 20 to 10 mg daily over another 3 months, and slower tapering thereafter. If vision is already affected, the dose is 60 to 80 mg daily, and some add 250 mg
hydrocortisone intravenously if vision has already been affected; there is no evidence that these higher doses are more effective. In the only controlled trial of steroids
and cyclophosphamide, neither was superior.
Early steroid therapy seems to prevent the most feared consequence of temporal arteritis, loss of vision. If therapy is started when one eye is affected, vision in the
other eye is protected. If vision has already been lost, chances of recovery are low. Aiello et al. (1993) found that 34 of 245 patients (14%) lost vision; in 32 of them,
the visual loss occurred before steroid therapy commenced.
The mortality rate is low, and most deaths that do occur are encountered in the first 4 months of the disease.
POLYMYALGIA RHEUMATICA
This condition is defined by the combination of myalgia, malaise, weight loss, and increased ESR in a person older than 50. In many patients, temporal artery biopsy
shows the changes of temporal arteritis, even if there is no headache or other symptomatic indication that cranial vessels are affected. The threat of visual loss is
lower if there are no cranial symptoms, but the similarities require the same steroid therapy.
The symptoms of polymyalgia rheumatica are nonspecific and could be reproduced by someone with an occult malignant tumor. It becomes a matter of clinical
judgment to decide whether there is time for a diagnostic therapeutic trial of steroid therapy (as described for temporal arteritis) with or without search for the possible
tumor. The other major consideration in differential diagnosis is polymyositis. In polymyalgia, however, there is no limb weakness, serum levels of creatine kinase are
normal, and there are no myopathic changes in muscle biopsy or electromyography; if any of these tests gave abnormal results, the syndrome would be
indistinguishable from polymyositis.
Treatment is the same as for temporal arteritis, but there may be more consistent symptomatic relief with even smaller doses of prednisolone, 15 to 20 mg daily,
dropping to 10 mg daily by 3 months. The long-term outlook is excellent, but there are recurrences in some patients.
ANTINEURONAL CYTOPLASMIC AUTOANTIBODY-POSITIVE GRANULOMATOUS GIANT CELL ARTERITIS: CHURG-STRAUSS

SYNDROME AND WEGENER GRANULOMATOSIS
The arterial lesions in these rare syndromes differ from those of periarteritis in that granuloma formation is more prominent, and they may be more necrotizing. There
are other differences. For instance, eosinophilia and asthma define the Churg-Strauss syndrome. Sensorimotor neuropathy is seen in about 70% of patients and,
sometimes, visual loss. Microscopic polyangiitis resembles periarteritis nodosa clinically and neurologically but affects smaller vessels, especially in the kidneys and
lungs (Table 155.5).
TABLE 155.5. FREQUENCY OF MANIFESTATIONS IN SMALL-VESSEL VASCULITIS (PERCENT OF PATIENTS)
Wegener granulomatosis has a predilection for the respiratory system and kidneys. According to criteria of the American Academy of Rheumatology, the diagnosis
can be made if there are two of the following four criteria: oral ulcers or purulent bloody nasal discharge; abnormal chest film showing nodules, fixed infiltrates, or
cavities; microhematuria; and biopsy evidence of granulomatous inflammation in the wall of an artery or perivascular tissue. Limited Wegemer disease shows the
typical pathology but spares lungs and kidney. Ninety percent of typical Wegener patients are ANCA positive; 50% to 80% have the C-ANCA pattern with
anti-proteinase 3, and 10% to 18% show the P-ANCA pattern with anti-myeloperoxidase. Neurologic manifestations, as in other vasculitis syndromes, more often
indicate a sensorimotor peripheral neuropathy than a CNS syndrome. The disease was once thought to be uniformly fatal, but survival is reported with modern
immunosuppressive therapy, including cyclophosphamide.
GRANULOMATOUS ANGIITIS OF THE BRAIN
In one form of granulomatous angiitis, clinical manifestations are restricted to the brain. Thus, this is appropriately called granulomatous angiitis of the brain (GAB). In
a few cases, the spinal cord is similarly affected, alone or with cerebral lesions. Therefore, the more comprehensive term is granulomatous angiitis of the nervous
system (GANS). This disorder is essentially defined by the characteristic histologic lesion, a granulomatous change that includes multinucleated giant cells; it is seen
in small or larger named cerebral blood vessels.
Lesions of this nature are found in some patients with clinical evidence of a cerebral infarct ipsilateral to herpes zoster ophthalmicus. Otherwise, there is no clinical
clue to the nature of the disease. A few patients have had evidence of immunosuppression with sarcoidosis, Hodgkin disease, or acquired immunodeficiency
syndrome.
After herpes zoster, the clinical manifestations may be those of an uncomplicated stroke, with severe or mild manifestations in different cases. When there is no
evidence of zosterian infection, the symptoms include two invariable but nonspecific sets, focal cerebral signs and mental obtundation, which may be preceded by
dementia. The course is subacute, so this can be regarded as a progressive encephalopathy.
Characteristically, there is CSF pleocytosis, up to 500 mononuclear cells per high-power field. CSF protein content is usually increased, exceeding 100 mg/dL in 75%
of cases, but CSF glucose content is normal.
There has been doubt about the necessity or desirability of brain biopsy for diagnosis. Advocates believe that pathologic proof is needed and that the risks of
meningeal biopsy are about 1%. On the other hand, the risks of immunotherapy are much higher and may be given for an erroneous diagnosis. Analyzing 30 biopsies
for presumed GANS, Goldstein and associates found that 50% had some other disease. Moreover, angiographic evidence of arteritis is unreliable when positive and
is absent in most cases of histologically proven granulomatous angiitis of the brain.
Others contend that a negative biopsy does not exclude the diagnosis and believe that sufficient evidence is given by angiographic beading of arteries. Cases so
diagnosed have been treated with cyclophosphamide, and, if the outcome was favorable, the authors concluded that the likely catastrophic outcome had been
averted. In autopsy-proven cases, however, the arteriogram is usually normal or shows evidence of an infarct or local tissue swelling but not beading. Moreover, the
clinical, arteriographic, and CSF manifestations can be caused by infiltration of meninges by tumor cells or viral infection; beading of cerebral arteries is a nonspecific
finding.
These different perspectives can be seen in a comparison of series defined by pathologic diagnosis (the neurologist's view) or by cerebral angiography and
pathology (the rheumatologist's view) ( Table 155.5). Neurologists do not consider diagnosis by arteriography reliable because beading is found in only 10% of
pathologically proven cases. Strokes are found in only 15%. In contrast to arteriographic diagnosis, pathologic diagnosis leads to a reasonably consistent picture:
encephalopathy (obtundation, cognitive loss); headache; onset over days or weeks, not apoplectic; and CSF protein content greater than 100 mg/dL.
Other problems of diagnosis include subacute bacterial, yeast, or neoplastic meningitis; these conditions are more likely if CSF glucose content is less than 40 mg/dL,
and if the glucose content is normal, CSF cytology is needed. GAB may simulate prion disease by causing severe dementia within a few weeks. If GAB produces a
mass lesion, brain biopsy makes the distinction from tumor. The diagnosis of GANS implies myelopathy, which is difficult to diagnose in life unless there is
concomitant evidence of herpes zoster or sarcoid.
The neurologists' consensus is that diagnosis in living patients can be verified only by a brain biopsy that includes meningeal vessels. In histologically proven cases
(without zoster), the outcome has been fatal in most cases within a few years. About half the patients die within 6 weeks, but a third live longer than 1 year after onset.
Treatment with immunosuppressive drugs has not been effective in most proven cases, but control of GAB has been documented in patients with biopsy-proven GAB
who were treated with immunosuppression, died later, and had no autopsy evidence of lingering inflammation; two of those patients also had amyloid angiopathy.
SYSTEMIC LUPUS ERYTHEMATOSUS
Systemic lupus erythematosus (SLE) is characterized by widespread inflammatory change in the connective tissue (collagen) of the skin and systemic organs. The
primary damage is to the subendothelial connective tissue of capillaries, small arteries, and veins; the endocardium; and the synovial and serous membranes.
Etiology and Incidence
The cause is not known, but immune complexes are deposited in small vessels. The initiating event could be a persistent viral infection, but sometimes serologic and
clinical manifestations follow administration of drugs, such as procainamide. Although rare, the incidence may be increasing. Most cases begin between ages 20 and
40, but the disease may be seen in children. Some 95% of adult patients are women.
Symptoms and Signs
The chief clinical manifestations are prolonged irregular fever, with remissions of variable duration (weeks, months, or even years); erythematous rash; recurrent
attacks with evidence of involvement of synovial and serous membranes (polyarthritis, pleuritis, pericarditis); depression of bone marrow function (leukopenia,
hypochromic anemia, moderate thrombocytopenia); and, in advanced stages, clinical evidence of vascular alteration in the skin, kidneys, and other viscera.
Neurologic manifestations can be divided into several major categories. The most common form, affecting up to 25% of all patients with SLE, is cerebral lupus, an
encephalopathy manifest by seizures, psychosis, dementia, chorea, or cranial nerve disorder. SLE is one of the few remaining causes of chorea in young women.
Other neurologic syndromes are transverse myelopathy, sensorimotor peripheral neuropathy, and polymyositis ( Table 155.6). These symptoms are often attributed to
thrombosis of small vessels or petechial hemorrhages. Microinfarcts may be related to fibrinoid degeneration of small vessels with deposition of antibodies to a
platelet membrane glycoprotein. The same neurologic symptoms are encountered in pediatric lupus.
TABLE 155.6. COMPARISON OF TWO CONCEPTS OF GRANULOMATOSIS ANGIITIS OF THE BRAIN: DIAGNOSIS BY HISTOPATHOLOGY OR
ARTERIOGRAPHY
Evidence of cerebral vasculitis is meager. The cause of cerebral symptoms is not known but they are attributed to mixed pathogenesis: antineuronal antibodies of
unknown type, microvascular occlusions from vasculitis, antiphospholipid antibodies, and noninflammatory vasculopathy. Although strokes are a feature of the
antiphospholipid syndrome, there is little evidence they are responsible for cerebral lupus. Antibodies to ribosomal protein P are said to be highly specific for
cerebral lupus but of poor sensitivity, found in only 20% of patients.
Stroke caused by occlusion of large cerebral vessels is distinctly uncommon. In 1994, Mitsias and Levine found only 30 reported cases, and they were due to diverse
mechanisms, including thrombus, dissection, fibromuscular dysplasia, vasculitis, and premature atherosclerosis. The short-term death rate was 40%, and recurrences
occurred in 13% of the survivors. Venous sinus thrombosis is also recognized. In general, little information has been provided by brain imaging of any kind, including
positron emission tomography and single-photon emission computed tomography.
The cause of cerebral lupus is therefore uncertain. In some cases, cerebral emboli arise from endocarditis or thrombotic thrombocytopenia.
Laboratory Data
In addition to anemia and leukopenia, there is often hematuria or proteinuria, signs of renal damage. Biologic false-positive tests for syphilis may be encountered. The
most important diagnostic test is the search for antinuclear antibodies (ANA), especially antibodies to double-stranded DNA, which are also used as a measure of
activity of the disease. Antibodies to a particular antigen (Sm for Smith) may be found more often in patients with cerebral disease. Although not used often these
days, phagocytic polymorphonuclear leukocytes ( LE cells) are found in 80% of all cases and are considered pathognomonic by some authorities. Serum complement
levels may be decreased in patients with renal disease; deposits of globulin and complement may be found in renal biopsy specimens. CSF is usually normal, but
there may be a modest increase in protein content. For reasons not known, the CSF glucose content is often decreased in SLE patients with myelitis.
Computed tomography and magnetic resonance imaging show nonspecific changes in cerebral lupus. Positron emission tomography may show lesions in brain in
SLE patients with normal magnetic resonance imaging; functional abnormality may precede structural abnormality.
Diagnosis
Diagnosis may be difficult. Fever; weight loss; arthritis; anemia; leukopenia; pleuritis; and cardiac, renal, or neurologic symptoms in a young woman should lead to a
consideration of this diagnosis. An erythematous rash on the bridge of the nose and the malar eminences in a butterfly-like distribution facilitates the diagnosis.
Finding LE cells or ANA in the blood is of value in establishing the diagnosis. Neurologic manifestations are only rarely the first manifestation of SLE, but the
diagnosis should be kept in mind when there is an acute encephalopathy in a young woman. Acute psychosis in a woman with known SLE may be due to the disease
or the effects of steroid therapy, which may be difficult to unravel.
Mixed connective tissue disease is an overlap syndrome with features of SLE, systemic sclerosis, and polymyositis. At first, there seemed to be an association with
antibodies to ribonucleoprotein, but the specificity disappeared. Also, polymyositis can be a manifestation of any collagen-vascular or vasculitis syndrome, with little
specificity. It is primarily systemic sclerosis that overlaps with both SLE and dermatomyositis. For instance, the multisystem disease described in Case Record
24-1995 may show polymyositis, with evidence of SLE (rash more like that of SLE than that of dermatomyositis) and high titer of ANA, and features of systemic
sclerosis (esophageal dysmotility, Raynaud phenomenon, and severe lung disease), but no skin lesions of scleroderma. SLE patients may also show features of
rheumatoid arthritis or Sjgren syndrome. It seems unlikely that mixed connective tissue disease is a unique condition, but the multisystem diseases are a diagnostic
and therapeutic challenge.
Course, Prognosis, and Therapy
Cerebral lupus is a medical catastrophe with poor prognosis. Recommendations include intravenous doses of methylprednisolone (1 g daily for 3 days), followed by
low-dose oral prednisolone. Some authorities add intravenous cyclophosphamide in the initial treatment. Plasmapheresis has not been established as beneficial, and
intravenous immunoglobulin therapy is still experimental. Cases are so few and the disease is so devastating that it has been difficult to carry out a therapeutic trial.
Treatment is equally uncertain for the less-threatening syndromes of peripheral neuropathy, myelitis, or polymyositis. Steroid therapy is the accepted treatment but not
established by therapeutic trial. In the long run, death may result from renal failure or infection.
OTHER COLLAGEN-VASCULAR DISEASES
Neurologic syndromes may complicate other collagen-vascular diseases, usually when the systemic disorder is evident. Sometimes, there are characteristic
syndromes. For instance, an aggressive polyneuropathy may be seen in patients with rheumatoid arthritis. Some clinicians believe the neuropathy may be precipitated
by steroid therapy. Another neurologic syndrome of rheumatoid arthritis is atlantoaxial dislocation with resulting cord compression; the syndrome is attributed to
resorption of the odontoid process.
Sjgren syndrome is defined clinically by internationally accepted criteria. There must be at least two of the following: xerostomia (dry mouth), which can be
documented by scintigraphy; xerophthalmia (dry eyes; pathologic documentation of abnormality in salivary gland biopsy); or keratoconjunctivitis sicca, as
demonstrated by the Shirmer test for tear production. Lip biopsy may show sialoadenitis. If the neurologic manifestations dominate, the term sicca complex has been
used. Sensorimotor peripheral neuropathy (primarily sensory or sensorimotor) and polymyositis are the most common neurologic manifestations. Sjgren disease is
one of the causes of trigeminal sensory neuropathy. CNS complications are rare, but venous sinus thrombosis, myelopathy, a form of motor neuron disease, or
aseptic meningitis is seen. The origin of the neuropathy is not known. Antineuronal antibodies have been found in some cases. Treatment, as usual in these diseases,
focuses on steroids in uncontrolled trials.
In Sjgren syndrome, peripheral neuropathy and polymyositis may be prominent. Peripheral neuropathy is also seen in more than half the patients with the idiopathic
hypereosinophilic syndrome, and there may be evidence of vasculitis in the nerve biopsy.
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CHAPTER 156. NEUROLOGIC DISEASE DURING PREGNANCY
MERRITTS NEUROLOGY
CHAPTER 156. NEUROLOGIC DISEASE DURING PREGNANCY

ALISON M. PACK AND MARTHA J. MORRELL
Biology of Pregnancy
Epilepsy
Preeclampsia and Eclampsia
Stroke
Cerebral Hemorrhage
Multiple Sclerosis
Migraine
Neoplasms
Neuropathies
Myasthenia Gravis
Movement Disorders
Suggested Readings
Pregnancy and the postpartum period are times of major biologic and social changes. Pregnancy may be associated with alterations in preexisting neurologic
conditions, such as epilepsy or migraine, or herald the emergence of neurologic disorders such as peripheral nerve entrapment or a movement disorder. This chapter
addresses the diagnosis, management, and treatment of neurologic disorders arising in or altered by pregnancy.
BIOLOGY OF PREGNANCY
Some physiologic changes during pregnancy may influence the expression of neurologic disease and complicate management. Alterations in neuroactive steroid
hormones may influence the phenotypic appearance of the disease. Changes in pharmacokinetics, compliance, and sleep patterns may make disease management
more challenging.
The concentration and type of circulating steroid hormones change during pregnancy. Estrogen production increases. In the nonpregnant state, the main circulating
estrogens are estradiol, which is synthesized by ovarian thecal cells, and estrone, which is produced by the extraglandular conversion of androstenedione. Estriol is a
peripheral metabolite of estrone and estradiol. In pregnancy, the concentrations of all these estrogens, particularly estriol, increase. As pregnancy progresses,
maternal steroids and dihydroisoandrostene from developing fetal adrenal glands are converted principally to estriol. Progesterone production also increases
dramatically. These hormonal changes may affect neurologic conditions that are hormone-responsive, including migraine, epilepsy, and multiple sclerosis.
Drug pharmacokinetics are affected by the physiologic changes of pregnancy ( Table 156.1). Renal blood flow and glomerular filtration increase as a function of
increased cardiac output. Plasma volume, extravascular fluid, and adipose tissue increase to create a larger volume of distribution. Serum albumin decreases, which
reduces drug-binding and increases drug clearance. These pharmacokinetic alterations may affect drug concentrations. The changes are most important for drugs
that are highly protein bound, hepatically metabolized, or renally cleared.
TABLE 156.1. PHYSIOLOGIC CHANGES DURING PREGNANCY
Other events of pregnancy that may compromise management are hyperemesis gravidarum, sleep deprivation, and poor compliance. Hyperemesis gravidarum can
make it difficult to maintain adequate concentrations of oral medications. Sleep deprivation aggravates many neurologic conditions and can be a particular problem in
the third trimester. Compliance may deteriorate because of a woman's concern that taking medication might harm her baby. Women are often advised by friends,
relatives, and even medical personnel to minimize fetal drug exposure. This may lead to skipped doses, reduced doses, or even self-discontinuation of an indicated
medication.
EPILEPSY
Each year 20,000 women with epilepsy become pregnant. This number has grown as marriage rates have increased for women with epilepsy, as parenting has
become more socially supported, and as the medical management of pregnancy in women with epilepsy has improved.
Seizure frequency may change during pregnancy. In women with preexisting epilepsy, 35% experience an increase in seizure frequency, 55% have no change, and
10% have fewer seizures. Changes responsible for this include changes in sex hormones, antiepileptic drug (AED) metabolism, sleep schedules, and medication
compliance. AED concentrations may change. The total AED concentration falls because of an increase in volume of distribution, decreased drug absorption, and
increased drug clearance. Although the total concentration decreases, the proportion of unbound or free drug increases because albumin levels and protein binding
decline. Therefore, it is necessary to follow the nonprotein-bound drug concentrations for AEDs that are highly protein-bound, including carbamazepine (Tegretol),
phenytoin sodium (Dilantin), and sodium valproate (Depakene). Dose adjustments should maintain a stable nonprotein-bound fraction.
The older AEDs (benzodiazepines, phenytoin, carbamazepine, phenobarbital, and valproate) are teratogenic in humans. Major malformations related to AED
exposure include cleft lip and palate and cardiac defects (atrial septal defect, tetralogy of Fallot, ventricular septal defect, coarctation of the aorta, patent ductus
arteriosus, and pulmonary stenosis). The incidence of these major malformations in infants born to mothers with epilepsy is 4% to 6%, compared to 2% to 4% for the
general population. These malformations can occur with exposure to any of the older AEDs. Neural tube defects (spina bifida and anencephaly) occur in 0.5% to 1%
of infants exposed to carbamazepine and 1% to 2% of infants exposed to valproate during the first month of gestation. Minor congenital anomalies associated with
AED exposure include facial dysmorphism and digital anomalies, which arise in 6% to 20% of infants exposed to AEDs in utero. This is a twofold increase over the
rate in the general population. However, these anomalies are usually subtle and may often be outgrown.
Since 1993, seven new AEDs have been introduced, with little information about effects on the developing fetus. A prospective registry has been established to learn
more about pregnancy and fetal outcome in women using AEDs (Table 156.2). The registry should be contacted regarding any woman who becomes pregnant while
taking AEDs.
TABLE 156.2. NORTH AMERICAN ANTIEPILEPTIC DRUG PREGNANCY REGISTRY
Several mechanisms have been postulated to explain the teratogenicity of AEDs. Some may be teratogenic because of free radical intermediates that may bind with
ribonucleic acid and disrupt deoxyribonucleic acid synthesis and organogenesis. Higher concentrations of oxide metabolites increase the risk of fetal malformations.
Some AEDs may cause folic acid deficiency, which is associated with higher occurrence and recurrence rates of neural tube defects. The American Academy of
Neurology (AAN) and the American College of Obstetric and Gynecologic Physicians (1996) recommend that all women of childbearing age taking AEDs should
receive folic acid supplementation of 0.4 to 5.0 mg per day.
Management of epilepsy in women of reproductive age should focus on maintaining effective control of seizures while minimizing fetal exposure to AEDs. This applies
to dosage and to number of AEDs. Medication reduction or substitution should be achieved prior to conception. Altering medication during pregnancy increases the
risk of breakthrough seizures and exposes the fetus to an additional AED. The recommended AED management in pregnancy is monotherapy at the lowest effective
dose. The drug of choice is the one most likely to be effective and well tolerated. Current information is not sufficient to identify a particular AED as favored in
pregnancy. If there is a family history of neural tube defects, an agent other than carbamazepine or valproate might be considered.
Once a woman is pregnant, prenatal diagnostic testing includes a maternal serum alpha-fetoprotein and a level II (anatomic) ultrasound at 14 to 18 weeks. This
combination will identify more than 95% of infants with neural tube defects. In some instances, amniocentesis may be indicated.
AEDs have also been associated with an increased risk for early fetal hemorrhage. This may be due to an AED-drug related vitamin K deficiency. Therefore, the AAN
recommends vitamin K supplementation (vitamin K1 at 10 mg per day) for the last month of gestation.
For pregnant women with new-onset seizures, the diagnostic strategy is similar to that for any patient with a first-time seizure. A complete neurologic history and
examination should be obtained, with attention to signs of a specific etiology, such as acute intracranial hemorrhage or central nervous system (CNS) infection. The
evaluation should also screen for hypertension, proteinuria, and edema to exclude eclampsia. Follow-up studies include serologic tests for syphilis and human
immunodeficiency virus, electroencephalogram (EEG), and magnetic resonance imaging (MRI). MRI is the preferred imaging technique for pregnant woman. As in
nonpregnant women with a first-time seizure, treatment depends on seizure type and etiology.
PREECLAMPSIA AND ECLAMPSIA
Preeclampsia and eclampsia are most often seen in young primigravida women. Preeclampsia is a multisystem disorder that is diagnosed clinically by hypertension,
proteinuria, and edema. Preeclampsia is associated with hepatic and coagulation abnormalities, hypoalbuminemia, increased urate levels, and hemoconcentration.
Eclampsia is manifested by seizures, cerebral bleeding, and death. The incidence in Europe and other developed countries is 1 per 2,000. In developing countries,
the incidence varies from 1 in 100 to 1 in 1,700. Worldwide, eclampsia probably accounts for 50,000 deaths annually.
Neurologic abnormalities associated with eclampsia include confusion, seizures, cortical blindness, visual-field defects, headaches, and blurred vision. Seizures are
most often generalized but may be partial. Cortical blindness and visual-field defects may occur with bilateral occipital lobe involvement.
The differential diagnosis of eclampsia includes subarachnoid hemorrhage and cerebral venous thrombosis. The diagnosis is established by increased blood
pressure plus proteinuria, edema, or both. A significant increase in blood pressure is defined as an increase of more than 15 mm Hg diastolic or 30 mm Hg systolic
above baseline measurements obtained before or early in pregnancy. If no early reading is available, a blood pressure of 140/90 mm Hg or higher in late pregnancy is
significant.
Neuroimaging, EEG, cerebrospinal fluid (CSF) analysis, and angiography may help in diagnosis. Computed tomography (CT) is usually normal in eclampsia but may
show hypodense regions in areas of cerebral edema. MRI permits better detection of edema in the cortical mantle. During an eclamptic convulsion, the EEG shows
spike-and-wave discharges. The CSF is usually normal in preeclampsia. In eclampsia, the CSF protein content is often moderately elevated, and the pressure may be
increased. In some patients, angiography shows arterial spasm.
Pathologic examination of eclamptic brains reveals petechial hemorrhages in cortical and subcortical patches. Microscopically, these petechial hemorrhages are ring
hemorrhages about capillaries and precapillaries occluded by fibrinoid material. Areas that are predisposed include the parietooccipital and occipital regions.
Treatment of eclampsia is controversial. The most accepted treatment is delivery of the fetus, if appropriate. Hypertension should be treated with antihypertensive
agents. The National Blood Pressure Education Program recommends magnesium sulfate for the treatment and prevention of eclamptic seizures. In the United States,
obstetricians have traditionally used magnesium sulfate. However, in the United Kingdom, they use phenytoin or diazepam. Randomized trials have compared these
agents for seizure prevention in women with preeclampsia/eclampsia. The results suggest that magnesium is the agent of choice, but no study has evaluated the
treatment of eclamptic seizures with both magnesium sulfate and an AED.
STROKE
Pregnancy is a risk factor for stroke, and the postpartum period is the most vulnerable time. Presumptive mechanisms include changes in the coagulation and
fibrinolytic systems leading to a hypercoagulable state and an increase in viscosity and stasis, which can promote thrombosis. In the postpartum period, the large
decrease in blood volume at childbirth, rapid changes in hormone status that alter hemodynamics and coagulation, and the strain of delivery may predispose to a
stroke.
Arterial occlusion causes 50% to 80% of ischemic strokes in pregnant women. Cerebral venous thrombosis is the next most common etiology. Arterial occlusion
occurs primarily in the second and third trimesters, whereas venous thrombosis most often occurs in the postpartum period. Arterial strokes most often occur as a
consequence of identifiable risk factors, including premature atherosclerosis, moyamoya disease, Takayasu arteritis, fibromuscular dysplasia, and primary CNS
vasculitis. Hematologic disorders can play an etiologic role in arterial and venous strokes. Such disorders include sickle-cell disease, antiphospholipid syndrome,
thrombotic thrombocytopenic purpura, and deficiencies in antithrombin III, protein C, protein S, and factor V Leiden. Other etiologies are cardiogenic and paradoxic
emboli.
Treatment of strokes in pregnancy is directed to the specific cause. Heparin does not cross the placenta and is the anticoagulant of choice in pregnancy. However,
long-term use (greater than 1 month) is associated with osteoporosis. Warfarin sodium (Coumadin) crosses the placenta and is a known teratogen. It is therefore
recommended only for women who cannot tolerate heparin or who have recurrent thromboembolic events. Aspirin complications in pregnancy include teratogenic
effects and bleeding in the neonate. However, low-dose aspirin (less than 150 mg) is safe in the second and third trimesters, with no increase in maternal or neonatal
adverse effects. Use of low-molecular-weight heparin is gaining acceptance during pregnancy. Like heparin, low-molecular-weight heparin does not cross the
placenta. The risk of bleeding with these compounds is small, and the development of osteoporosis is less likely, although there is little information about appropriate
doses in pregnancy.
CEREBRAL HEMORRHAGE
The risk of cerebral hemorrhage increases in pregnancy. Cerebral hemorrhage occurs in 1 to 5 pregnancies per 10,000, with an associated mortality of 30% to 40%.
Factors that predispose to hemorrhage include physiologic changes of pregnancy such as hypertension, high concentrations of estrogens causing arterial dilation,
and increases in cardiac output, blood volume, and venous pressure. Pregnancy-related conditions also increase the risk of hemorrhage. These include eclampsia,
metastatic choriocarcinoma, cerebral emboli, and coagulopathies.
Subarachnoid hemorrhage accounts for 50% of all intracranial bleeding in pregnancy and carries a high mortality. Cerebral aneurysms and arteriovenous
malformations cause most subarachnoid hemorrhages in pregnancy. Other causes include eclampsia, cocaine use, coagulopathies, ectopic endometriosis,
moyamoya disease, and choriocarcinoma. Aneurysmal bleeding usually occurs in older patients in the second and third trimesters. In contrast, hemorrhages from
arteriovenous malformations occur in younger women throughout gestation, with the highest risk during labor and the puerperium.
The diagnosis and treatment of subarachnoid hemorrhage and intracerebral hemorrhage in pregnant women are similar to those in nonpregnant patients.
Subarachnoid hemorrhage is diagnosed by clinical manifestations and CT. If brain CT is normal and the clinical signs are consistent with intracranial hemorrhage,
lumbar puncture should be performed. Once intracranial hemorrhage is detected, follow-up studies include MRI and four-vessel angiography. Noncontrast CT is also
the most sensitive means of diagnosing intracerebral hemorrhage. Treatment of these conditions is directed to supporting the mother and fetus and preventing
complications. Blood pressure should be carefully monitored, and fetal monitoring is indicated. The specific treatment depends on the etiology of the hemorrhage.
MULTIPLE SCLEROSIS
Multiple sclerosis (MS) affects 1 in 10,000 people in Western countries, primarily women in the childbearing years. A multicenter, prospective observational study
(Pregnancy in Multiple Sclerosis Study; Confavreux, 1998) and other surveys found that the rate of relapse declines in pregnancy, especially in the third trimester, and
increases in the first 3 months postpartum. Long-term disability was not affected.
The mechanisms responsible for the change in the rate of relapses include humoral and immunologic changes, as seen also in pregnant women with other
autoimmune diseases such as rheumatoid arthritis or systemic lupus erythematosus. There is no correlation of relapse rate with the physical stress of childbirth and
caring for the newborn, sleep deprivation, type and dose of anesthesia, breast-feeding, or socioeconomic factors.
Many women with relapsing-remitting MS are treated with interferon beta-1b (Betaseron), interferon beta-1a (Avonex), or glatiramer acetate (Copaxone). None of
these has been tested formally in pregnant women and discontinuation of these agents is recommended. In addition, there have been no controlled trials addressing
the safety of medication for MS relapses. If a severe relapse does occur with pregnancy, a short course of corticosteroid therapy is recommended. However, neonatal
adrenal suppression may follow maternal corticosteroid use, and large prenatal doses in animals caused growth retardation and compromised development of the
CNS.
MIGRAINE
Migraine is diagnosed in 18% of women of childbearing years, and 60% to 80% of migraine headaches improve during pregnancy. Women who had migraine onset at
menarche or who have had menstrual migraines are more likely to experience improvement, especially in the first or second trimester. Higher levels of estrogen are
probably responsible for this improvement during pregnancy. The subsequent fall in estrogen levels may cause postpartum headaches. It is not known why migraine
may start or become worse in pregnancy.
If migraine arises in pregnancy, the differential diagnosis must be considered. A new-onset migraine with aura can be a symptom of vasculitis, brain tumor, or occipital
arteriovenous malformation. Subarachnoid hemorrhage can cause headache any time during pregnancy or delivery. Other disorders with headache include stroke,
cerebral venous thrombosis, eclampsia, pituitary tumor, and choriocarcinoma.
Medication use during pregnancy should be limited. If necessary, acetaminophen, nonsteroidal antiinflammatory drugs, codeine, or other narcotics may be used;
low-dose aspirin may also be given. Antiemetics such as metoclopramide or prochlorperazine may relieve the headache and associated nausea and vomiting. These
agents are generally safe and effective. Ergotamine, dihydroergotamine mesylate (D.H.E. 45), and sumatriptan succinate (Imitrex) should be avoided. For someone
with recurrent headaches, a beta-adrenergic blocker, such as propanolol, may be used prophylactically. However, adverse effects including intrauterine growth
retardation have been reported with beta-adrenergic blockers. Therefore, the choice of medication for migraine in pregnant women should balance the the mother's
comfort with the least fetal risk.
NEOPLASMS
Brain tumors rarely become symptomatic during pregnancy. The types of tumors arising in pregnancy differ from those in nonpregnant women. Glioma is the most
common, followed by meningioma, acoustic neuroma, and then a variety of other tumors, including pituitary tumors. Tumor growth may be exacerbated by pregnancy,
especially meningioma. Possible mechanisms include increased blood volume, fluid retention, and stimulation of tumor growth by hormones.
Systemic cancer is unusual in young women and rarely begins during pregnancy. Choriocarcinoma is the only systemic tumor specifically associated with pregnancy.
Brain metastases are common in choriocarcinoma; among patients diagnosed with choriocarcinoma, 3% to 20% have brain disease at diagnosis.
Cerebral neoplasms cause headaches, seizures, focal signs, or symptoms of increased intracranial pressure. The seizures may be partial or generalized. Nausea and
vomiting in the first trimester can be confused with morning sickness. All women suspected of having a brain tumor should be examined with MRI.
NEUROPATHIES
During pregnancy and the puerperium, women are at an increased risk for peripheral neuropathy. Backache or poorly localized paresthesia is common. At least 50%
of pregnant women have back pain, Among the specific rare neuropathies that occur with a higher incidence during pregnancy are carpal tunnel syndrome, facial
nerve palsy, meralgia paresthetica, and chronic inflammatory demyelinating polyneuropathy (CIDP) (see Chapter 63 and Chapter 105).
Carpal tunnel syndrome is the most frequent neuropathy of pregnancy. It usually begins in the third trimester and disappears after delivery; it is attributed to
generalized edema. Bell palsy appears with a slightly higher frequency during pregnancy, mostly in the third trimester. Prognosis for recovery is excellent and is
similar to that in nonpregnant women. Treatment is symptomatic, including protection of the eye. Meralgia paresthetica, a sensory neuropathy of the lateral femoral
cutaneous nerve of the thigh, is attributed to compression of the nerve under the lateral part of the inguinal ligament. Swelling during pregnancy, increased body
weight, and increased lordosis during pregnancy are possible causes. Numbness, burning, tingling, or pain in the lateral thigh suggests the diagnosis. A local
anesthetic with or without steroids is usually all that is necessary. Most women improve in the postpartum period. The incidence of CIDP is slightly higher during
pregnancy. As in nonpregnant women, treatment includes plasmapheresis, intravenous gamma globulin, or steroids.
MYASTHENIA GRAVIS
Symptoms of myasthenia gravis (MG) may increase during menstruation, pregnancy, or the puerperium. About one-third of MG patients become worse, one-third
show no change, and one-third show improvement. If symptoms begin during pregnancy, the diagnosis is established, and treatment is symptomatic, with
plasmapheresis and intravenous immunoglobulin. Thymectomy is deferred until long after delivery.
Neonatal MG affects 12% to 20% of infants born to mothers with MG. The symptoms clear within a few weeks.
MOVEMENT DISORDERS
Movement disorders are unusual in young women, but those that specifically occur during pregnancy include the restless leg syndrome, chorea, and drug-induced
movement disorders.
The restless leg syndrome is probably the most common movement disorder of pregnancy. It is characterized by a crawling, burning, or aching sensation in the calves
with an irresistible urge to move the legs. It occurs in 10% to 20% of pregnant women. Treatment includes massage, flexion and extension, walking, benzodiazepines,
opiates, or levodopa. Chorea gravidarum occurs in pregnancy (see Chapter 109). Treatment is reserved for those with violent and disabling chorea and includes
haloperidol or benzodiazepines.
Drugs that block dopamine receptors are often used to treat the nausea and vomiting of pregnancy. These drugs can cause new-onset chorea, tremor, dystonia, or
parkinsonism. Idiopathic Parkinson disease is uncommon in women younger than 40 years. More common is secondary parkinsonism caused by medication or toxins.
There is no definite evidence that Parkinson disease worsens during pregnancy, and there is little information about the toxicity of antiparkinson medications.
Successful pregnancies have been reported in women taking levodopa.
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Movement Disorders
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CHAPTER 157. ALCOHOLISM
MERRITTS NEUROLOGY
SECTION XXIII. ENVIRONMENTAL NEUROLOGY

CHAPTER 157. ALCOHOLISM
JOHN C.M. BRUST
Ethanol Intoxication
EthanolDrug Interactions
Ethanol Dependence and Withdrawal
Wernicke-Korsakoff Syndrome
Alcoholic Cerebellar Degeneration
Alcoholic Polyneuropathy
Alcoholic Amblyopia
Pellagra
Alcoholic Liver Disease
Hypoglycemia
Alcoholic Ketoacidosis
Infection in Alcoholics
Trauma in Alcoholics
Alcohol and Cancer
Alcohol and Stroke
Alcoholic Myopathy
Central Pontine Myelinolysis and Marchiafava-Bignami Disease
Alcoholic Dementia
Fetal Alcohol Syndrome
Treatment of Chronic Alcoholism
Suggested Readings
In the United States, 7% of all adults and 19% of adolescents are problem drinkers: addicted to ethanol or, even if abstinent most of the time, likely to get into trouble
when they drink. Ethanol-related deaths exceed 100,000 each year, accounting for 5% of all deaths in the United States. The devastation is direct (from intoxication,
addiction, and withdrawal) or indirect (from nutritional deficiency or other ethanol-related diseases).
ETHANOL INTOXICATION
Ethanol acts at many levels of the neuraxis and affects a number of neurotransmitter systems, especially t-aminobutyric acid and glutamate. Like general anesthetics,
ethanol disrupts (fluidizes) the phospholipid bilayer of cell membranes. How much of its actions on neurotransmitter receptors and protein channels is indirectly the
result of this less specific effect is uncertain.
To obtain a mildly intoxicating blood ethanol concentration (BEC) of 100 mg/dL, a 70-kg person must drink about 50 g (2 oz) of 100% ethanol. Following zero-order
kinetics, ethanol is metabolized at about 70 to 150 mg/kg of body weight per hour, with a fall in BEC of 10 to 25 mg/dL per hour. Thus, most adults require 6 hours to
metabolize a 50-g dose, and the ingestion of only 8 g of additional ethanol per hour would maintain the BEC at 100 mg/dL.
Symptoms and signs of acute ethanol intoxication are due to cerebral depression, possibly at first of the reticular formation with cerebral disinhibition and later of the
cerebral cortex itself. Manifestations depend not only on the BEC but also on the rate of climb and the person's tolerance, which is related less to increased
metabolism than to poorly understood adaptive changes in the brain. At any BEC, intoxication is more severe when the level is rising than when it is falling, when the
level is reached rapidly, and when the level has only recently been achieved. A single BEC determination therefore is not a reliable indicator of drunkenness, and the
correlations of Table 157.1 are broad generalizations. Death from respiratory paralysis may occur with a BEC of 400 mg/dL and survival may occur at 700 mg/dL; a
level of 500 mg/dL would be fatal in 50% of individuals.
TABLE 157.1. CORRELATION OF SYMPTOMS WITH BLOOD ETHANOL CONCENTRATION (BEC)
Low-to-moderate BECs cause slow saccadic eye movements and interrupted jerky pursuit movements that may impair visual acuity. Esophoria and exophoria cause
diplopia. With a BEC of 150 to 250 mg/dL, there is increased electroencephalogram (EEG) beta activity (beta buzz); higher BECs cause EEG slowing. During sleep,
suppression of the rapid eye movement (REM) stage is followed by REM rebound after a few hours.
The term pathologic intoxication refers to sudden extreme excitement with irrational or violent behavior after even small doses of ethanol. Episodes are said to last for
minutes or hours, followed by sleep and, on awakening, amnesia for the events that took place. Delusions, hallucinations, and homicide may occur during bouts of
pathologic intoxication. Some cases are probably psychologic dissociative reactions; others may be due to the kind of paradoxic excitation that sometimes follows
barbiturate administration.
The term alcoholic blackout refers to amnesia for periods of intoxication, sometimes lasting several hours, even though consciousness at the time did not seem to be
disturbed. Although sometimes considered a sign of physiologic dependence, blackouts also occur in occasional drinkers. Their nature is uncertain.
Acute ethanol poisoning causes more than 1,000 deaths each year in the United States. In stuporous alcoholic patients, subdural hematoma, meningitis, and
hypoglycemia are important diagnostic considerations, but it is equally important to remember that ethanol intoxication alone can be fatal.
Blood ethanol causes a rise of blood osmolality, about 22 mOsm/L for every 100 mg/dL of ethanol; however, there are no transmembrane shifts of water, and the
hyperosmolarity does not cause symptoms. Ethanol overdose should be considered in any comatose patient whose serum osmolarity is higher than predicted by
calculation of the sum of serum sodium, glucose, and urea.
Patients stuporous or comatose from ethanol intoxication are generally managed similarly to those poisoned by other depressant drugs ( Table 157.2). Death comes
from respiratory depression, and artificial ventilation in an intensive care unit is the mainstay of treatment. Hypovolemia, acidbase or electrolyte imbalance, and
abnormal temperature require attention, and if there is any uncertainty about the blood glucose level, 50% glucose is given intravenously, along with parenteral
thiamine. Because ethanol is rapidly absorbed, gastric lavage does not help unless other drugs have been ingested. In obstreperous or violent patients, sedatives
(including phenothiazines and haloperidol) should be avoided because they may push patients into stupor and respiratory depression. When a patient is being
addressed, he or she may be alert but then lapse into stupor or coma when stimuli are decreased.
TABLE 157.2. TREATMENT OF ACUTE ETHANOL INTOXICATION
In a nonhabitual drinker, a BEC of 400 mg/dL takes 20 hours to return to zero. The only practical agent that might accelerate ethanol metabolism and elimination is
fructose, but this causes gastrointestinal upset, lactic acidosis, and osmotic diuresis. (An imidazobenzodiazepine drug has been developed that reverses symptoms of
mild-to-moderate ethanol intoxication; it is available for experimental use only.) Hemodialysis or peritoneal dialysis can be used for BECs greater than 600 mg/dL; for
severe acidosis; for concurrent ingestion of methanol, ethylene glycol, or other dialyzable drugs; or for severely intoxicated children. Analeptic agents such as
ethamivan, caffeine, or amphetamine have no useful role and can cause seizures and cardiac arrhythmia. Although patients are often depleted of magnesium,
administration of magnesium sulfate may further depress the sensorium in intoxicated patients. Reports suggesting that naloxone hydrochloride (Narcan) benefits
patients with ethanol intoxication require confirmation.
ETHANOLDRUG INTERACTIONS
The combination of ethanol with other drugs, often in suicide attempts, causes 2,500 deaths annually, or 13% of all drug-related fatalities. Ethanol is often taken with
marijuana, barbiturates, opiates, cocaine, hallucinogens, and inhalantswith varying interactions. Alcoholics often abuse barbiturates, and although ethanol and
barbiturates are cross-tolerant, they lower the lethal dose of either alone or when taken acutely in combination. Ethanol with chloral hydrate (Mickey Finn) may be
especially dangerous.
Impaired judgment and respiratory depression are also hazards when ethanol is combined with hypnotics, such as methaqualone (Quaalude), sedating
antihistamines, antipsychotic agents, and tranquilizers such as meprobamate and benzodiazepines. Hypnotic drugs with long half-lives may cause potentially
dangerous incoordination when ethanol is consumed the following day.
The cross-tolerance of ethanol with general anesthetics such as ether, chloroform, or fluorinated agents raises the threshold to sleep induction, but synergistic
interaction then increases the depth and length of the anesthetic stage reached. Tricyclic antidepressants do not have a consistent effect; desipramine hydrochloride
antagonizes the effects of ethanol, and amitriptyline potentiates them. Ethanol and morphine, repeatedly used, can increase each other's potency, and methadone
addicts not only frequently become alcoholics but also can then develop a characteristic encephalopathy. Death has followed ethanol taken with propoxyphene
hydrochloride. A mild reaction resembling that caused by disulfiram (Antabuse) occurs when patients combine ethanol with sulfonylureas such as tolbutamide
(Orinase) or with some antibiotics, including chloramphenicol, griseofulvin, isoniazid, metronidazole, and quinacrine hydrochloride.
ETHANOL DEPENDENCE AND WITHDRAWAL
The term hangover refers to the headache, nausea, vomiting, malaise, nervousness, tremulousness, and sweating that can occur in anyone after brief but excessive
drinking. Hangover does not imply ethanol addiction, but ethanol withdrawal does imply addiction and encompasses several disorders ( Table 157.3), which may occur
alone or in combination after reduction or cessation of drinking. Severity depends on the length and degree of a particular binge.
TABLE 157.3. ETHANOL WITHDRAWAL SYNDROMES
Tremulousness, the most common ethanol withdrawal symptom, usually appears in the morning after several days of drinking. It is promptly relieved by ethanol, but if
drinking cannot continue, tremor becomes more intense, with insomnia, easy startling, agitation, facial and conjunctival flushing, sweating, anorexia, nausea, retching,
weakness, tachypnea, tachycardia, and systolic hypertension. Except for inattentiveness and inability to fully recall the events that occurred during the binge,
mentation is usually intact. Symptoms subside in a few days, but it may be 2 weeks before they completely disappear.
Perceptual disturbances, with variable insight, occur in about 25% of ethanol-addicted patients and include nightmares, illusions, and hallucinations, which are most
often visual but may be auditory, tactile, olfactory, or a combination of these. Imagery includes insects, animals, or people. Hallucinations are usually fragmentary,
lasting minutes at a time for several days. Sometimes, however, auditory hallucinations of threatening content last much longer, and occasionally, a persistent state of
auditory hallucinosis with paranoid delusions that resembles schizophrenia develops in these patients and may require care in a mental hospital. Repeated bouts of
acute auditory hallucinosis may predispose to the chronic form.
Ethanol can precipitate seizures in any epileptic; seizures usually occur the morning after weekend or even single-day drinking rather than during inebriation.
Alcohol-related seizures affecting alcoholics not otherwise epileptic have traditionally been considered a withdrawal phenomenon, usually occurring within 48 hours of
the last drink in persons who have abused ethanol chronically or in binges for months or years. The minimal duration of drinking sufficient to cause seizures is
uncertain, but the risk is dose-related, beginning at only 50-g absolute ethanol daily. Seizures usually occur singly or in a brief cluster; status epilepticus is infrequent.
Focal features are present in 25% and do not consistently correlate with evidence of previous head injury or other structural cerebral pathology. Alcohol seizures
sometimes accompany tremulousness or hallucinosis, but they may occur in otherwise asymptomatic individuals. Their frequent appearance during active drinking or
after more than 1 week of abstinence suggests that mechanisms other than withdrawal play a role in some individuals.
The diagnosis of alcohol-related seizures depends on an accurate history and exclusion of other cerebral lesions. Because reliable follow-up is unlikely, a seizure
workup should be done, including computed tomography (CT) or magnetic resonance imaging and examination of cerebrospinal fluid (CSF). Fewer than 10% of
patients with rum fits have spontaneous EEG abnormalities, compared with 50% of those with idiopathic epilepsy. A reported high frequency of electrographic
photomyoclonic and photoconvulsant responses during ethanol withdrawal was not borne out by subsequent studies.
In contrast to tremor, hallucinosis, or seizures, which usually occur within 1 or 2 days of abstinence, delirium tremens usually begins from 48 to 72 hours after the last
drink. Patients with delirium tremens are often hospitalized for other reasons. Delirium tremens may follow withdrawal seizures either before the postictal period has
cleared or after 1 or 2 asymptomatic days, but when seizures occur during a bout of delirium tremens, some other diagnosis (e.g., meningitis) should be considered.
Symptoms typically begin and end abruptly, lasting from hours to a few days. There may be alternating periods of confusion and lucidity. Infrequently, relapses may
prolong the disorder for a few weeks. Patients are typically agitated, inattentive, and grossly tremulous, with fever, tachycardia, and profuse sweating. They pick at the
bed clothes or stare wildly about and intermittently shout at or try to fend off hallucinated people or objects. Quiet delirium is infrequent. Mortality is as high as 15%;
death is usually due to other diseases (e.g., pneumonia or cirrhosis), but it may be attributed to unexplained shock, lack of response to therapy, or no apparent cause.
Treatment of ethanol withdrawal includes prevention or reduction of early symptoms, prevention of delirium tremens, and management of delirium tremens after it
starts (Table 157.4). Sedatives have been recommended for recently abstinent alcoholics or those with mild early withdrawal symptoms, with theoretical consideration
given to cross-tolerance with ethanol. Popular agents include paraldehyde, barbiturates, and benzodiazepines. With any of these agents, the aim is to give a loading
dose likely to cause symptoms of mild intoxication (calming, dysarthria, ataxia, fine nystagmus), and then to adjust subsequent doses to avoid intoxication and
tremulousness. After 1 or 2 days, dosage is gradually tapered, with reinstitution of intoxicating doses should withdrawal symptoms reappear. Beta-adrenergic blocking
agents dampen alcohol withdrawal tremor and have been reported to decrease agitation and autonomic signs as well, reducing the need for benzodiazepines or other
sedatives.
TABLE 157.4. TREATMENT OF ETHANOL WITHDRAWAL
Ethanol, when used parenterally, has the disadvantage of a low therapeutic index. Because ethanol is directly toxic to many organs, it should be avoided during
hospitalization, even though most patients resume drinking on discharge. Neither haloperidol nor phenothiazines have a specific effect on hallucinations; theoretically,
they are less likely to prevent hallucinosis or delirium tremens than drugs cross-tolerant with ethanol, and they can exacerbate seizures.
Phenytoin sodium (Dilantin) appears to be of no value in preventing seizures during withdrawal. Status epilepticus during ethanol withdrawal is treated as in other
situations; intravenous phenobarbital or diazepam has an advantage, compared with phenytoin, of reducing other withdrawal symptoms when the patient awakens.
Long-term anticonvulsants in patients with ethanol withdrawal seizures are superfluous; abstainers do not need them, and drinkers do not take them. An epileptic
whose seizures are often precipitated by ethanol abuse unfortunately does need treatment, even though compliance is unlikely.
Hypomagnesemia is common during early ethanol withdrawal, and although it may not be the primary cause of symptoms, magnesium sulfate should be given to
hypomagnesemic patients. Hypokalemia and hypocalcemia may also be present, and the latter may respond to treatment only when hypomagnesemia is corrected.
Parenteral thiamine and multivitamins are given even if there are no clinical signs of depletion.
Delirium tremens, once it appears, cannot be abruptly reversed by any agent, and specific cross-tolerance of a sedative with ethanol is less important in full-blown
delirium tremens than in early abstinence. Parenteral diazepam is more effective than paraldehyde in rapid calming and has fewer adverse reactions (including
apnea) and lower mortality. The required doses might be fatal in a normal person (see Table 157.4), but one cannot predict in any individual patient how high the
tolerable dose is. Liver disease decreases the metabolism of diazepam, and patients with cirrhosis are more vulnerable to the depressant effects of sedatives; as
delirium tremens clears, hepatic encephalopathy takes its place.
General medical management in delirium tremens is intensive. Although dehydration may be severe enough to cause shock, patients with liver damage may retain
sodium and water. Hypokalemia can cause cardiac arrhythmias. Hypoglycemia may be masked, as may other serious coexisting illnesses, such as alcoholic hepatitis,
pancreatitis, meningitis, or subdural hematoma. Occasionally encountered during abstinence is either parkinsonism or chorea, which tends to clear over days or
weeks. Such movement disorders are presumably related to ethanol effects on striatal dopamine.
WERNICKE-KORSAKOFF SYNDROME
Although pathologically indistinguishable, Wernicke and Korsakoff syndromes are clinically distinct. Wernicke syndrome, when full-blown, consists of mental, eye
movement, and gait abnormalities. Korsakoff syndrome is only a mental disorder that differs qualitatively from Wernicke syndrome ( Table 157.5). Both are the result of
thiamine deficiency.
TABLE 157.5. MAJOR NUTRITIONAL DISTURBANCES IN ALCOHOLICS
In acute Wernicke syndrome, mental symptoms most often consist of a global confusional state that appears over days or weeks; there is inattentiveness,
indifference, decreased spontaneous speech, disorientation, impaired memory, and lethargy. Stupor and coma are unusual, as is selective amnesia. Disordered
perception is common; a patient might identify the hospital room as his or her apartment or a bar. In fewer than 10%, mentation is normal.
Abnormal eye movements include nystagmus (horizontal with or without vertical or rotatory components), lateral rectus palsy (bilateral but usually asymmetric), and
conjugate gaze palsy (horizontal with or without vertical), progressing to complete external ophthalmoplegia. Although sluggishness of pupillary reaction is common,
total loss of reactivity to light does not seem to occur, and ptosis is rare. Whether mental symptoms in acute Wernicke syndrome ever occur without abnormal eye
movements is uncertain.
Truncal ataxia, present in more than 80% of patients, may prevent standing or walking. Dysarthria and limb ataxia, especially in the arms, are infrequent. Peripheral
neuropathy, which occurs to some degree in most patients, may cause weakness sufficient to mask the ataxia. Abnormalities of caloric testing are common, with
gradual improvement, often incomplete, over several months.
Patients with Wernicke syndrome frequently have signs of nutritional deficiency (e.g., skin changes, tongue redness, cheilosis) or liver disease. Autonomic signs are
common. Although beriberi heart disease is rare, acute tachycardia, dyspnea on exertion, and postural hypotension unexplained by hypovolemia are common, and
sudden circulatory collapse may follow mild exertion. Hypothermia is less frequent; fever usually indicates infection.
In acute Wernicke syndrome, the EEG may show diffuse slowing, or it may be normal. CSF is normal except for occasional mild protein elevation. Elevated blood
pyruvate, falling with treatment, is not specific. Decreased blood transketolase (which requires thiamine pyrophosphate as cofactor) more reliably indicates thiamine
deficiency.
In most patients, the more purely amnestic syndrome of Korsakoff emerges as the other mental symptoms of Wernicke syndrome respond to treatment. How often
Korsakoff syndrome occurs without a background of Wernicke syndrome is disputed and bound up with the question of alcoholic dementia (see below). Pathologic
changes of Wernicke-Korsakoff are sometimes encountered unexpectedly at autopsy, suggesting the presence of subclinical or atypical forms, including unexplained
coma.
The amnesia of Korsakoff syndrome is both anterograde, with inability to retain new information, and retrograde, with rather randomly lost recall for events months or
years old. Alertness, attentiveness, and behavior are relatively preserved, but there tends to be a lack of spontaneous speech or activity. Confabulation is not
invariable and, if initially present, tends gradually to disappear. Insight is usually impaired, and there may be flagrant anosognosia for the mental disturbance.
The histopathologic lesions of Wernicke-Korsakoff syndrome consist of variable degrees of neuronal, axonal, and myelin loss; prominent blood vessels; reactive
microglia, macrophages, and astrocytes; and, infrequently, small hemorrhages. Nerve cells may be relatively preserved in the presence of extensive myelin
destruction and gliosis, and astrocytosis may predominate chronically.
Lesions affect the thalamus (especially the dorsomedial nucleus and the medial pulvinar), the hypothalamus (especially the mamillary bodies), the midbrain
(especially the oculomotor and periaqueductal areas), and the pons and medulla (especially the abducens and medial vestibular nuclei). In the anterosuperior vermis
of the cerebellum, severe Purkinje cell loss and astrocytosis accompany lesser degrees of neuronal loss and gliosis in the molecular and granular layers.
The traditional view that the memory impairment of Korsakoff syndrome is the result of lesions in the mamillary body has been challenged by others who attribute
amnesia to lesions in the dorsomedial nucleus of the thalamus. The global confusion of Wernicke syndrome may occur without visible thalamic lesions and may be a
biochemical disorder. Periaqueductal, oculomotor, or abducens nucleus lesions may explain ophthalmoparesis, which is also seen in patients whose eye movement
disorders resolved before death. The cerebellar and vestibular lesions probably contribute to ataxia.
Experimental and clinical evidence ascribes a specific role to thiamine in the Wernicke-Korsakoff syndrome. A genetic influence is implied because only a few
alcoholic or otherwise malnourished people are affected, and whites seem more susceptible than blacks.
Untreated Wernicke-Korsakoff syndrome is fatal, and the mortality rate is 10% among treated patients. Concomitant liver failure, infection, or delirium tremens often
makes the cause of death unclear. Postural hypotension and tachycardia call for strict bedrest; associated medical problems may require intensive care. The
cornerstone of treatment is thiamine, 50 to 100 mg daily, until a normal diet can be taken; intramuscular or intravenous administration is preferred because thiamine
absorption is impaired in chronic alcoholics. Hypomagnesemia may retard improvement after thiamine treatment; magnesium is therefore replaced, along with other
vitamins. Protein intake may have to be titrated against the patient's liver status.
With thiamine treatment, the ocular abnormalities (especially abducens and gaze palsies) improve within a few hours and usually resolve within 1 week; in about 35%
of the patients, horizontal nystagmus persists indefinitely. Global confusion may improve in hours or days and usually resolves within 1 month, leaving Korsakoff
amnesia in more than 80%. In less than 25% of these patients, there is eventual clearing of the memory deficit. Ataxia may improve in a few days, but recovery is
complete in less than 50% of patients, and nearly 35% do not show improvement at all.
ALCOHOLIC CEREBELLAR DEGENERATION
Cerebellar cortical degeneration may occur in nutritionally deficient alcoholics without Wernicke-Korsakoff syndrome (see Table 157.5). Instability of the trunk is the
major symptom, often with incoordination of leg movements. Arm ataxia is less prominent; nystagmus and dysarthria are rare. Symptoms evolve in weeks or months
and eventually stabilize, sometimes even with continued drinking and poor nutrition. Ataxia without Wernicke disease is less likely to appear abruptly or to improve.
Pathologically, the superior vermis is invariably involved, with nerve cell loss and gliosis in the molecular, granular, and especially the Purkinje cell layers. There may
be secondary degeneration of the olives and of the fastigial, emboliform, globose, and vestibular nuclei. Involvement of the cerebellar hemispheric cortex is
exceptional and limited to the anterior lobes. Pathologic evidence of Wernicke disease may coexist, even though it is unsuspected clinically. CT and autopsies,
moreover, have revealed cerebellar atrophy in alcoholics who were not clinically ataxic.
Alcoholic cerebellar degeneration is probably nutritional in origin. Identical lesions occur in malnourished nonalcoholics, and ataxia may begin in malnourished
alcoholics after weeks of abstinence. The clinical and pathologic similarity to the cerebellar component of Wernicke syndrome suggests shared mechanisms, but most
patients with alcoholic cerebellar degeneration do not have pathologic evidence of Wernicke disease.
ALCOHOLIC POLYNEUROPATHY
Alcoholic polyneuropathy is a sensorimotor disorder, probably of nutritional origin, that stabilizes or improves with abstinence and an adequate diet (see Table 157.5).
Neuropathy is found in most patients with Wernicke-Korsakoff syndrome but more often occurs alone. Paresthesia is usually the first symptom; there may be burning
or lancinating pain and exquisite tenderness of the calves or soles. Impaired vibratory sense is usually the earliest sign; proprioception tends to be preserved until
other sensory loss is substantial. Loss of ankle jerks is another early sign; eventually, there is diffuse areflexia. Weakness appears at any time and may be severe.
Distal leg muscles are affected first, although proximal weakness may be marked. Radiologically demonstrable neuropathic arthropathy of the feet is common, as are
skin changes (e.g., thinning, glossiness, reddening, cyanosis, hyperhidrosis). Peripheral autonomic abnormalities are usually less prominent than in diabetic
neuropathy but may cause urinary and fecal incontinence, hypotension, hypothermia, cardiac arrhythmia, dysphagia, dysphonia, impaired esophageal peristalsis,
altered sweat patterns, or abnormal Valsalva ratio. Pupillary parasympathetic denervation is rare. The CSF is usually normal except for occasional mild elevation of
protein content.
Pathologically, there is degeneration of both myelin and axons; it is not certain which occurs first. Clinical and experimental evidence suggests that alcoholic
polyneuropathy is nutritional in origin and that more than thiamine may be lacking.
Peripheral nerve pressure palsies, especially radial and peroneal, are common in alcoholics. Nutritional polyneuropathy may increase the vulnerability of peripheral
nerves to compression injury in intoxicated individuals, who tend to sleep deeply in unusual locations and positions. Recovery usually takes days or weeks; splints
during this period can prevent contractures.
ALCOHOLIC AMBLYOPIA
Alcoholic amblyopia is a visual impairment that progresses over days or weeks, with development of central or centrocecal scotomas and temporal disc pallor (see
Table 157.5). Demyelination affects the optic nerves, chiasm, and tracts, with predilection for the maculopapular bundle. Retinal ganglion cell loss is secondary.
Ethanol (or tobacco) toxicity plays little or no role; amblyopia clears in patients who receive dietary supplements but continue to smoke and drink ethanol. Alcoholic
amblyopia does not progress to total blindness; it may remain stable without change in drinking or eating habits. Improvement, which is often incomplete, nearly
always follows nutritional replacement.
PELLAGRA
Nicotinic acid deficiency in alcoholics causes pellagra, with dermatologic, gastrointestinal, and neurologic symptoms. Altered mentation progresses over hours, days,
or weeks to amnesia, delusions, hallucinations, or delirium. Nicotinic acid therapy (plus other vitamins, deficiency of which can be contributory) usually results in
prompt improvement.
ALCOHOLIC LIVER DISEASE
Cirrhosis is the sixth leading cause of death in the United States, and nearly all deaths from cirrhosis in people older than 45 years are caused by ethanol. Altered
mentation in an alcoholic therefore always raises the possibility of hepatic encephalopathy, which may accompany intoxication, withdrawal, Wernicke syndrome,
meningitis, subdural hematoma, hypoglycemia, or other alcohol states. Hepatic encephalopathy is discussed in detail in Chapter 148. Other neurologic disorders
encountered in alcoholic cirrhotics include a poorly understood syndrome of altered mentation, myoclonus, and progressive myelopathy following portacaval shunting,
as well as acquired chronic hepatocerebral degeneration, a characteristic syndrome of dementia, dysarthria, ataxia, intention tremor, choreoathetosis, muscular
rigidity, and asterixis, which usually occurs in patients who have had repeated bouts of hepatic coma.
HYPOGLYCEMIA
Metabolism of ethanol by alcohol dehydrogenase and of acetaldehyde by mitochondrial aldehyde dehydrogenase utilizes nicotinamide adenine dinucleotide (NAD).
The resulting elevated NADH-to-NAD ratio impairs gluconeogenesis, and if food is not being eaten and liver glycogen is depleted, there may be severe hypoglycemia
with altered behavior, seizures, coma, or focal neurologic deficit. Residual symptoms are common, including dementia. Even after appropriate treatment with
intravenous 50% dextrose, these patients require close observation; blood glucose may fall again, with the return of symptoms and possibly permanent brain damage.
Ethanol stimulates intestinal release of secretin, which aggravates reactive hypoglycemia, especially in children, by enhancing glucose-stimulated insulin release.
ALCOHOLIC KETOACIDOSIS
In alcoholic ketoacidosis, b-hydroxybutyric acid and lactic acid accumulate in association with heavy drinking. The mechanism is unclear. Typical patients are chronic
alcoholic young women who increase their ethanol consumption for days or weeks and then stop drinking when they are overcome by anorexia. Vomiting,
dehydration, confusion, obtundation, and Kussmaul respiration ensue. Blood glucose may be normal, low, or moderately elevated, with little or no glycosuria. A large
anion gap is accounted for by b-hydroxybutyrate, lactate, and lesser amounts of pyruvate and acetoacetate. Serum insulin levels are low, and serum levels of growth
hormone, epinephrine, glucagon, and cortisol are high, but glucose intolerance usually clears without insulin and is not demonstrable on recovery. It is not unusual for
patients to have repeated attacks of alcoholic ketoacidosis.
Alcoholics may have other reasons for metabolic acidosis with a large anion gap (e.g., methanol or ethylene glycol poisoning). When b-hydroxybutyrate is the major
ketone present, the nitroprusside test (Acetest) may be negative. Treatment includes infusion of glucose (and thiamine), correction of dehydration or hypotension, and
replacement of electrolytes such as potassium, magnesium, and phosphate. Small amounts of bicarbonate may be given. Insulin is usually not needed.
INFECTION IN ALCOHOLICS
Alteration of white blood cell function contributes to the alcoholic's predisposition to infection (e.g., bacterial and tuberculous meningitis). Infectious meningitis must
always be considered in alcoholics with seizures or altered mental status, even when the clinical picture seems to be that of intoxication, withdrawal, thiamine
deficiency, hepatic encephalopathy, hypoglycemia, or other alcoholic disturbances. Alcoholic intoxication is a risk factor for human immunodeficiency virus infection.
TRAUMA IN ALCOHOLICS
Thrombocytopenia, a direct effect of ethanol and a consequence of cirrhosis, increases the likelihood of intracranial hematomas after head injury. Abnormalities of
clotting factors also increase the possibility of intracranial hematomas. Experimentally, moreover, acute ethanol enhances bloodbrain barrier leakage around areas
of cerebral trauma. Close observation is essential after even mild head injury in intoxicated patients; an abnormal sensorium must not be dismissed as drunkenness.
ALCOHOL AND CANCER
Independently of tobacco, ethanol in moderate amounts increases the risk of carcinoma of the mouth, esophagus, pharynx, larynx, liver, and breast.
ALCOHOL AND STROKE
As with coronary artery disease, epidemiologic studies suggest that low-to-moderate amounts of ethanol decrease stroke risk, whereas higher amounts increase it.
Reports have been inconsistent, however. Some studies indicate increased risk for hemorrhagic stroke at any dose; some find ethanol protective in whites but not
Japanese; and some observe increased stroke risk temporally related to binge drinking. Ethanol could either prevent or cause stroke by several mechanisms. Acutely
and chronically, ethanol causes hypertension. It reportedly lowers blood levels of low-density lipoproteins, raises levels of high-density lipoproteins, decreases
fibrinolytic activity, increases or inhibits platelet reactivity, dilates or constricts cerebral vessels, and indirectly reduces cerebral blood flow through dehydration.
Alcoholic cardiomyopathy predisposes to embolic stroke.
ALCOHOLIC MYOPATHY
Alcoholic myopathy is of three types. Subclinical myopathy consists of elevated serum creatine kinase levels and electromyographic changes, sometimes with
intermittent cramps or weakness. With chronic myopathy, there is progressive proximal weakness. Acute rhabdomyolysis causes sudden severe weakness, muscle
pain, swelling, and myoglobinuria with renal shutdown. Ethanol toxicity rather than nutritional deficiency is the likely cause of myopathy, and symptoms sometimes
emerge during a binge. Alcoholic cardiomyopathy often coexists. Whether subclinical, chronic, or acute, myopathy improves with abstinence.
CENTRAL PONTINE MYELINOLYSIS AND MARCHIAFAVA-BIGNAMI DISEASE
Central pontine myelinolysis occurs in both alcoholics and nondrinkers and is a consequence of overvigorous correction of hyponatremia. Marchiafava-Bignami
disease is nearly always associated with alcoholism (including wine, beer, and whiskey). It is of unknown origin and causes symptoms, including death, that are
scarcely explained by the characteristic callosal lesions. Marchiafava-Bignami disease and central pontine myelinolysis are discussed in detail in Chapter 134 and
Chapter 135, respectively.
ALCOHOLIC DEMENTIA
Alcoholic dementia refers to progressive mental decline in alcoholics without apparent cause, nutritional or otherwise. Symptoms are said to correlate with enlarged
cerebral ventricles and widened sulci, and both cognition and radiographic changes allegedly improve with abstinence. The subject is controversial, however. True
brain atrophy should not be radiographically reversible, and some workers maintain that most or all cases of alleged alcoholic dementia actually represent other
conditions, such as nutritional deficiency, previous trauma, or liver failure. In animals, prolonged administration of moderate amounts of ethanol causes behavioral
and neuropathologic abnormalities not found in pair-fed controls. Some studies suggest synergism between ethanol toxicity and thiamine deficiency. The clinical
relevance of animal studies to humans is uncertain. If ethanol is indeed neurotoxic, it remains to be seen what constitutes a safe dose.
FETAL ALCOHOL SYNDROME
Ethanol ingestion during pregnancy causes congenital malformations and delayed psychomotor development. Major clinical features of the fetal alcohol syndrome
include cerebral dysfunction, growth deficiency, and distinctive facies ( Table 157.6); less often, there are abnormalities of the heart, skeleton, urogenital organs, skin,
and muscles. Neuropathologic abnormalities include absence of the corpus callosum, hydrocephalus, and abnormal neuronal migration, with cerebellar dysplasia,
heterotopic cell clusters, and microcephaly. These changes occur independently of other potentially incriminating factors, such as maternal malnutrition, smoking,
other drug use, or age. Binge drinking, which may produce high ethanol levels at a critical fetal period, may be more important than chronic ethanol exposure, and
early gestation appears to be the most vulnerable period.
TABLE 157.6. CLINICAL FEATURES OF FETAL ALCOHOL SYNDROME
Children of alcoholic mothers are often intellectually borderline or retarded without other features of the fetal alcohol syndrome; fetal effects of ethanol thus cover a
broad spectrum. Stillbirth and attention deficit disorder seem especially frequent among offspring of heavy drinkers, and each anomaly of the fetal alcohol syndrome
may occur alone or in combination with others. The face of a typical patient with the fetal alcohol syndrome is distinctive and as easily recognized at birth as that of
the infant with Down syndrome. Irritability and tremulousness with poor suck reflex and hyperacusis are usually present at birth and last weeks or months. Of these
children, 85% perform more than two standard deviations below the mean on tests of mental performance; those who are not grossly retarded rarely have even
average mental ability. Older children are often hyperactive and clumsy, and there may be hypotonia or hypertonia. Except for neonatal seizures, epilepsy is not a
component of the syndrome.
Ethanol is directly teratogenic to many animals, but the mechanism is not known. In humans, the risk of alcohol-induced birth defects is established with more than 3
oz of absolute alcohol daily. Below that, the risk is uncertain; a threshold of safety has not been defined. The incidence of fetal alcohol syndrome may be as high as 1
to 2 per 1,000 live births, with partial expression in 3 to 5 per 1,000. It may affect 1% of infants born to women who drink 1 oz of ethanol daily early in pregnancy. More
than 30% of the offspring of heavy drinkers are affected by fetal alcohol syndrome, which thus may be the leading teratogenic cause of mental retardation in the
Western world.
TREATMENT OF CHRONIC ALCOHOLISM
The literature on the treatment of alcoholism is voluminous, and strong opinions outweigh scientific data. Not all problem drinkers consume physically addicting
quantities of ethanol, no personality type defines an alcoholic, and the relative roles of genetics and social deprivation vary from patient to patient. (Animal and human
studies indicate genetic influences in alcoholism, but the association is complex and undoubtedly involves more than one gene.) Of course, such variability of
alcoholic populations means that no treatment modality (e.g., psychotherapy, group psychotherapy, family or social network therapy, drug therapy, behavioral
[aversion] therapy) or no single therapeutic setting (e.g., general hospital, halfway house, vocational rehabilitation clinic, Alcoholics Anonymous) is appropriate for all.
For example, the success rate of Alcoholics Anonymous has been estimated to be 34%.
Use of tranquilizing and sedating drugs is especially controversial because they may lead to switching of dependency or to drugethanol interactions. Some clinicians
espouse short-term use of these drugs in doses high enough to reduce the psychologic tensions that lead to ethanol use but low enough not to block symptoms of
ethanol withdrawal.
Disulfiram inhibits aldehyde dehydrogenase and reduces the rate of oxidation of acetaldehyde, accumulation of which accounts for the symptoms that appear soon
after someone taking disulfiram drinks ethanol. Within 5 to 10 minutes, there is warmth and flushing of the face and chest, throbbing headache, dyspnea, nausea,
vomiting, sweating, thirst, chest pain, palpitations, hypotension, anxiety, confusion, weakness, vertigo, and blurred vision. The severity and duration of these
symptoms depend on the amount of ethanol drunk; a few milliliters can cause mild symptoms followed by drowsiness, sleep, and recovery; severe reactions can last
hours or be fatal and require hospital admission, with careful management of hypotension and cardiac arrhythmia.
Taken in the morning, when the urge to drink is least, disulfiram, 0.25 to 0.5 g daily, does not alter the taste for ethanol and helps only patients who strongly desire to
abstain. In the United States, 150,000 to 200,000 patients are maintained on disulfiram, although controlled studies demonstrating substantial long-term benefit are
lacking. Side effects of disulfiram that are unrelated to ethanol ingestion include drowsiness, psychiatric symptoms, and cardiovascular problems. Paranoia, impaired
memory, ataxia, dysarthria, and even major motor seizures may be difficult to distinguish from ethanol effects, as may peripheral neuropathy. Hypersensitivity hepatitis
also occurs.
Approved by the U.S. Federal Drug Administration in 1994 as adjunctive therapy for alcoholism, the opiate antagonist naltrexone hydrochloride (ReVia) probably acts
at the level of the mesolimbic reward circuit to blunt the pleasurable effects of ethanol. In Europe, acamprosate, a drug with an uncertain mechanism of action, is
available. Other proposed treatments for alcoholism include lithium, serotonin-uptake inhibitors, dopaminergic agonists, opiates, and psychotherapy. None is
scientifically accredited.
SUGGESTED READINGS
Alcohol-related mortality and years of potential life lostUnited States. MMWR 1990;39:173178.
Alldredge BK, Lowenstein DH, Simon RP. A placebo-controlled trial of intravenous diphenylhydantoin for short-term treatment of alcohol withdrawal seizures. Am J Med 1989;87:645648.
Brust JCM. Ethanol. In: Neurological aspects of substance abuse. Boston: Butterworth-Heinemann, 1993:190252.
Brust JCM. Ethanol. In: Schaumburg HH, Spencer PS, eds. Experimental and clinical neurotoxicology, 2nd ed. Baltimore: Williams & Wilkins, 1999.
Brust JCM. Stroke and substance abuse. In: Barnett HJM, Mohr JP, Stein BM, et al., eds. Stroke: pathophysiology, diagnosis, and management, 3rd ed. Philadelphia: WB Saunders, 1998:9791000.
Camargo CA. Moderate alcohol consumption and stroke: the epidemiologic evidence. Stroke 1989;20:16111626.
Charness ME, Simon RP, Greenberg DA. Ethanol and the nervous system. N Engl J Med 1989;321:442454.
Cloninger CR. D2 dopamine receptor gene is associated but not linked with alcoholism. JAMA 1991;266:17931800.
Day NL, Jasperse D, Richardson D, et al. Prenatal exposure to alcohol: effect on infant growth and morphologic characteristics. Pediatrics 1989;84:536541.
Fisch BJ, Hauser WA, Brust JCM, et al. The EEG response to diffuse and patterned photic stimulation during acute untreated alcohol withdrawal. Neurology 1989;39:434436.
Fuller RK, Branhey L, Brightwell DR, et al. Disulfiram treatment of alcoholism. A Veterans Administration Cooperative Study. JAMA 1986;256:14491455.
Goldstein DB. Effects of alcohol on cellular membranes. Ann Emerg Med 1986;15:10131018.
Joyce EM. Aetiology of alcoholic brain damage: alcoholic neurotoxicity or thiamine malnutrition? Br Med Bull 1994;50:99114.
Lemoine P, Lemoine P. Avenir des infants de meres alcooliques (etude de 105 case retrouves a l'age adult) et quelques constatations d'interet prophylactique. Ann Pediatr 1992;29:226230.
Neiman J, Lang AE, Fornazarri L, Carlen PL. Movement disorders in alcoholism: a review. Neurology 1990;40:741746.
Ng SKC, Hauser WA, Brust JCM, et al. Alcohol consumption and withdrawal in new-onset seizures. N Engl J Med 1988;319:666673.
O'Connor PG, Schottenfeld RS. Patients with alcohol problems. N Engl J Med 1998;338:592602.
Suzdak PD, Glowa JR, Crawley JN, et al. A selective imidazobenodiazepine antagonist of ethanol in the rat. Science 1986;234:12431247.
Tabakoff B, Hoffman PL. Alcohol addiction: an enigma among us. Neuron 1996;16:909912.
Thompson WL, Johnson AD, Maddrey WL, et al. Diazepam and paraldehyde for treatment of severe delirium tremens: a controlled trial. Ann Intern Med 1975;82:175180.
Thun MJ, Peto R, Lopez AD, et al. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. N Engl J Med 1997;24:17051714.
Urbano-Marquez AM, Estruch R, Navarro-Lopez F, et al. The effects of alcoholism on skeletal and cardiac muscle. N Engl J Med 1989;320:409415.
Victor M. Persistent altered mentation due to ethanol. Neurol Clin 1993;11:639661.
Victor M, Adams RD. The effect of alcohol on the nervous system. Res Publ Assoc Res Nerv Ment Dis 1953;32:526573.
Victor M, Adams RD, Collins GH. The Wernicke-Korsakoff syndrome, 2nd ed. Philadelphia: FA Davis Co, 1989.
Victor M, Adams RD, Mancall EL. A restricted form of cerebellar cortical degeneration occurring in alcoholic patients. Arch Neurol 1959;1:579688.
CHAPTER 158. DRUG DEPENDENCE
MERRITTS NEUROLOGY
CHAPTER 158. DRUG DEPENDENCE

JOHN C.M.BRUST
Drugs of Dependence
Trauma
Infection
Seizures
Stroke
Altered Mentation
Fetal Effects
Miscellaneous Effects
Suggested Readings
There are two kinds of drug dependence. Psychic dependence leads to craving and drug-seeking behavior. Physical dependence produces somatic withdrawal
symptoms and signs. Depending on the particular drug and the circumstances of its administration, psychic and physical dependence can coexist or occur alone.
Addiction is psychic dependence.
In the United States, dependence of one or both types is encountered with a variety of agents, licit and illicit ( Table 158.1). Different classes of drugs produce diverse
symptoms of intoxication and withdrawal, as well as medical and neurologic complications. Their legal status has little to do with potential harmfulness.
TABLE 158.1. DRUGS OF DEPENDENCE
DRUGS OF DEPENDENCE
Opioids
Opioids include agonists (e.g., morphine, heroin, methadone, fentanyl citrate [Sublimaze], meperidine hydrochloride (Demerol HCl), hydromorphone hydrochloride
(Dilaudid), codeine, propoxyphene hydrochloride [Darvon]), antagonists (e.g., naloxone hydrochloride [Narcan], naltrexone hydrochloride [ReVia]), and mixed
agonist-antagonists (e.g., pentazocine [Talwin], buprenorphine hydrochloride [Buprenex], butorphanol tartrate [Stadol]). At desired levels of intoxication, agonist
opioids produce drowsy euphoria, analgesia, cough suppression, miosis, and often nausea, vomiting, sweating, pruritus, hypothermia, postural hypotension,
constipation, and decreased libido. Taken parenterally, they produce a rush, a brief ecstatic feeling followed by euphoria and either relaxed nodding or garrulous
hyperactivity. Overdose causes coma, respiratory depression, and pinpoint (but reactive) pupils. For adults with respiratory depression, treatment consists of
respiratory support and naloxone, 2 mg intravenously, repeated as needed up to 20 mg; for those with normal respirations, smaller doses (0.4 to 0.8 mg) are given to
avoid precipitation of withdrawal signs. Naloxone is short-acting, and so patients receiving it require admission and close observation.
Opioid agonist withdrawal symptoms include irritability, lacrimation, rhinorrhea, sweating, yawning, mydriasis, myalgia, muscle spasms, piloerection, nausea, vomiting,
abdominal cramps, fever, hot flashes, tachycardia, hypertension, and orgasm. In adults, seizures and delirium are not features of opioid withdrawal, which is rarely
life-threatening and can usually be prevented or treated with methadone, 20 mg once or twice daily. By contrast, untreated opioid withdrawal in newborns is severe,
protracted, and often fatal; treatment is with titrated doses of methadone, paregoric, or, if additional drug withdrawal is suspected, a barbiturate.
Psychostimulants
Psychostimulants include amphetamines, methamphetamine, methylphenidate hydrochloride (Ritalin HCl), ephedrine, phenylpropanolamine hydrochloride, other
anorectics and decongestants, and cocaine (which, in contrast to other psychostimulants, is also a local anesthetic). Desired effects include alert euphoria with
increased motor activity and physical endurance. Taken parenterally or smoked as alkaloidal cocaine (crack) or methamphetamine (ice), psychostimulants produce
a rush clearly distinguishable from that of opioids. With repeated use, there is stereotypic activity progressing to bruxism or other dyskinesias and paranoia
progressing to frank hallucinatory psychosis. Overdose causes headache, chest pain, tachycardia, hypertension, flushing, sweating, fever, and excitement. There may
be delirium, cardiac arrhythmia, seizures, myoglobinuria, shock, coma, and death. Treatment includes benzodiazepine sedation, bicarbonate for acidosis,
anticonvulsants, cooling, an antihypertensive (preferably a direct vasodilator such as sodium nitroprusside [Nitropress]), respiratory and blood pressure support, and
cardiac monitoring.
Psychostimulant withdrawal produces fatigue, depression, and increased hunger and sleep. Objective signs are few, but depression can require treatment or even
hospitalization.
Sedatives
Sedative agents include barbiturates (e.g., phenobarbital, pentobarbital sodium, amobarbital, secobarbital [Seconal]), benzodiazepines (e.g., diazepam,
chlordiazepoxide hydrochloride [Librium], alprazolam [Xanax], lorazepam (Ativan), triazolam [Halcion], flunitrazepam), and miscellaneous products (e.g., glutethimide,
ethchlorvynol [Placidyl], methaqualone [Quaalude]). Desired effects and overdose both resemble ethanol intoxication, although respiratory depression is much milder
with benzodiazepines. Treatment is supportive; for severe benzodiazepine poisoning, there is a specific antagonist, flumazenil (Romazicon). Withdrawal causes
tremor and seizures, which can be prevented or treated with titrated doses of a barbiturate or benzodiazepine. Delirium tremens is a medical emergency requiring
intensive care.
Marijuana
Marijuana, from the hemp plant Cannabis sativa, contains many cannabinoid compounds, of which the principal psychoactive agent is d9-tetrahydrocannabinol.
Hashish refers to preparations made from the plant resin, which contains most of the psychoactive cannabinoids. Usually smoked, marijuana produces a relaxed
dreamy euphoria, often with jocularity, disinhibition, depersonalization, subjective slowing of time, conjunctival injection, tachycardia, and postural hypotension. High
doses cause auditory or visual hallucinations, confusion, and psychosis, but fatal overdose has not been documented. Withdrawal symptoms, other than craving, are
minimal; there may be jitteriness, anorexia, and headache.
Hallucinogens
Hallucinogenic plants are used ritualistically or recreationally around the world. In the United States, the most popular agents are the indolealkylamines psilocybin and
psilocin (from several mushroom species), the phenylalkylamine mescaline (from the peyote cactus), and the synthetic ergot compound lysergic acid diethylamide
(LSD). Several synthetic phenylalkylamines are also available, including 3,4-methylenedioxymethamphetamine (MDMA; ecstasy), which has both hallucinogenic and
amphetamine-like effects. The acute effects of hallucinogens are perceptual (distortions or hallucinations, usually visual and elaborately formed), psychologic
(depersonalization or altered mood), and somatic (dizziness, tremor, and paresthesia). Some users experience paranoia or panic, and some, days to months after
use, have flashbacks, the spontaneous recurrence of drug symptoms without taking the drug. High doses of LSD cause hypertension, obtundation, and seizures, but
fatalities have usually been the result of accidents or suicide. Treatment of overdose consists of a calm environment, reassurance, and, if necessary, a
benzodiazepine. Withdrawal symptoms do not occur.
Inhalants
Recreational inhalant use is especially popular among children and adolescents, who sniff a wide variety of products, including aerosols, spot removers, glues, lighter
fluid, fire-extinguishing agents, bottled fuel gas, marker pens, paints, and gasoline. Compounds include aliphatic hydrocarbons such as n-hexane, aromatic
hydrocarbons such as toluene, and halogenated hydrocarbons such as trichloroethylene; in addition, nitrous oxide is sniffed from whipped-cream dispensers and
butyl or amyl nitrite from room odorizers. Despite such chemical diversity, desired subjective effects are similar to those of ethanol intoxication. Overdose can cause
hallucinations, seizures, and coma; death has resulted from cardiac arrhythmia, accidents, and aspiration of vomitus. Symptoms tend to clear within a few hours, and
treatment consists of respiratory and cardiac monitoring. There is no predictable abstinence syndrome other than craving.
Phencyclidine
Developed as an anesthetic, phencyclidine hydrochloride (PCP or angel dust) was withdrawn because it caused psychosis. As a recreational drug, it is usually
smoked. Low doses cause euphoria or dysphoria and a feeling of numbness; with increasing intoxication, there is agitation, nystagmus, tachycardia, hypertension,
fever, sweating, ataxia, paranoid or catatonic psychosis, hallucinations, myoclonus, rhabdomyolysis, seizures, coma, respiratory depression, and death. Treatment
includes a calm environment with benzodiazepine sedation and restraints as needed, gastric suctioning, activated charcoal, forced diuresis, cooling,
antihypertensives, anticonvulsants, monitoring of cardiorespiratory and renal function, and, for frank psychosis, haloperidol. Symptoms can persist for hours or days.
Withdrawal signs are not seen.
Anticholinergics
The recreational use of anticholinergics includes ingestion of the plant Datura stramonium, popular among American adolescents, as well as use of antiparkinson
drugs and the tricyclic antidepressant amitriptyline. Intoxication produces decreased sweating, tachycardia, dry mouth, dilated unreactive pupils, and delirium with
hallucinations. Severe poisoning causes myoclonus, seizures, coma, and death. Treatment includes intravenous physostigmine salicylate (Antilirium), 0.5 to 3 mg,
repeated as needed every 30 minutes to 2 hours, plus gastric lavage, cooling, bladder catheterization, respiratory and cardiovascular monitoring, and, if necessary,
anticonvulsants. Neuroleptics, which have anticholinergic activity, are contraindicated. There is no withdrawal syndrome.
TRAUMA
Trauma may be a consequence of a drug's acute effects, for example, automobile and other accidents during marijuana, inhalant, or anticholinergic intoxication;
violence in psychostimulant or PCP users; and self-mutilation during hallucinogen psychosis. Trauma among users of illicit drugs, however, is most often the result of
the illegal activities necessary to distribute and procure them. Overprescribing of sedatives is a major contributor to falls in the elderly.
INFECTION
Parenteral users of any drug are subject to an array of local and systemic infections, which in turn can affect the nervous system. Hepatitis leads to encephalopathy or
hemorrhagic stroke. Cellulitis and pyogenic myositis produce more distant infection, including vertebral osteomyelitis with myelopathy or radiculopathy. Endocarditis,
bacterial or fungal, leads to meningitis, cerebral infarction or abscess, and septic or mycotic aneurysm. Tetanus, often severe, affects heroin users, and botulism
occurs at injection sites or, among cocaine users, in the nasal sinuses. Malaria has occurred in heroin users from endemic areas.
By 1998, nonhomosexual parenteral drug users composed 26% of acquired immunodeficiency syndrome (AIDS) cases reported to the Centers for Disease Control
and Prevention; male homosexual drug users accounted for another 6%. Nearly two-thirds of patients receiving methadone maintenance treatment are seropositive
for human immunodeficiency virus (HIV). Parenteral drug users experience the same neurologic complications of AIDS as do other groups and are particularly
susceptible to syphilis and tuberculosis, including drug-resistant forms. Because of promiscuity and associated sexually transmitted diseases, nonparenteral cocaine
users are also at increased risk for AIDS. Heroin and cocaine are themselves immunosuppressants (heroin users were vulnerable to unusual fungal infections before
the AIDS epidemic), yet their use in HIV-seropositive individuals does not seem to accelerate the development of AIDS.
SEIZURES
Seizures are a feature of withdrawal from sedatives, including, infrequently, benzodiazepines. Methaqualone and glutethimide have reportedly caused seizures during
intoxication. Opioids lower seizure threshold, but seizures are seldom encountered during heroin overdose. Myoclonus and seizures more often occur in meperidine
users, a consequence of the active metabolite normeperidine. Seizures are also frequent in parenteral users of pentazocine combined with the antihistamine
tripelennamine (T's and blues). Seizures may occur in cocaine users without other evidence of overdose. In animals, repeated cocaine administration produces
seizures in a pattern suggestive of kindling. Amphetamine and other psychostimulants are less epileptogenic than cocaine, but seizures have occurred in users of
the over-the-counter anorectic phenylpropanolamine hydrochloride. A casecontrol study found that marijuana was protective against the development of new-onset
seizures. In animal studies, the nonpsychoactive cannabinoid compound cannabidiol is anticonvulsant.
STROKE
Illicit drug users frequently abuse ethanol and tobacco, increasing their risk for ischemic and hemorrhagic stroke. Parenteral drug users are subject to stroke through
systemic complications such as hepatitis, endocarditis, and AIDS. Heroin users develop nephropathy with secondary hypertension, uremia, and bleeding. Heroin has
also caused stroke in the absence of other evident risk factors, perhaps through immunologic mechanisms. Stroke in injectors of pentazocine combined with
tripelennamine has resulted from embolism of foreign particulate material passing through secondary pulmonary arteriovenous shunts.
Amphetamine users are prone to intracerebral hemorrhage following acute hypertension and fever. They are also at risk for occlusive stroke secondary to cerebral
vasculitis affecting either medium-sized arteries (resembling polyarteritis nodosa) or smaller arteries and veins (resembling hypersensitivity angiitis). Ischemic and
hemorrhagic stroke is also a frequent consequence of cocaine use, regardless of route of administration. Whether stroke is ischemic or hemorrhagic, a common
mechanism may be acute hypertension and direct cerebral vasoconstriction, with hemorrhage occurring during reperfusion. Cerebral saccular aneurysms and
vascular malformations have been found in more than 50% of patients undergoing angiography for cocaine-related intracranial hemorrhage. LSD and PCP are
vasoconstrictive, and occlusive and hemorrhagic strokes have followed their use.
ALTERED MENTATION
Dementia in illicit drug users may be the result of concomitant ethanol abuse, malnutrition, head trauma, or infection. Parenteral drug users are at risk for HIV
encephalopathy. Whether the drugs themselves cause lasting cognitive or behavioral change is more difficult to establish, for predrug mental status is nearly always
uncertain and many drug users are probably self-medicating preexisting psychiatric conditions (e.g., cocaine for depression). The weight of evidence is against
chronic mental abnormalities secondary to opioids, marijuana, or hallucinogens. Controversy exists over whether psychostimulants predispose to lasting depression
or PCP to schizophrenia. Cerebral atrophy and irregularly decreased cerebral blood flow have been reported in chronic cocaine users. Sedatives can cause
reversible dementia in the elderly, and their use in small children has been associated with delayed learning. Lead encephalopathy has developed in gasoline
sniffers, and toluene sniffers have had cerebral white matter lesions with dementia.
FETAL EFFECTS
The effects of illicit drugs on intrauterine development are also difficult to separate from damage secondary to ethanol, tobacco, malnutrition, and inadequate prenatal
care. Infants exposed in utero to heroin have reportedly been small for gestational age, at risk for respiratory distress, and cognitively impaired later in life. Marijuana
exposure has been associated with decreased birthweight and length. Cocaine exposure has reportedly caused abruptio placentae, decreased birthweight, congenital
anomalies, microcephaly, tremor, perinatal stroke, and developmental delay. A prospective study found diffuse or axial hypertonia more often among cocaine-exposed
neonates than controls; this spastic tetraparesis cleared by 24 months of age, and there were no differences in mental or motor development.
MISCELLANEOUS EFFECTS
Guillain-Barr-type neuropathy and brachial or lumbosacral plexopathy, probably immunologic in origin, have been associated with heroin use. (Brachial plexopathy
has also resulted from septic aneurysm of the subclavian artery.) Severe sensorimotor polyneuropathy occurs in sniffers of glue containing n-hexane. Rhabdomyolysis
and renal failure have followed use of heroin, amphetamine, cocaine, and PCP. Myeloneuropathy indistinguishable from cobalamin deficiency occurs in nitrous oxide
sniffers. Anemia is absent, and serum vitamin B 12 levels are usually normal. The mechanism is inactivation of the cobalamin-dependent enzyme methionine
synthetase. Severe irreversible parkinsonism developed in Californians exposed to a meperidine analog contaminated with
1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), a metabolite of which is toxic to neurons in the substantia nigra. Symptoms respond to levodopa. Dementia,
ataxia, quadriparesis, blindness, and death have occurred in European smokers of heroin pyrolysate. Autopsies show spongiform changes in the central nervous
system white matter. The responsible toxin has not been identified. Blindness developed in a heavy heroin user whose mixture contained quinine; however, it
improved when he resumed using a quinine-free preparation. Chronic cocaine users experience dystonia and chorea, and cocaine has precipitated symptoms in
patients with Tourette syndrome. Marijuana inhibits luteinizing and follicle-stimulating hormones, causing reversible impotence and sterility in men and menstrual
irregularity in women. Ataxia and cerebellar white matter changes have occurred in toluene sniffers.
SUGGESTED READINGS
Breiter HC, Gollub RI, Weisskoff RM, et al. Acute effects of cocaine on human brain activity and emotion. Neuron 1997;19:591611.
Brust JCM. Neurological aspects of substance abuse. Boston: Butterworth Heinemann, 1993.
Brust JCM. Stroke and substance abuse. In: Barnett HJM, Mohr JP, Stein BM, et al., eds. Stroke: pathophysiology, diagnosis,and management, 3rd ed. Philadelphia: WB Saunders, 1998:9791000.
Chiriboga CA. Fetal effects. Neurol Clin 1993;11:707728.
Chiriboga CA, Brust JCM, Bateman D, et al. Dose response effect of fetal cocaine exposure on newborn neurological function. Pediatrics 1999;103:7985.
Khanzian EJ, McKenna GJ. Acute toxic and withdrawal reactions associated with drug use and abuse. Ann Intern Med 1979;90:361372.
Levine SR, Brust JCM, Futrell N, et al. Cerebrovascular complications of the use of the crack form of alkaloidal cocaine. N Engl J Med 1990;323:699704.
Lowenstein DH, Massa SM, Rowbotham MC, et al. Acute neurologic and psychiatric complications associated with cocaine abuse. Am J Med 1987;83:841846.
Nestler EJ, Aghajanian GK. Molecular and cellular basis of addiction. Science 1997;278:5863.
Ng SKC, Brust JCM, Hauser WA, et al. Illicit drug use and the risk of new onset seizures: contrasting effects of heroin, marijuana, and cocaine. Am J Epidemiol 1990;132:4757.
Pascual Leone A, Dhuna A, Anderson DC. Cerebral atrophy in habitual cocaine abusers: a planimetric CT study. Neurology 1991;41:3438.
Sloan MA, Kittner SJ, Feeser BR, et al. Illicit drug associated ischemic stroke in the Baltimore Washington Stroke Study. Neurology 1998;50:16881698.
Stolerman I. Drugs of abuse: behavioral principles, methods and terms. Trends Pharmacol Sci 1992;13:170176.
Weinrieb RM, O'Brien CP. Persistent cognitive deficits attributed to substance abuse. Neurol Clin 1993;11:663691.
CHAPTER 159. IATROGENIC DISEASE
MERRITTS NEUROLOGY
CHAPTER 159. IATROGENIC DISEASE

LEWIS P.ROWLAND
Suggested Readings
The growing number of drugs used to treat human disease and the growing number of invasive procedures used for diagnosis and therapy have generated a new
class of illness. Twenty years ago, 3% of admissions to Boston hospitals were due to adverse drug reactions, and 30% of all patients in those hospitals had at least
one adverse drug reaction. Neurologic reactions accounted for 20% of all adverse reactions in another study. In 1996, Nelson and Talbert found that 16% of
admissions to an intensive care unit in Texas were drug-related. In Australia, according to Roughead and associates (1996), 12% of all admissions to medical wards
were drug-related, as were 15% to 22% of all emergency admissions.
A partial list of the neurologic syndromes seems formidable at first glance ( Table 159.1), and it is important to keep some perspective. The drugs listed do not cause
an adverse reaction every time they are used. For example, penicillin is high on the list of drugs that cause convulsive encephalopathies, but only a few cases have
been recorded. Most of the other disorders are rare.
TABLE 159.1. ADVERSE NEUROLOGIC REACTIONS DUE TO DRUGS OR PROCEDURES FOR DIAGNOSIS OR THERAPY
Some reactions, however, are common. Tardive dyskinesia is a price paid by many individuals for control of mental disorders, and levodopa-induced dyskinesia is the
exchange many make for control of parkinsonism. Cerebral hemorrhage or femoral neuropathy due to retroperitoneal hemorrhage is the price a few patients pay for
the prevention of stroke in many other patients. Drug-induced confusion and ataxia are common effects of anticonvulsants, and mental dulling or poor school
performance are matters of concern for those who treat epilepsy. The adverse effects of radiotherapy limit our treatment of brain tumors. Control or elimination of
these effects by alternative agents or procedures therefore has high priority in the therapeutic needs of neurology. The same must be said for the adverse effects of
drugs used to treat neurologic disease that may damage other organs (e.g., corticosteroids, immunosuppressive drugs, antineoplastic drugs). There is even concern
that levodopa may accelerate the course of Parkinson disease; on balance this seems unlikely.
It is sometimes difficult to list the rare side effects of a drug without inappropriately frightening patients or physicians. When considering the list of adverse reactions,
one must consider the relative risks and the benefits expected from the use of specific drugs or specific procedures; patients must understand the tradeoffs involved if
they are to be able to give truly informed consent.
There is another aspect of these drug reactions: Some have had what might be considered beneficial effects. For instance, the neuroparalytic accidents that followed
the use of rabies vaccine led to the discovery of experimental autoimmune encephalomyelitis, and this in turn has had a lasting impact on our concepts of multiple
sclerosis. In the meantime, rabies vaccine has been revised and now rarely leads to neurologic disease. Similarly, penicillamine-induced myasthenia gravis (MG) is a
rare syndrome, but it has led to valuable observations about the nature of MG. Penicillin has also become important in the study of experimental epileptic neurons.
Other drugs have been used to analyze the nature of peripheral neuropathies; some act on Schwann cells or myelin, others on the perikaryon, and others distally on
the axon. Understanding the pathogenesis of some adverse reactions may lead to improved medical care in areas beyond the direct impact of the drugs involved.
New syndromes have arisen from these reactions. For instance, epidural lipomatosis was first recognized as a complication of steroid therapy, then a consequence of
obesity, then an idiopathic disorder and finally a complication of anabolic steroid abuse by body builders. Another example is the serotonin syndrome, which is most
often caused by use of serotonin-reuptake inhibitors. The Sternbach (1991) criteria for diagnosis are three: (1) After a serotoninergic drug is started or its dosage
increased, three of the following appear: altered mental state, agitation, myoclonus, hyperreflexia, shivering, tremor, diarrhea, or incoordination. (2) Other possible
etiologies are excluded, including infection, metabolic aberration, or substance abuse. (3) No other antipsychotic drug has been started or increased in dosage.
Although numerous drugs can be responsible, several are often used by neurologists, such as sumatriptan succinate (Imitrex) for migraine and selegeline
hydrochloride (Eldepryl) for Parkinson disease. Recognition of the syndrome and withdrawal of the offending drug are followed by reversal of symptoms.
The problems do not stop with drugs. Many procedures generate their own problems, including bone marrow transplantation, organ transplantation, brain implants,
plasmapheresis, intravenous immunoglobulin therapy, pumps for intrathecal delivery of drugs, and more. The complications of a single therapy may take diverse
forms; for instance, bone marrow transplantation may cause a graft-versus-host reaction and immunosuppression may also lead to central nervous system infections
by bacteria, fungi, or viruses. Intensive care units are life-saving but also fraught with hazards.
Drugs and procedures are not the only iatrogenic disorders. The attitude and behavior of a physician can also contribute to chronic disability in patients. Both
physicians and patients seem to prefer a serious diagnosis of nerve or muscle rather than confront the possibility that symptoms may be psychogenic. Modern
epidemics of chronic fatigue syndrome, chronic Epstein-Barr syndrome, and chronic Lyme disease are new incarnations of psychasthenia and neurasthenia;
physicians have a responsibility in propagating these disorders by emphasizing immunologic and other hypothetical disorders, even though study after study has
shown the importance of psychosocial factors.
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CHAPTER 160. COMPLICATIONS OF CANCER CHEMOTHERAPY
MERRITTS NEUROLOGY
CHAPTER 160. COMPLICATIONS OF CANCER CHEMOTHERAPY

MASSIMO CORBO AND CASILDA M.BALMACEDA
Antineoplastic Drugs
Immunosuppressant Drugs
Biologic Response Modifiers
Bone Marrow Transplantation
Suggested Readings
ANTINEOPLASTIC DRUGS
Antitumor chemotherapy may be toxic to both the peripheral and central nervous system (CNS). Several antineoplastic drugs may induce more than one side effect,
causing different neurologic disorders ( Table 160.1). The incidence of neurotoxicity may depend on dosage, route and schedule of administration, patient age and
general medical condition, and the combination with other neurotoxic drugs or with radiation therapy.
TABLE 160.1. NEUROTOXICITY OF ANTINEOPLASTIC DRUGS
Peripheral Nervous System Toxicity
The vinca alkaloids, vincristine sulfate and vinblastine sulfate (Velban), may cause a sensorimotor neuropathy. Vincristine binds to tubulin and disrupts microtubules of
the mitotic apparatus of cell division, arresting cells in metaphase. The effect on microtubules involved in axoplasmic transport may be responsible for axonal
neuropathy. The severity of symptoms is related to total dose and duration of therapy. Distal paresthesia is the most common symptom, occurring in about 50% of
patients. Later, there is distal sensory loss with weakness of the intrinsic hand muscles and the foot and toe dorsiflexors. Sensation is impaired more than motor
function. Tendon reflexes are depressed. Although sensory loss tends to persist, paresthesia and weakness improve when dosage is reduced or therapy stopped.
Cranial neuropathies tend to be bilateral; unilateral symptoms may suggest metastatic disease. Oculomotor paresis and transient vocal cord paralysis have been
reported. Jaw pain results from trigeminal nerve toxicity, occurs suddenly or within 3 days after administration, and resolves spontaneously in a few days, usually
without recurring with subsequent doses. An autonomic neuropathy may affect the gastrointestinal tract, causing abdominal pain and constipation in 45% to 60% of
patients. Paralytic ileus may follow. Other manifestations include urinary retention, impotence, and orthostatic hypotension. Vincristine neurotoxicity may be more
severe in patients with increased age, preexisting neuropathy, and liver dysfunction and in combination with with asparaginase (Elspar) or etoposide (VePesid).
Muscle cramps may be the first symptom of neurotoxicity. Patients previously treated with other spindle poisons, such as paclitaxel (Taxol), may not tolerate
vincristine. Vinorelbine (Navelbine), a new semisynthetic vinca alkaloid, has less severe neurotoxicity, presumably because of weaker activity on axonal microtubules.
Cisplatin (Platinol) causes a dose-dependent, predominantly sensory polyneuropathy when given intravenously or after intraarterial treatment. Neuropathy follows a
total cumulative dose greater than 300 to 500 mg/kg and is usually reversible by terminating therapy. Rarely, symptoms begin and progress when cisplatin is
discontinued. The dorsal root ganglia are the most vulnerable structures, followed by peripheral nerves. Large myelinated fibers are most susceptible; proprioceptive
sensory loss may be profound, with marked sensory ataxia. The motor system is spared. The adrenocorticotropic hormone analogs, glutathione, and nimodipine
(Nimotop) may be neuroprotective when given concomitantly. Autonomic neuropathy is rare. Hearing loss is due to toxic effects on cochlear hair cells and may be
irreversible. Neuropathies of cranial nerves III, V, and VI may follow intracarotid infusion. Lhermitte symptom is due to drug effects or may suggest spinal cord
metastasis.
Carboplatin (Paraplatin), a cisplatin analog, has less severe neurologic toxicity but more pronounced hematologic toxicity. Oxaliplatin has a dose-limiting neurotoxicity,
producing an acute neuropathy at a dose of 135 mg/m 2. The taxanes, paclitaxel and docetaxel (Taxotere), make microtubules excessively stable and thereby inhibit
cell division. Paclitaxel produces a predominantly axonal sensory neuropathy after a single dose of 250 mg/m 2 or at lower doses with repeated treatment. Of treated
patients, 50% to 90% are affected, depending on dosing regimens, and axonal sensory neuropathy may be the main dose-limiting toxicity. Early symptoms include
distal numbness and tingling; examination reveals loss of tendon jerks and impaired perception of vibration. Proximal limb weakness and myalgia have been
described. The neurotoxicity of the combination of docetaxel and cisplatin is more severe than when either medication is given alone. Less frequently, peripheral
nerve dysfunction may also be caused by other antineoplastic agents, including suramin, cytarabine (Cytosar-U), fludarabine phosphate (Fludara), procarbazine
hydrochloride (Matulane), and etoposide.
Central Nervous System Toxicity
Most chemotherapeutic agents penetrate the bloodbrain barrier poorly, and acute neurotoxicity is uncommon. However, symptoms and signs of CNS dysfunction
may be induced by ifosfamide (IFEX) (10% to 30%), fludarabine (10% to 38%), asparaginase (15% to 40%), and procarbazine (less than 14%). 5-Fluorouracil (5-FU)
neurotoxicity is rare (5%) but includes an acute cerebellar syndrome with dysarthria, dysmetria, ataxia, vertigo, and nystagmus. The symptoms usually clear within 1
to 6 weeks after drug withdrawal. An inflammatory leukoencephalopathy with enhancing white matter lesions on magnetic resonance imaging (MRI) may follow
combined administration of 5-FU and levamisole hydrochloride (Ergamisol). Vacuolar and necrotic lesions are found particularly in the brainstem and cerebellum. A
cerebellar syndrome is also the most common neurologic adverse effect of high-dose cytarabine therapy (3 g/m 2 every 12 hours for 12 doses per course). Other
manifestations are anosmia, somnolence, optic atrophy, bulbar and pseudobulbar palsies, and hemiparesis. The frequency of CNS side effects is 6% to 47%, usually
within 1 week after the first dose. Patients older than 60 years may be at increased risk. Symptoms often subside within weeks. Complications after intrathecal
administration of cytarabine include meningismus, seizures, or paraparesis, often with pain and loss of sensation. Although CNS toxicity is uncommon with vincristine
treatment, intrathecal administration may cause seizures, encephalopathy, or myelopathy.
High doses of chemotherapy in conjunction with stem cell support or bone marrow transplantation may result in neurotoxicity that is not seen with conventional doses.
This occurs with the alkylating agents busulfan (Myleran), the nitrosoureas, or thiotepa (Thioplex), as well as with etoposide. High-dose or intracarotid therapy with
carmustine (BiCNU) may cause encephalopathy or retinopathy. Carotid artery injection of cisplatin may cause loss of vision or seizures. Drug streaming after
intraarterial infusion may expose local areas of brain to extremely high concentrations of the drug, resulting in focal cerebral necrosis.
Methotrexate in conventional doses has little or no neurotoxicity when given intravenously, but high-dose therapy may cause an acute strokelike encephalopathy. This
syndrome usually occurs abruptly several days after the initiation of therapy and resolves within days after treatment stops. It is characterized by seizures, confusion,
hemiparesis, speech disorders, and loss of consciousness. A vascular or embolic etiology has been postulated. Intrathecal methotrexate therapy, used in the
prophylaxis of meningeal leukemia and in the treatment of leptomeningeal carcinomatosis, may induce an acute arachnoiditis in 5% to 40% of patients. Starting a few
hours after drug administration, the syndrome includes headache, nausea, vomiting, fever, back pain, dizziness, meningismus, and signs of increased intracranial
pressure. It usually resolves within a few days. If methotrexate is given intrathecally two to three times a week, a subacute myelopathy or encephalopathy may follow.
Subacute methotrexate neurotoxicity seems to be mediated by release of adenosine, and it is relieved by giving aminophylline, which displaces adenosine from its
receptor.
A chronic delayed leukoencephalopathy may be caused by intravenous high-dose methotrexate, with symptoms beginning several months after the start of treatment
and involving personality changes followed by dementia, focal seizures, spasticity, and alterations in consciousness. Most patients show improvement if treatment
ceases. A progressive leukoencephalopathy may also be seen in patients given methotrexate intrathecally combined with prophylactic cranial radiotherapy. Computed
tomography (CT) or MRI shows extensive, deep, bilateral white matter lesions. Calcification may be observed in children. The syndrome typically follows a delay of 1
to 2 years and is a major problem in patients successfully treated for leukemia. Although the combined effects of methotrexate and radiation are held responsible
rather than the methotrexate alone, this combination is still considered an important strategy for the treatment of acute lymphoblastic leukemia. However, the
incidence of leukoencephalopathy (18%) following treatment with intrathecal moderate-dose methotrexate (8 to 12 mg/m 2; cumulative dose, 24 to 90 mg) and
prophylactic radiotherapy (18 to 24 Gy) appears to be less than that following treatment with intravenous high-dose methotrexate (50% to 68%). Rarely, a focal
leukoencephalopathy is seen if the Ommaya reservoir tip is misplaced in the white matter. Leukoencephalopathy has also been described after oral methotrexate
therapy for rheumatoid arthritis.
IMMUNOSUPPRESSANT DRUGS
Cyclosporine (Sandimmune) is the mainstay therapy in preventing organ transplant rejection. It acts by inhibiting interleukin-2 (IL-2) production by T cells and is
successful in suppressing T-cell response to transplantation antigens and thus prolonging graft survival. In addition to nephrotoxicity and hypertension, neurotoxicity
in 8% to 47% of patients includes tremor, paresthesias, seizures, lethargy, ataxia, and quadriparesis. Toxicity, more frequently observed with serum levels greater
than 500 ng/mL, may also cause a cerebral blindness that is usually reversible, improving with cessation of therapy or dose reduction. Reversible cerebral white
matter lesions are seen on CT or MRI; cortical lesions in both occipital lobes may be present. Hemiparesis may suggest that cyclosporine focally damages blood
vessels, but the frequency of cyclosporine neurotoxicity increases in HLA-mismatched and unrelated donor transplants, suggesting that immune factors play a role.
Cyclosporine induces activity of the hepatic cytochrome P-450, which also mediates drug oxidation. Consequently, hepatic dysfunction or concomitant administration
of agents that induce the P-450 system can cause increased or reduced concentrations of cyclosporine in blood. In the circulation, cyclosporine is bound to
lipoproteins; a reduction in serum cholesterol to less than 120 mg/dL may increase free-drug levels and neurotoxicity. Corticosteroids also increase plasma
cyclosporine levels.
OKT3, a powerful immunosuppressive drug, is the first monoclonal murine antibody to become available for therapy in humans. It is used to treat acute allograft
rejection. An asymptomatic cerebrospinal fluid pleocytosis occurs in most patients so treated. Neurologic complications may develop within hours of administration
and include altered mental function, seizures, and lethargy. Contrast-enhancing cerebral lesions may be seen on MRI. Aseptic meningitis, visual loss, and transient
sensorineural hearing loss are other adverse effects.
Tacrolimus (Prograf) has cyclosporine-like activity and is approved for immunosuppression in organ transplantation, particularly if organ rejection is not responsive to
OKT3 therapy. It may cause acute tremor, headache, and paresthesias, but neurotoxicity occurs in only 5% to 10% of patients. Neurologic symptoms begin when the
tacrolimus level in blood is at a peak, and eventually resolve after the dose is reduced or stopped. In a tacrolimus-related leukoencephalopathy, demyelination in the
parietooccipital region and centrum semiovale may be seen on MRI, as in the syndrome caused by cyclosporine. Clinical recovery is usually accompanied by reversal
of radiologic abnormalities. Transient cortical blindness and cerebellar symptoms have been described.
BIOLOGIC RESPONSE MODIFIERS
Cytokines, such as interferons and IL-2, are used as biologic response modifiers to treat cancer. Neurotoxic effects include vertigo, memory loss, confusion, emotional
instability, somnolence, depression, seizures, and hemiparesis. Cytokine-related encephalopathy is self-limited and probably related to increased levels of circulating
cytokines after renal allografting. Risk factors include delayed graft function, cadaveric transplantation, and diabetes. Corticosteroid treatment may be helpful.
BONE MARROW TRANSPLANTATION
Bone marrow transplantation (BMT) of cells from an HLA-matched donor is widely used to treat refractory leukemia or myelodysplastic conditions. It often results in an
immunologic reaction of donor T lymphocytes against recipient tissues, called graft-versus-host-disease (GVHD). Acute GVHD involves the skin, gastrointestinal tract,
and liver. Chronic GVHD occurs in 30% to 40% of patients who survive more than 100 days. Manifestations include altered immune function,
hypergammaglobulinemia, increased susceptibility to viral infection, and symptoms of collagen-vascular disease. Neurologic disorders of chronic GVHD are
polymyositis, myasthenia gravis, sensorimotor neuropathy, aseptic meningitis, or leukoencephalopathy. Remission of neurologic toxicity may follow successful
treatment of GVHD with steroids and immunosuppressive drugs.
The most common neurologic complications in patients who undergo allogeneic or autologous BMT are cerebral hemorrhage (4%), metabolic encephalopathy (3%),
and CNS infections (2%). Hemorrhages are most common with autologous BMT, are mostly subdural, and are attributed to thrombocytopenia. A post-BMT
leukoencephalopathy occurs particularly in patients who have had prior cerebral irradiation. It is characterized by focal signs, lethargy, confusion, and progressive
deterioration. An acute parkinsonian syndrome has been described. Progressive multifocal leukoencephalopathy may occur in immunocompromised patients after
autologous or allogeneic BMT for chronic myelogenous leukemia. The most common neuropathologic findings in patients undergoing BMT are cerebrovascular
lesions, including areas of hemorrhagic necrosis and infarction.
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Antineoplastic Drugs
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Immunosuppressant Drugs: General
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Cyclosporine and Tacrolimus
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OKT3
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Biologic Response Modifiers
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Licinio J, Kling MA, Hauser P. Cytokines and brain function: relevance to interferon-alpha-induced mood and cognitive changes. Semin Oncol 1998;25:3038.
Michel M, Vincent F, Sigal R, et al. Cerebral vasculitis after interleukin-2 therapy for renal cell carcinoma. J Immunother Emphasis Tumor Immunol 1995;18:124126.
Bone Marrow Transplantation
Amato AA, Barohn RJ, Sahenk Z, et al. Polyneuropathy complicating bone marrow and solid organ transplantation. Neurology 1993;43:15131518.
Anderson BA, Young PV, Kean WF, et al. Polymyositis in chronic graft-versus-host disease. Arch Neurol 1982;39:188190.
Bolger GB, Sullivan KM, Spence AM, et al. Myasthenia gravis after allogeneic bone marrow transplantation: relationship to chronic graft-versus-host disease. Neurology 1986;36:10871091.
Ferrara JLM, Deeg HJ. Graft-versus-host disease. N Engl J Med 1991;324:667674.
Graus F, Saiz A, Sierra J, et al. Neurologic complications of autologous and allogeneic bone marrow transplantation in patients with leukemia: a comparative study. Neurology 1996;46:10041009.
Lockman LA, Sung JH, Krivit W. Acute parkinsonian syndrome with demyelinating leukoencephalopathy in bone marrow transplant recipients. Pediatr Neurol 1991;7:457463.
Owen RG, Patmore RD, Smith GM, Barnard DL. Cytomegalovirus-induced T-cell proliferation and the development of progressive multifocal leucoencephalopathy following bone marrow
transplantation. Br J Haematol 1995;89:196198.
Provenzale JM, Graham ML. Reversible leukoencephalopathy associated with graft-versus-host disease: MR findings. AJNR 1996;17:12901294.
Seong D, Bruner JM, Lee KH, et al. Progressive multifocal leukoencephalopathy after autologous bone marrow transplantation in a patient with chronic myelogenous leukemia. Clin Infect Dis
1996;23:402403.
Snider S, Bashir R, Bierman P. Neurologic complications after high-dose chemotherapy and autologous bone marrow transplantation for Hodgkin's disease. Neurology 1994;44:681684.
Tahsildar HI, Remler BF, Creger RJ, et al. Delayed, transient encephalopathy after marrow transplantation: case reports and MRI findings in four patients. J Neurooncol 1996;27:241250.
CHAPTER 161. OCCUPATIONAL AND ENVIRONMENTAL NEUROTOXICOLOGY
MERRITTS NEUROLOGY
CHAPTER 161. OCCUPATIONAL AND ENVIRONMENTAL NEUROTOXICOLOGY

LEWIS P.ROWLAND
Heavy Metal Intoxication

Other Intoxications
Suggested Readings
Neurotoxicology commands newspaper attention these days. Is there a Gulf War syndrome? Did exposure there to anticholinesterase nerve gases cause amyotrophic
lateral sclerosis (ALS)? Do silicon breast implants cause autoimmune disorders, including multiple sclerosis? Are behavioral changes due to subclinical occupational
exposure? Do nearby petrochemical plants or high power electrical lines increase the incidence of brain tumors? Can mercury intoxication result from inhalation of the
element from dental amalgams and can that cause multiple sclerosis, ALS, or other diseases? These and similar questions have been debated in an atmosphere of
contentious uncertainty. In this chapter we focus on the particular clinical syndromes that result from exposure to heavy metals, solvents, and natural neurotoxins
(Table 161.1). Clinical diagnosis, laboratory proof of diagnosis, and treatment are the practical issues. We bypass detailed discussion of behavioral effects from
chronic low-level exposures as beyond the scope of this chapter. More detailed information is provided in the General section of Suggested Readings.
TABLE 161.1. NEUROTOXIC SYNDROMES
HEAVY METAL INTOXICATION
Pathogenesis
The heavy metals have diverse toxic effects on cell nuclei, mitochondria, other organelles, cytoplasmic enzymes, and membrane lipids. Clinical syndromes may result
from combinations of these effects that do not readily explain the real-life disorders or why the assault should affect the central nervous system (CNS) in some people,
peripheral nerves in others, or both.
Lead provides an example of the complexity. It interferes with the sulfhydryl enzymes of heme biosynthesis, especially d-aminolevulinic acid dehydratase,
coproporphyrin oxidase, and ferrochetalase. As a result of these partial blocks, several metabolites accumulate in blood and urine: d-aminolevulinic acid,
coprophorphyrin III, and zinc protoporphyrin. Other heme-containing enzymes are also affected, including cytochrome P450 in the liver and mitochondrial cytochrome
c oxidase. Lead also interferes with calcium-activated enzymes, calcium channels, and Ca 2+-ATPase. Lead has similarly multiple and diverse biochemical ill effects
on cell metabolism. Sorting out these interactions and their relationship to the clinical syndromes is not a simple task, and there is even less basic information about
other neurointoxicants.
Nevertheless, metals and biologic toxins have been used experimentally to analyze the pathogenesis of the neuropathies according to effects on axons, myelin, or
Schwann cells.
Recognizing Intoxication Clinically
The clinical manifestations of an intoxication can result from diverse causes. Other possible causes must therefore be excluded ( Table 161.2) by considering systemic
or metabolic disease and evaluating therapeutic drugs the patient may be taking. More reliable diagnosis depends on the recognition of exposure by occupation or
recreation, recognition of a specific syndrome and elimination of other causes (as in the acute lead encephalopathy of childhood), or associated laboratory
abnormalities. Outbreaks or clusters may be encountered with the relatively mild symptoms of glue sniffing or the devastating encephalomyelopathy of Minamata
disease in Japan, which was caused by methyl mercury. The circumstances of attempted suicide or fire usually identify carbon monoxide exposure; a motor running in
a parked automobile or a faulty gasoline-fueled heater are most often responsible. For the following discussions, the primary at-risk occupations are listed in Table
161.1 and are not repeated in the text.
TABLE 161.2. CLUES TO THE DIAGNOSIS OF INTOXICATIONS
Acute Encephalopathy
Syndromes of confusion, hyperactivity or somnolence, memory impairment, and behavioral change arise from many different disorders, as described under delirium in
Chapter 1. The acute encephalopathy of lead poisoning is one that affects children; seizures and increased intracranial pressure without a mass lesion may be clues
to diagnosis. The circumstances of intoxication may be evident as in glue sniffing or dialysis dementia. Heavy metal intoxication is not encountered frequently among
the causes of delirium but may be the result of attempted murder by poisoning.
Chronic Encephalopathy
Dementia with or without tremor can be a manifestation of occupational exposure to heavy metals. Therefore, when confronted with a patient who may have been
poisoned, it may be more important to know the occupational history than to order a sweeping laboratory survey of blood and urine. Mercury intoxication may be more
often associated with tremor than other exposures, but this is probably not a reliable guide. Parkinsonism can arise in workers in manganese smelters; monitoring
guidelines are not always heeded. Parkinsonism may also follow chronic exposure to carbon disulfide.
Peripheral Neuropathy
Neuropathy may be caused by any heavy metal, almost always the result of occupational exposure. The symptoms are those of any sensorimotor neuropathy with
acroparesthesia and distal limb weakness. Optic and autonomic neuropathies seem to be rare. A hallmark of thallium neuropathy is baldness. The neuropathy of
organophosphate poisoning may be accompanied by upper motor neuron signs that imply a myelopathy; sometimes the residual signs include those of the lower
motor neuron but the occupational history and the sensory loss differentiate the syndrome from motor neuron disease.
Cranial Neuropathy
Trichlorethylene causes a selective sensory neuropathy of the trigeminal nerve; the syndrome is so specific that it was once seriously evaluated as a treatment for
idiopathic trigeminal neuralgia. Visual loss from optic neuropathy or retinopathy is a manifestation of methanol toxicity and many therapeutic drugs.
Specific Clinical Syndromes of Intoxication
Lead
Acute lead encephalopathy in children was first recognized in 1904 and even then was attributed to lead-containing house paint. The syndrome also occurs in adults
who are occupationally exposed. The childhood syndrome has been linked to pica, the ingestion of flaking lead-containing paint on the walls of old houses. Inhalation
of dust from the ancient paint is another important source of household contamination and makes paint removal hazardous, especially when the paint is burned.
Because symptoms are difficult to detect in toddlers, the Centers for Disease Control and Prevention advocates periodic screening of blood lead for all children aged
9 to 36 months. That policy has been debated, but recognition and treatment can prevent the sometimes devastating cerebral consequences. Blood lead levels in
U.S. children declined by 78% largely because lead was removed from automobile gasoline and also because lead has been eliminated from house paint. Acute lead
encephalopathy is now rare in the United States. However, it is feared that early lead exposure can adversely affect later behavior and school performance. Evidence
from several sources suggests that higher blood lead levels are associated with lower IQ. Because of increasing doubt about the efficacy of chelation therapy,
prevention is now the goal, as described below.
Lead neuropathy is probably restricted to heavy occupational exposure, which is monitored by regulations established by the Occupational Safety and Health
Administration; overt neuropathy is rare. Cases attributed to retained bullets in the abdomen or drinking from lead-lined glasses require confirmation by biochemical
markers lacking in published reports. Traditionally, the characteristic syndrome of lead neuropathy is confined to motor fibers restricted to or especially involving the
radial nerve. However, the presence of visible fasciculation and brisk reflexes or frank upper motor neuron signs suggests that this could be a myelopathy similar to
that of ALS. However, there have been no convincing case reports of an ALS-like syndrome in lead workers since 1974.
Mercury
The relations between elemental, inorganic, and organic forms of mercury involve transformations from one form to another. Chronic occupational exposure to
mercury may lead to the Mad Hatter syndrome, which is dominated by a tremor resembling essential tremor but which can be severe, even affecting head and trunk.
Memory loss, social withdrawal, and emotional lability may be prominent. Similar symptoms may result from exposure to inorganic mercury, which is presumably
broken down to elemental mercury in the environment. Inorganic mercury is more likely to cause a sensorimotor neuropathy.
Mercury was held responsible for Minamata disease, which affected 2,500 people near the bay of that name in Japan. The outbreak illustrates the conversion of
inorganic mercury to more toxic organic mercury by fish. A factory was using mercuric chloride in the manufacture of vinyl chloride. Waste material from the plant was
discharged into the bay, ingested by fish, and converted into more toxic methylmercury. The fish were eaten by people, who were also intoxicated. The syndrome
comprised cognitive change, cerebellar ataxia, and sensorimotor neuropathy. Visual loss was often severe and may be related to damage of the occipital cortex.
Symptoms progressed for 3 to 10 years.
Arsenic
Acute arsenic poisoning is a multisystem disaster: vomiting, bloody diarrhea, myoglobinuria, renal failure, arrhythmias, hypotension, seizures, coma, and death. In
survivors, Mees lines on the fingernails and sensorimotor neuropathy appear in 7 to 14 days. Sensory symptoms dominate, and weakness is more profound in the
legs than in the arms and hands. Slow and incomplete recovery takes years. Nerve conduction velocities are typically slow. Cognition may be impaired in some
survivors, depending on the severity of the acute encephalopathy.
Intoxication by inhalation may be acute or chronic. The chronic version is blackfoot disease with vascular changes and gangrene and a less severe peripheral
neuropathy. Most arsenic exposure is occupational, but arsenic contamination of groundwater is a growing problem in poverty areas of India and elsewhere. The use
of arsenic trioxide to treat leukemia may also be followed by arsenic neuropathy.
Thallium
A rare syndrome, thallium intoxication is usually the result of unwittingly ingesting a rat poison. The acute episode is dominate by gastrointestinal symptoms.
Paresthesias may be noted soon afterward, but overt signs of neuropathy may take 2 weeks to appear. The encephalopathy may include cognitive impairment and
choreoathetosis, myoclonus, or other involuntary movements. The unique clue to diagnosis is loss of hair, which begins 1 to 3 weeks after exposure. Neuropathy and
dermatitis may be prominent in chronic exposure.
Manganese
George Cotzias, discoverer of the therapeutic value of levodopa in Parkinson disease, followed an unusual path to that achievement. He was a biochemist, interested
in the role of metals in enzyme activity. Manganese was one such metal and that took him to an outbreak of parkinsonism in South American miners. At about that
time, Hornykewicz identified the lack of dopamine in the substantia nigra of patients with Parkinson disease; Cotzias gave the precursor in amounts larger than others
had used previously.
Manganese intoxication reproduces the essential motor features of Parkinson disease but with sufficient clinical and pathologic differences to indicate the conditions
are not identical. The outlook is gloomy, including severe cognitive loss. Responses to levodopa and to chelation therapy are limited.
Aluminum
Dialysis dementia has been attributed to the presence of aluminum in the dialysis water and also in ingested phosphate binders used to control blood phosphorus
levels. Treatment of the water and avoidance of the binders have decreased the incidence of the syndrome. Encephalopathy, however, has also occurred in uremic
patients dialyzed with deionized water and also in some who took the binders without dialysis, implying that abnormal retention of aluminum is a characteristic of
uremia.
Paresthesias and weakness were part of potroom palsy, a complex syndrome in workers in a smelter who were exposed to pots that had not been vented properly.
Other manifestations included ataxia, tremor, and memory loss.
Biochemical Diagnosis
Measurement of blood lead levels is the time-honored diagnostic method even though technical variations render values somewhat uncertain in individual cases. The
mean whole blood level in adults who are not exposed to occupational hazards is less than 5 g/dL. Standard recommendations now consider levels safe up to 30
g/dL; some consider a higher safe limit, 50 g/dL. Workers are monitored closely if levels exceed 40 g/dL. The upper limit of lead in urine is 150 g/g creatinine.
Peripheral neuropathy is usually accompanied by blood lead levels greater than 70 g/dL.
In children, the warning mark is a blood lead level of 10 g/dL, and estimates suggest that 1.7 million children still have higher levels. Children with levels exceeding
10 g/dL are more likely to be African-American, poor, and living in large cities. For them, the major source of poisoning is lead paint, followed by contaminated soils
and dust. Chelation therapy commences with levels of 40 g/dL. Testing blood lead levels is recommended for children with presumed autism, attention deficit
disorder, pervasive development disorder, mental retardation, or language problems. The blood lead level is considered a more reliable indicator than the biochemical
tests mentioned below.
A provocative test with Ca-EDTA has been advocated but has been used less and less often. The patient is given 500 mg/m 2 Ca-EDTA in 5% glucose infused in 1
hour. If urinary lead excretion in the next 8 hours exceeds 60% of the amount of EDTA given, the test is positive, that is, the chelator is presumed to have combined
with and mobilized excessive body stores of lead. The test is cumbersome, and reliability is debated.
A diagnosis of lead intoxication is supported if blood zinc protoporphyrin exceeds 100 g/dL or if urinary aminolevulinic acid excretion is higher than 15 mg/L. With
blood lead levels of 10 g/dL, the activity of aminolevulinic acid dehydratase is low. At higher lead levels, the activities of coproporphyrinogen oxidase and
ferrochetalase are also low. Anemia and basophilic stippling of erythrocytes are characteristic. No other neurotoxin generates similarly specific biochemical
abnormalities that can be used diagnostically. Nerve conduction velocities are nonspecifically slow in lead and other neuropathies.
The diagnosis of arsenic intoxication is confirmed by urinary levels greater than 75 g/dL. Hair analysis has been used but is not deemed reliable. The
length-dependent neuropathy is primarily axonal with secondary demyelination.
After acute exposure, blood tests are not useful for detecting thallium because the metal is taken up by cells so rapidly that blood levels do not rise. Urinary thallium
can be detected by atomic absorption spectrometry. Normal urinary values are 0.3 to 0.8 g/L and levels of 200 to 300 are seen in overt poisoning. A provocative test
depends on KCl, which is given orally in a dose of 45 mEq. Potassium displaces thallium from tissue stores and blood levels rise, which can be detected by serial
measurement of urinary content.
Prevention and Treatment
Preventive measures have been most publicized for lead with special concern for the welfare of children. Education programs, paint removal, and deleading house
paints have all played a role. Personnel involved in deleading must be protected. Workers in industries at risk have been increasingly monitored and removed from
exposure when blood lead levels begin to rise. Motor nerve conduction studies have also been used.
Once symptoms of intoxication appear and the diagnosis of lead poisoning is clear, removal from exposure is mandatory. Chelation therapy can be instituted. For
children with blood levels less than 45 g/dL, oral treatment can be instituted with 2,3-dimercaptosuccinic acid and penicillamine. For acute encephalopathy and blood
levels more than 70 g/dL, Ca-EDTA and dimercaprol (2,3-dimercaptopropanol), also called British anti-Lewisite (BAL), can be used together, starting with BAL, 3 to 5
mg/kg intramuscularly; this is followed by simultaneous but separate intramuscular injections of both chelators given every 4 hours for the next 3 to 5 days. For
symptomatic neuropathy, Ca-EDTA can be used alone at doses of 50 to 75 mg/kg every 12 hours in a 3- to 5-day course and a 2- to 3-week rest between courses
until the blood level is normal. Treatment of the encephalopathy is also symptomatic or surgical.
Prevention of mercury intoxication requires monitoring in high-risk occupations, including dental offices, and correction of inadequate ventilation, avoiding vacuuming
of spilled mercury, and removal of workers whose urinary level has increased fourfold or is more than 50 g/L. Control of industrial pollution may require major effort.
If the person is symptomatic, treatment commences with dimercaprol, which is given intramuscularly 3 to 5 mg/kg every 4 hours for day 1, every 12 hours on day 2,
and then once a day for the next 3 days, followed by a 2-day interruption. Other agents are 2,3-dimercaptosuccinic acid and 2,3-dimercapto-propane-1-sulfonate, a
water-soluble form of BAL. All agents are somewhat effective for organic and inorganic mercury poisoning.
BAL therapy is also used for acute arsenic poisoning and is most effective before symptoms of neuropathy appear. BAL is considered more effective than
penicillamine in treating the chronic neuropathy. Hemodialysis is another treatment for the acute episode.
Aside from monitoring occupational exposure to thallium, an important preventive measure is protection of children against the ingestion of candylike pellets.
Treatment of acute poisoning depends in part on enhancing urinary and fecal excretion of thallium by giving laxatives and using Prussian Blue or activated charcoal to
retard absorption. Urinary excretion is enhanced by forced diuresis and administration of KCl; hemodialysis may be effective.
OTHER INTOXICATIONS
Organophosphates
Organophosphates, sometimes in combination with carbamates, are used as pesticides by more than 2.5 million agriculture workers and also by amateur gardeners.
Also exposed are those engaged in the manufacture of these compounds and military personnel who use or store compounds designed for chemical warfare. It is
estimated that 150,000 to 300,000 people have pesticide-induced illness each year. Popular compounds include malathion, parathion, and others. Most are lipid
soluble and readily absorbed after ingestion, inhalation, or application to the skin. They are powerful inhibitors of acetylcholinesterase.
Three clinical stages follow in sequence. First, acute cholinergic crisis comprises nicotinic effects (limb weakness, fasciculation, tachycardia) and muscarinic
manifestations (miosis, lacrimation, salivation). CNS signs include ataxia, seizures, altered consciousness, and sometimes coma. Second, the intermediate syndrome
appears in 2 to 4 days after exposure. Weakness may be profound, affecting the proximal limbs, cranial muscles, neck flexors, and respiration; tendon reflexes are
lost. The differential diagnosis includes the Guillain-Barr syndrome, periodic paralysis, and myasthenia gravis. Among survivors, recovery may be slow but is the
rule. Third, organophosphate-induced delayed neuropathy appears 1 to 5 weeks after exposure. The syndrome was first described during the period of prohibition in
the United States when illicit whiskey was made in home stills: 50,000 people consumed Jamaica Ginger or Jinger Jake that was later found to contain
triorthocresyl phosphate. Paresthesias and distal leg weakness appeared weeks later. Triorthocresyl phosphate is not an anticholinesterase, but the syndrome was
then seen after exposure to cholinergic organophosphates. The disorder as been attributed to inhibition of neuropathy target esterase, disruption of axonal transport,
and a dying back neuropathy. Although paresthesias may be noted, the disorder is dominantly motor. Among survivors, upper motor neuron signs implicate the CNS,
which in combination with profound lower motor neuron signs may simulate ALS except that there is no progression for years.
Exposure can be documented by levels of the drug or its metabolites in blood or urine. Measurement of red cell or plasma cholinesterase is an indirect marker. In
electrodiagnostic studies there may be a repetitive response to a single nerve stimulus.
The acute disorder is a medical emergency risking death from respiratory paralysis. If the patient has been splashed, clothing must be stripped and the skin washed
thoroughly to prevent further absorption. Gastric lavage may be needed. Airway control and ventilation must be ensured and cardiac function monitored. Atropine is
the best antidote; subcutaneous doses of 0.5 to 1.0 mg are given every 15 minutes until an effect is observed in the form of dilated pupils, flushed face, dry mouth,
and dry skin with cessation of sweating. To suppress airway secretions, some give intravenous doses up to 2 mg every hour. Glycopyrrolate can be added to atropine.
Oxime therapy is also recommended in seriously ill patients. These compounds reactivate acetylcholinesterase and should be given as soon as possible after
exposure by continuous intravenous infusion.
Solvents and Organic Compounds
Hexacarbon neuropathy results from mixtures that produce 2,5-hexanedione. Outbreaks arise from industrial exposure to n-hexane, recreational abuse, and industrial
exposure to methyl-n-butyl ketone. Paresthesias and weakness appear distally in the legs and only later are the hands affected. Acutely, the syndrome may resemble
the Guillain-Barr syndrome, including slow conduction velocity. Alternatively, progression may be slow. Optic neuropathy is rare. The characteristic pathologic
change is neurofilamentous axonal swelling and distal axonal degeneration. Effective measures have been taken to reduce industrial exposure and to eliminate the
toxins from glues formerly used for glue sniffing. Epidemics have largely disappeared.
Other organic compounds that induce axonal neuropathy by industrial exposure are acrylamide, carbon disulfide, methyl bromide, and triorthocresyl phosphate. A
current debate is whether house painters are at risk for solvent-induced behavioral disorders.
Carbon Monoxide
Carbon monoxide intoxication is more often deliberate than accidental, about 600 a year accidentally in the United States and 5 to 10 times more often in suicide
attempts. Accidents are caused predominantly by automobile exhausts and poorly ventilated gasoline-powered heaters. Methylene chloride, a paint remover, is
another source. Toxicity results from issue hypoxia and direct damage to cellular structures. CO competes with oxygen for binding to hemoglobin; it binds to other
proteins, including myoglobin and cytochrome c oxidase.
Symptoms may be mild, simulating viral infection, or it may occur with another emergency, smoke inhalation. Nonspecific symptoms may comprise headache, malaise,
dizziness, nausea, difficulty concentrating, and dyspnea. A delayed neuropsychiatric syndrome may follow acute exposure by 3 to 240 days, with cognitive and
personality changes, parkinsonism, and psychotic behavior. Although the syndrome seems ominous, 50% to 75% of patients recover.
Diagnosis is made by finding high levels of carboxyhemoglobin. However, serum levels may have fallen by the time the patient reaches the emergency room.
Measurement of CO in expired air can therefore be useful. Blood taken at the scene by emergency technicians can be used.
Rescue from fires is of prime importance. Hospital admission is reserved for the more seriously affected or those with other medical problems. Oxygen is administered
because it shortens the half-life of carboxyhemoglobin. Hyperbaric oxygen therapy has been used with increasing frequency, but it is uncertain whether it hastens
recovery or reduces the rate of late sequelae. Coma is a clear indication for hyperbaric therapy. Prevention is largely a matter of monitoring equipment, monitoring
workers, and education about the hazards of running a motor vehicle in a closed space.
Nitrous Oxide Myelopathy (Layzer Syndrome)
In 1978, Layzer described 15 patients; 14 were dentists. Thirteen had abused nitrous oxide for 3 months to several years; 2 patients had been exposed only
professionally, working in poorly ventilated offices. Symptoms included early paresthesias, Lhermitte symptoms, ataxia, leg weakness, impotence, and sphincter
disturbances. Examination showed signs of sensorimotor polyneuropathy, often combined with signs implicating the posterior and lateral columns of the spinal cord in
a pattern identical to that of subacute combined system disease (SCD) due to B 12 deficiency. Electrodiagnostic tests showed axonal polyneuropathy; cerebrospinal
fluid and other laboratory results were normal. Layzer surmised that the gas interfered with the action of B 12.
Subsequent experience proved him correct. Additional cases were reported in abusers of nitrous oxide, and improvement was seen in weeks or months after exposure
ceased. Another version of the disorder was seen in people, including a vegetarian, who had hematologic evidence of B 12 deficiency but were asymptomatic until the
neurologic disorder was precipitated by nitrous oxide anesthesia for surgery. Magnetic resonance imaging shows the characteristic distribution of lesions in the spinal
cord.
Scott et al. (1981) reproduced the syndrome by maintaining monkeys in an atmosphere of nitrous oxide. If the diet was supplemented with methionine, the disorder
was prevented, but in controls, symptoms progressed to a moribund state; the spinal cord and peripheral nerves of the unsupplemented monkeys showed changes of
SCD. Inability to resynthesize methionine from homocysteine seemed responsible, and the primary lesion producing SCD in humans with pernicious anemia may also
be impaired synthesis of methionine biosynthesis. Cyanocobalamin is involved in the conversion of l-methylmalonyl coenzyme A to succinyl coenzyme A and the
formation of methionine by methylation of homocysteine, a reaction essential for DNA synthesis and for maintenance of the myelin sheath by the methylation of myelin
basic protein. Active vitamin B 12 contains cobalt and nitrous oxide produces irreversible oxidation of the Co 2+, rendering B12 inactive.
Seafood Intoxication
Ciguatera or the marine neurotoxic syndrome is the most common nonbacterial form of food poisoning in the United States and Canada. It is caused by eating tropical
reef fish that contain several toxins in edible parts; the toxins are thought to arise in dinoflagellates. It is endemic in subtropical regions, and food shipped to other
parts of the world spreads the disease. The acute symptoms are gastrointestinal followed by sensory symptoms, paresthesias, and pruritus. Sensory inversion
describes the peculiarity that cold feels hot and vice versa. Myalgia, fasciculations, areflexia, trismus, and carpopedal spasm may be noted. Respiratory failure is
exceptional. Other systems may be involved prominently, including pain on sexual activity.
None of the physical findings is diagnostic, and there are no formal criteria for diagnosis. Most associated toxins open sodium channels, but at least one affects
calcium channels. Peripheral nerve conduction velocities are often slow. Bioassays for the ciguatoxins or immunochemical methods are being developed, but none
has yet achieved approval by consensus. Treatment is therefore symptomatic.
Shellfish poisoning can result from contamination of mollusks by saxitoxin, which blocks sodium channels. The symptoms are similar to ciguatera but more severe,
and respiratory depression is a threat. The toxin originates in a dinoflagellate. In the series of De Carvalho et al. (1998), cerebellar ataxia was the dominant finding
and peripheral nerve conduction was normal. Recovery was rapid in those patients, but among those described by Gessner et al., 3 of 11 patients were treated with
mechanical ventilation and 1 died. Hypertension was also prominent. Binding assays and liquid chromatography identified the toxin in serum and urine. In Japan, the
agent of puffer fish poisoning is tetrodotoxin. Treatment of these conditions is symptomatic.
Methanol (Methyl Alcohol)
Methanol intoxication is seen in drinkers who take it as a substitute for ethanol. Acute poisoning was dominated by gastrointestinal symptoms, drunkenness, and
coma. Severe acidosis results from the conversion of methanol to formaldehyde and formic acid. Viscera and brain show petechial hemorrhages and edema. In the
series of Liu et al. (1998), the mortality rate was 36%; coma, seizures, and high methanol concentrations were predictors of poor prognosis. Visual loss is attributed to
retinal metabolism of methanol (rather than an action of circulating formic acid) because the local oxidation of methanol to formic acid parallels the depletion of retinal
ATP. Retinal glial cells may be the first target. It has therefore been suggested that inhibitors of aldehyde dehydrogenase could be therapeutic; here it would mean the
administration of ethanol to block the first step of the toxic metabolic pathway. For similar reasons, administration of ethanol blocks the metabolism of methanol in the
liver and unchanged toxin is excreted in the urine. 4-Methylpyrazole (fomepizole) has also been used for this purpose. Correction of acidosis and hemodialysis may
be used. Exposure to large amounts is fatal within 72 hours. Vision is usually restored in survivors, who incur no other chronic neurologic symptoms.
Obsolete Epidemics
Many syndromes described here could be eliminated if care were taken to protect the environment. In fact, some epidemics pointed the way to correction. For
instance, the outbreak of subacute myelo-optic neuropathy was attributed to an oral antiparasitic agent, clioquinol. The resulting peripheral neuropathy and blindness
affected an estimated 10,000 people in Japan. The practice has ceased, and there have been no new cases; investigations indicate that the drug is converted to a
potent mitochondrial toxin. Another transient outbreak was the eosinophilia-myalgia syndrome, which involved skin, muscle, lungs, and blood vessels and axonal
neuropathy. The disorder was attributed to a toxic contaminant in the preparation of tryptophan, which was taken as a health supplement. That syndrome has also
largely disappeared, but it seems likely that new epidemics will appear as new industries and new health fads arise.
SUGGESTED READINGS
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Arsenic
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CHAPTER 162. ABUSE OF CHILDREN
MERRITTS NEUROLOGY
CHAPTER 162. ABUSE OF CHILDREN

CLAUDIA A. CHIRIBOGA
Pediatric Acquired Immunodeficiency Syndrome and Human Immunodeficiency Virus Infection

Fetal Alcohol Syndrome
Fetal Cocaine Effects
The Battered Child
Suggested Readings
PEDIATRIC ACQUIRED IMMUNODEFICIENCY SYNDROME AND HUMAN IMMUNODEFICIENCY VIRUS INFECTION
Woman and children are the fastest-growing population affected by the acquired immunodeficiency syndrome (AIDS) and the human immunodeficiency virus (HIV).
Most children with AIDS in the United States are infected perinatally. In inner cities, about 2% to 4% of live births are HIV-1 antibody positive. Intravenous drug abuse
and sexual contact with HIV-infected partners are the maternal risk factors in more than 85% of perinatal cases. Most infections occur during the last trimester of
pregnancy and time of delivery. Risk factors for vertical transmission are recent maternal HIV seroconversion, high viral load, and maternal AIDS. Premature infants
are also at increased risk of infection. Infection may result from exposure to blood and other body fluids at delivery or transmitted in breast milk. Mother-to-child HIV
transmission rates range from 14% to 30%; rates decrease to 8% with prenatal and neonatal zidovudine treatment.
Determination of HIV infection in children is complicated because maternal HIV antibody transfers across the placenta and may persist up to age 18 months.
HIV-seropositive children are considered HIV infected if they test positive for HIV on two separate occasions by either HIV culture or HIV polymerase chain reaction
(PCR) or if they develop AIDS. HIV-seropositive children who do not meet these criteria are considered perinatally exposed, and HIV-seropositive children without
AIDS and without laboratory evidence of infection who on testing after age 6 months have negative antibody are seroreverters. The 1994 revised classification system
for HIV infection in children has four clinical categories: N, not symptomatic; A, mildly symptomatic; B, moderately symptomatic; and C, severely symptomatic, which
includes all AIDS-defining conditions except lymphoid hyperplasia ( Table 162.1). These clinical categories are further classified immunologically depending on the
child's age and absolute CD4 count: no evidence of suppression, moderate suppression, and severe suppression ( Table 162.2). For example, A2 indicates mild signs
and symptoms of infection with moderate immunosuppression.
TABLE 162.1. REVISED CENTERS FOR DISEASE CONTROL AND PREVENTION CLINICAL CATEGORIES FOR CHILDREN WITH HUMAN
IMMUNODEFICIENCY VIRUS (HIV) INFECTION
TABLE 162.2. IMMUNOLOGICAL CATEGORIES BASED ON CHILD'S AGE-SPECIFIC CD4 + T LYMPHOCYTE COUNT AND PERCENT OF TOTAL
LYMPHOCYTES
Diagnostic Tests
Because of early testing, most HIV-positive children are identified soon after birth. Viral load (i.e., quantified HIV DNA or RNA PCR) is more sensitive than viral
cultures and p24 antigen in identifying HIV infection in asymptomatic newborns and infants. By age 4 to 6 months, over 95% of HIV-infected children are identified by
a positive PCR. In newborns, a negative PCR test for HIV does not exclude infection but decreases the risk of HIV infection to 3%. Viral load runs higher in
asymptomatic children than in asymptomatic adults. Sustained high viral load in adults predicts progression to AIDS. High viral loads in early infancy predict early
onset of symptomatic HIV disease. HIV-1 syncytial-inducing phenotypes are linked to aggressive early symptomatic disease.
Mild HIV infection includes diarrhea, unexplained persistent fever, lymphadenopathy, and parotitis. Table 162.1 lists the range of signs of symptomatic HIV infection.
Lymphoid interstitial pneumonitis and recurrent bacterial infections are seen in children with AIDS but not in adults. Severe manifestations in early infancy, such as
progressive encephalopathy or opportunistic infections (e.g., Pneumocystis carinii), carry a poor prognosis for survival.
Mechanism of Action
HIV infection is maintained by viral persistence in helper T lymphocytes and macrophages. HIV strains with tropism for monocyte-derived macrophages have a
predilection to infect cerebral vascular endothelium and central nervous system (CNS). Infected macrophages traverse the bloodbrain barrier and infect microglial
cells; neurons are spared from direct infestation. Nonproductive infection of astrocytes is reported, but infection of other glial cells has not been firmly established.
Neuronal dropout is seen as the disease advances, but it is not known how HIV induces neural damage. Postulated mechanisms include release of soluble
neurotoxins by HIV-infected macrophages and lymphocytes (e.g., cytokines, quinolinic acid, viral antigens, or undefined viral products), neurotoxin amplification by
astrocytemacrophage interaction, and impaired bloodbrain barrier function secondary to HIV-related endothelial damage. These neurotoxins are thought to produce
a reversible metabolic encephalopathy that may disappear with effective antiretroviral treatment. Children with HIV encephalopathy who respond to antiretroviral
therapy may show nonprogressive corticospinal tract sequelae.
Pathology
Glial nodules and endothelial hyperplasia with calcification, dystrophic calcification, and perivascular mononuclear inflammation are common pathologic findings of
subacute encephalitis in HIV-infected brains. The glial nodule comprises a cluster of chronic inflammatory cells in the neurophil and is often associated with
multinucleated giant cells that are presumed to arise from coalescent microglia.
Human Immunodeficiency Virus Encephalopathy
Two types of encephalopathy are seen in children: progressive and static. The evolution of the progressive encephalopathy may be fulminant, inexorably progressive,
or stepwise. Progressive encephalopathy is characterized by loss of developmental milestones, progressive pyramidal tract dysfunction, and acquired microcephaly or
impaired brain growth. The static encephalopathy is less well defined, and not all cases may be HIV induced.
The neurologic abnormalities commonly include abnormalities of muscle tone, hyperreflexia, clonus, and impaired head growth. Hypotonia with corticospinal tract
dysfunction may be seen in infants early in the course of the encephalopathy and evolves into a spastic diparesis; with newer antiretroviral treatments, progression to
a spastic tetraparesis, with or without pseudobulbar palsy, is seldom seen. Ataxia and rigidity are uncommon. Progressive neurologic dysfunction is the first evidence
of progression to AIDS in 10% of infected children. There is always evidence of underlying HIV infection, such as immunologic compromise (low CD4 counts) or high
viral load, at the time of onset of neurologic symptoms. Many infected children exhibit global developmental delay, regardless of neurologic findings. In young
children, motor development is more impaired than mental development.
The incidence of neurologic abnormalities reported in HIV-infected cohorts before the advent of antiretroviral treatments was 30%. Older HIV-infected children may
show problems in visual-spatial processing functions and expressive language and may develop AIDS-dementia complex indistinguishable from that described in
adults.
HIV-associated myelopathy, polyneuropathy, and myopathy are rare in children. Spinal cord pathology shows demyelinating changes of the corticospinal tracts,
vacuolar changes, or myelitis attributable to HIV. Acute inflammatory demyelinating polyneuropathy is a rare complication in pediatric HIV. Low-dose treatment with
dideoxyinosine causes a painful sensory neuropathy in less than 10% of patients treated. The neuropathy is dose related and usually reverts with cessation of
treatment. The mitochondrial myopathy induced by zidovudine has not been seen in children.
Focal Manifestations
HIV brain infection is nonfocal and subcortical. Seizures are not common. Focal signs or seizures raises the possibility of neoplasm, strokes, or, less likely,
opportunistic infections.
Primary Central Nervous System Lymphoma
This is the most common cause of focal cerebral signs in HIV- infected children, found in 3% to 4% of cases. Seizures are reported in about 33% of patients. It may be
difficult to differentiate this tumor from toxoplasma brain abscess; diagnosis requires brain biopsy. Magnetic resonance imaging (MRI) spectroscopy may prove helpful
in distinguishing CNS toxoplasmosis from lymphoma.
Stroke
HIV infection produces inflammation of cerebral vessels, increasing the risk of stroke, which occurs at a rate of 1.3% a year in HIV-infected children. More than 50% of
strokes are hemorrhagic and occur with thrombocytopenia (especially immune thrombocytopenic purpura) or CNS neoplasia. Nonhemorrhagic stroke and
subarachnoid hemorrhage are attributable to an arteriopathy affecting the large vessels of the circle of Willis or meninges. HIV-related strokes may be clinically silent,
so the true incidence is probably higher.
Opportunistic Central Nervous System Infection
Compared with adults, opportunistic CNS infection is infrequent in HIV-infected children, affecting primarily older children and adolescents. Only a few have had
progressive multifocal leukoencephalopathy.
Imaging
In children with HIV encephalopathy, computed tomography or MRI may show diffuse cerebral atrophy or may be normal. There may be foci of demyelination. Frontal
lobe or basal ganglia enhancement and calcifications are late manifestations of HIV encephalopathy and occur primarily in symptomatic infants ( Fig. 162.1).
HIV-related myelopathy on spinal MRI may show a high signal but is usually normal. Bilateral cerebral lesions may mimic myelopathy and must be excluded with MRI
or computed tomography. Lesions of progressive multifocal leukoencephalopathy are commonly located in the parietooccipital or frontal region affecting both
periventricular and subcortical white matter. These lesions may be difficult to distinguish from HIV demyelination.
FIG. 162.1. Computed tomography of an infant with human immunodeficiency virus encephalopathy showing cortical and subcortical atrophy, basal ganglia, and
frontal lobe calcifications. (Courtesy of Dr. Ram Kairam.)
Cerebrospinal Fluid
Cerebrospinal fluid (CSF) examination is commonly normal in children with HIV infection. In the absence of opportunistic infection, CSF findings in children with
progressive encephalopathy are nonspecific, with a lymphocytic pleocytosis and elevated protein content. Intra-bloodbrain barrier synthesis of HIV-specific antibody
or antigen detection in CSF has not been useful in predicting encephalopathy. CSF viral load, although still experimental, may prove useful in determining HIV
encephalopathy in children.
Antiretroviral Therapy
Combination antiretroviral therapy is needed to avoid emergence of resistant HIV strains. Triple combination antiretroviral therapies that include a protease inhibitor
are effective in diminishing viral load and suppressing active viral replication. This in turn correlates with increases in CD4 count, weight gain, improved morbidity
(including CNS symptomatology), and mortality. Whether high systemic viral load predicts the development of HIV encephalopathy has not been firmly established.
FETAL ALCOHOL SYNDROME
The fetal alcohol syndrome (FAS) affects children of chronic alcoholic women but also occurs with binge drinking, as defined by five drinks or more on one occasion.
Fetal susceptibility to the effects of alcohol is greatest during the first trimester of pregnancy. FAS is characterized by abnormalities of growth, CNS, and facial
features; birth defects are common (Table 162.3). FAS rates in the United States are 2 to 4 per 1,000 live births and 2% to 4% among children of alcohol-abusing
women. FAS is confined to infants of alcohol-abusing women. Most children with FAS are mildly or moderately retarded, with mean IQ scores of 65 to 70, but
intellectual ability varies widely. In families with several affected siblings, the youngest child is usually the most cognitively impaired. Learning disabilitiesin
particular difficulty with arithmetic, speech delay, and hyperactivityare commonly observed.
TABLE 162.3. FETAL ALCOHOL SYNDROME
Less severe alcohol-related effects are associated with wide patterns of drinking. These fetal alcohol effects are probably a lower point on the continuum of alcohol
effects on the fetus. Maternal alcohol abuse is associated with increased risk of spontaneous abortions, infant mortality, intrauterine growth retardation, and
prematurity. Birth defects are common. Minor or major congenital anomalies occur in about a third of infants born to heavy drinkers, compared with 9% of minor
anomalies in infants of women who abstain from alcohol. Depressed birth weight has been seen with ingestion of as little as 100 g of alcohol a week (about 1 drink a
day); hampered brain growth may be seen with 20 mL (1.5 drinks) a day. Decrease of alcohol intake during pregnancy is beneficial to the offspring, reducing rates of
growth retardation and dysmorphic features. Heavy alcohol exposure prenatally, but not mild or moderate exposure, has been linked to decrease in IQ scores,
hyperactive behavior, attention problems, learning difficulties, and speech disorders.
Postnatal Alcohol Exposure
Alcohol transferred through breast milk impairs motor development but not mental development at age 1 year. Ingestion of alcohol by children may lead to
hypoglycemic seizures.
Withdrawal Syndrome
Infants born to women who drink large amounts of alcohol during pregnancy may rarely exhibit signs of withdrawal. Restlessness, agitation, tremulousness,
opisthotonus, and seizures are seen shortly after birth and disappear within a few days.
FETAL COCAINE EFFECTS
In U.S. cities, about 1 in every 10 newborns is exposed prenatally to cocaine. The long-term consequences of fetal cocaine exposure to the developing nervous
system are not well known.
Cocaine use during pregnancy has been linked to spontaneous abortion, abruptio placentae, stillbirth, and premature delivery. These events may immediately follow
large intakes of cocaine and are attributed to drug-induced vasoconstriction of intrauterine vessels. Women who use cocaine tend to resort to prostitution, increasing
risks for syphilis and HIV. They also tend to lack prenatal care, adding to the risks of infant death, low birth weight, and prematurity.
Low birth weight and intrauterine growth retardation are common among cocaine-exposed infants. Fetal brain growth is impaired independently of birth weight or
gestational age. Sudden infant death syndrome has also been linked to cocaine exposure in utero.
Neurobehavior
State regulation difficulties are well described among cocaine-exposed newborns, although findings are inconsistent. Some reports describe irritability, excitability,
poor feeding, and sleep disturbances among cocaine and cocaine/methamphetamine infants, whereas others describe decreased organizational response and
interactive behavior, even if the exposure to cocaine was limited to the first trimester of pregnancy. Modulation of attention is impaired among cocaine-exposed infants
who, unlike unexposed infants, prefer higher rates of stimuli when in a high level of arousal. Exposed infants also show motor and movement abnormalities, including
excessive tremor and hypertonia. Dose-response effects of cocaine on state regulation and neurologic findings are reported in newborns. Some studies show no
neurobehavioral effects, however.
Strokes
Experimentally, cocaine has a vasoconstrictive effect on fetal cerebral vessels and decreases cerebral blood flow. Neonatal stroke and porencephaly have been
associated with prenatal cocaine exposure. Some cases may be related to other neonatal stroke risk factors that accompany fetal cocaine exposure, such as abruptio
placentae or birth asphyxia. Intracranial hemorrhage was not associated with cocaine in a prospective study of prematures.
Seizures
Focal seizures may occur in cocaine-exposed newborns with strokes. Electroencephalograms in cocaine-exposed infants show bursts of sharp waves and spikes that
are often multifocal. These findings do not correlate with clinical seizures or neurologic abnormalities and may disappear in 3 to 12 months. Cocaine-exposed
premature infants are at increased risk of neonatal seizures. Seizures are rare if there is no stroke.
Malformations
Prenatal cocaine exposure has been linked with urogenital malformations, limb reduction deformities, and intestinal atresia and infarction. Agenesis of the corpus
callosum and septooptic dysplasia have also been noted. These teratogenic effects may result from cocaine-induced vasoconstriction and fetal vascular disruption in
early organogenesis.
Neurodevelopmental Impact
In experiment models, prenatal cocaine has been reported to affect serotonin, norepinephrine, and dopaminergic systems. Lower CSF levels of homovanillic acid
found in human newborns exposed to cocaine suggest dopaminergic involvement. In infancy, there may be a high incidence of spastic tetraparesis and diparesis that
resolves by age 24 months (Table 162.4). In toddlers and school-aged children, prenatal cocaine exposure did not decrease cognitive abilities, except as mediated
through cocaine effects on brain growth. Cocaine-exposed children seem to suffer from an excess of neurobehavioral abnormalities, including irritability, impulsivity,
and aggressive behavior, which may reflect coexisting maternal psychopathology rather than direct cocaine effects.
TABLE 162.4. COCAINE-RELATED EFFECTS
Cocaine Exposure in Childhood
Passive intoxication with cocaine may be caused by breast-feeding or passive inhalation of free-base cocaine (crack). Seizures are the chief manifestation of
symptomatic intoxication, but intoxication may be unsuspected. Urine toxicology screen to detect illicit substances is indicated in evaluating seizures in infants and
children, regardless of socioeconomic status.
Withdrawal Symptoms
There is no evidence of a cocaine-induced withdrawal syndrome. Even with remote prenatal cocaine exposure, cocaine-exposed infants may show hypertonicity and
tremor, which are probably cerebral manifestations of fetal cocaine effects.
THE BATTERED CHILD
Child abuse may be physical or psychological. Physical abuse includes skin burns, welts, bruises, bone fractures, head trauma, and failure to thrive. Psychological
abuse frequently accompanies physical abuse and may lead to growth, behavioral, and developmental impairments. The shaken baby syndrome, an increasingly
recognized form of physical abuse, is characterized by bilateral subdural hematomas or subarachnoid hemorrhage, retinal hemorrhages, and the absence of external
signs of trauma. It is seen in infants mostly under age 1 year who are shaken repeatedly and violently. The aggressor, usually a parent, shakes the crying infant until
he or she quiets and later denies doing so.
Depressed mental status, seizures, and signs of increased intracranial pressure are common. Neurogenic pulmonary edema may occur rarely. Bilateral retinal
hemorrhages, in the absence of a coagulopathy, are the most specific signs of shaken baby syndrome. Hemorrhages may be flame shaped, round and intraretinal,
preretinal, or vitreal. The speed with which blood disappears varies by type: Flame-shaped hemorrhage disappears within a few days, but round intraretinal
hemorrhage may last 2 weeks. Retinal folds occasionally are seen. A dilated funduscopic examination should be performed quickly in any child with suspected child
abuse to identify retinal hemorrhages before they disappear.
Shaken baby syndrome should be suspected with sudden infant death syndrome or near-miss sudden infant death syndrome, with sudden lethargy, with seizures of
unknown cause, or if there is a discrepancy between the history and the clinical signs. Broken ribs and chest bruises may be seen in infants held by the chest during
shaking, and spiral fractures of the long bones or epiphysial separation may be seen in those shaken by the arms or legs. A skeletal survey showing old fractures
helps confirm abuse. Infants with shaken baby syndrome may suffer neurologic sequelae, including hydrocephalus, blindness, developmental delay, mental
retardation, microcephaly, and spastic tetraparesis.
SUGGESTED READINGS
Caffey J. The whiplash shaken baby syndrome: manual shaking by the extremities with whiplashed-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and
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Chiriboga CA. Neurological correlates of fetal cocaine exposure in cocaine and the developing brain. Ann N Y Acad Sci 1998;846:109125.
Chiriboga CA, Brust JCM, Bateman D, Hauser WA. Dose-response effect of fetal cocaine exposure on newborn neurological function. Pediatrics 1999;103:7985.
Forsyth BW Primary care of children with HIV infection. Curr Opin Pediatr 1995;7:502512.
Gendelman HE, Epstein LG. HIV encephalopathy in children. Curr Opin Pediatr 1995;7:655662.
Park YD, Belman AL, Kim TS, et al. Stroke in pediatric acquired immunodeficiency syndrome. Ann Neurol 1990;28:303311.
Pizzo PA, Wilfert CM. Markers and determinant of disease progression in children with HIV infection. The Pediatric AIDS Siena Workshop II. J Acquir Immune Def Syndr Hum Retrovir 1995;8:3044.
1994 Revised classification system for human immunodeficiency virus (HIV) infection in children less than 13 years of age. MMWR Morb Mortal Wkly Rep 1994;43:RR12.
Streissguth AP. Fetal alcohol syndrome: early and long-term consequences. NIDA Res Monogr 1992;119:126130.
CHAPTER 163. FALLS IN THE ELDERLY
MERRITTS NEUROLOGY
CHAPTER 163. FALLS IN THE ELDERLY

LEWIS P. ROWLAND
Epidemiology
Neurology of Falls
Environmental Factors
Prevention
Suggested Readings
Falls in the elderly are often taken for granted and considered an inevitable consequence of aging. Analysis of the factors that lead to falls, however, raises the
possibility of prevention. The problem is certainly serious for individuals, families, and society ( Table 163.1).
TABLE 163.1. FALLS IN THE ELDERLY
EPIDEMIOLOGY
It is estimated that 5% to 10% of falls in the elderly result in injury. Most falls occur at home, but the rate of falling is higher in long-term care facilities. Injury is the
sixth leading cause of death after age 65, and most injuries result from a fall. Although people over 65 comprise about 12% of the total population, they account for
74% of all deaths caused by falls. Fatality rates increase with age in both men and women ( Table 163.2).
TABLE 163.2. DEATH RATES FROM ACCIDENTAL FALLS IN 1982
The likelihood of admission to a nursing home increases with the number of falls an elderly person has had. Once a person is in a nursing home, the use of
antidepressants increases the likelihood of falls. Falls are as likely among those who take selective serotonin reuptake inhibitors as among those taking tricyclics; use
of newer drugs does not reduce the higher rates of falling.
NEUROLOGY OF FALLS
Few falls seem to be related to syncope, drop attacks, transient ischemic attacks, or overt myopathy. Instead, a propensity to falls is generated by the cumulative
handicaps of poor vision, poor balance, unsteady gait, stooped posture, and impaired proprioception. Sensitivity to drugs is another factor; falls are more frequent in
people who take more than one drug. Intuitively, it seems likely that the motor impairment of Parkinson disease or previous stroke would increase the likelihood of
falls and so would the physical impediments of arthritis or the intellectual failure of dementia.
Disequilibrium of unknown cause increases the likelihood of falling. The condition is identified as a triad: Impaired balance is a symptom; gait is impaired on
examination; and no cause is discerned by medical, neurologic, and vestibular examination.
ENVIRONMENTAL FACTORS
Most falls in the elderly are accidental. Examples include missing the last step on descent, slippery surfaces, poor lighting, unexpected appearance of a child or pet,
and poorly fitting shoes.
PREVENTION
In one study, 46% of fallers were repeaters. The first fall led to loss of mobility and loss of confidence, making the next one more likely. Interventions included walking
aids, home nursing visits to assess environmental hazards (including lighting, stairs, bathrooms, and rugs), educating patients, care in taking medications, and
physical therapy for gait and balance. The list of medications should be reviewed periodically to be certain that all are needed; this is especially true of all
psychoactive drugs. In the Prevention of Falls in the Elderly Trial, these measures reduced the risk of falling and of recurrent falls and the likelihood of hospital
admission. Death rates from falls among people over 75 decreased by 50% between 1960 and 1980.
SUGGESTED READINGS
Avorn J. Depression in the elderlyfalls and pitfalls. N Engl J Med 1998;339:91820.
Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of Falls in the Elderly Trial (PROFET): a randomized controlled trial. Lancet 1999;353:9397.
Fife TD, Baloh RW. Disequilibrium of unknown cause in older people. Ann Neurol 1993;34:694702.
Kerber KA, Enrietto JA, Jacobson KM, Baloh RW. Disequilibrium in older people: a prospective study. Neurology 1998;51:574580.
Lacomis D, Chad DA, Smith TW. Myopathy in the elderly: evaluation of the histopathologic spectrum and the accuracy of clinical diagnosis. Neurology 1993;43:825828.
Nutt JG, Marsden CD, Thompson PD. Human walking and higher-level gait disorders, particularly in the elderly. Neurology 1993;43:268279.
Saper CB. All fall down: the mechanism of orthostatic hypotension in multiple systems atrophy and Parkinson's disease. Ann Neurol 1998;43:149151.
Sorock GS. Falls among the elderly: epidemiology and prevention. Am J Prevent Med 1988;4:282288.
Thajeb P. Gait disorders and multi-infarct dementia. Acta Neurol Scand 1993;87:239242.
Thapa PB, Gideon P, Cost TW, Milam AB, Ray WA. Antidepressants and the risk of falls among nursing homs residents. N Engl J Med 1998;339:875882.
Tinetti ME, Speechley M. Prevention of falls among the elderly. N Engl J Med 1989;320:10551059.
Tinetti ME, Williams CS. Falls, injuries due to falls and the risk of admission to a nursing home. N Engl J Med 1997;337:12791284.
CHAPTER 164. NEUROLOGIC REHABILITATION
MERRITTS NEUROLOGY
SECTION XXIV. REHABILITATION

CHAPTER 164. NEUROLOGIC REHABILITATION
LAURA LENNIHAN AND GLENN M. SELIGER
Occupational Therapy
Physical Therapy
Dysphagia Therapy
Language and Cognitive Therapies
Incontinence Therapy
Suggested Readings
Neurologic disorders commonly cause temporary or permanent impairments that impede simple daily functions and complex intellectual and physical activities.
Neurologists play an important role in prescribing rehabilitation therapies to maximize functional recovery. The proper selection and timing of these therapies make a
substantial contribution to optimum quality of life for patient and family despite persistent neurologic impairments. Although it is preferable for rehabilitation to begin
soon after a neurologic injury, many people with chronic neurologic conditions have never received adequate rehabilitation therapy. Nevertheless, if they are given
proper training and equipment, they may still improve in personal independence, access to the community, or ease with which a caregiver assists them. At a time
when neurologists are assuming the role of principal care physicians, experience in neurorehabilitation is essential in the management continuum from acute to
chronic neurologic disorders.
The World Health Organization definitions of impairment, disability, and handicap ( Table 164.1) provide a structure for understanding the impact of disease on
personal independence and integration into society. These criteria help to identify patients who may benefit from rehabilitation. The planning and prescription of a
rehabilitation program for a neurologically impaired individual requires characterization of the neurologic disorder with regard to natural history, localization, and
extent of nervous system involvement; determination of functional disabilities caused by cognitive and physical impairments; and definition of these disabilities in the
context of the patient's physical and social environment. With this information, the type and intensity of rehabilitation therapies can be planned.
TABLE 164.1. WORLD HEALTH ORGANIZATION DEFINITION OF IMPAIRMENT, DISABILITY, AND HANDICAP
Two principal approaches are used in rehabilitation therapy. The first is to bypass the neurologic impediment by teaching adaptive techniques using preserved
neurologic function. For example, a person with a paralyzed arm can be trained in one-handed activities using the normal arm. The second approach is to facilitate
the return of neurologic function. For example, the person with a paralyzed arm is given tasks to increase effective movement of that arm. Both methods are usually
applied in rehabilitation programs. The efficacy of the first approach in improving functional independence and reducing disability is accepted. The second approach
is the focus of active clinical research. In a primate model, restraint of the normal arm resulting in forced use of the paretic arm after motor cortex injury leads to better
functional recovery of the affected arm than when the normal arm is unrestrained. No functional recovery occurs if the paretic arm is restrained. Case reports in
humans similarly support the efficacy of this forced-use paradigm. Gait training on a treadmill while a harness provides partial body weight support is thought to recruit
spinal pattern generators for walking. This technique may produce better balance, motor recovery, walking speed, and endurance compared with conventional gait
training with patients bearing their full body weight.
Current research on the neurobiology of recovery from central nervous system injury and the efficacy of treatments to improve the speed and completeness of
recovery is relevant to the practice of neurorehabilitation. For example, norepinephrine plays an important role in modulating central nervous system recovery. In
animal models of focal brain injury and in people with strokes, amphetamine administered coincident with physical therapy has resulted in better motor recovery than
in placebo-treated subjects. Drugs with central catecholamine antagonist activity, such as haloperidol, prazosin, or clonidine, interfere with motor recovery in animals.
Enhancement of activity of the inhibitory neurotransmitter GABA by drugs such as diazapam, phenytoin, or phenobarbital also reduces neurologic recovery in animals.
In a retrospective study, stroke patients who received either class of drug had poorer motor recovery than those who did not.
Functional outcome is improved by treatment in a comprehensive rehabilitation program. Stroke patients who receive rehabilitation therapies on a stroke rehabilitation
unit have better functional outcomes and shorter hospital stays than those treated on a general neurology ward. Similarly, stroke patients admitted to hospital-based
acute rehabilitation programs have better functional recovery and are more likely to return home than those treated in a subacute rehabilitation program at a skilled
nursing facility.
A comprehensive inpatient neurorehabilitation program requires an interdisciplinary team: physician, physical therapist, occupational therapist, speech therapist,
neuropsychologist, social worker, and rehabilitation nurse. The physician, as team leader, defines the type and prognosis of the neurologic disorder; is responsible for
coordination of rehabilitation services and setting of realistic treatment goals; and provides medical care, especially for the prevention and treatment of complications
of a disabling disorder, for instance, deep vein thrombosis or reflex sympathetic dystrophy.
The physical therapist's role is to maximize leg function and mobility. The occupational therapist promotes maximum independence in activities of daily living by
improving arm function and cognitive skills. The speech therapist characterizes and treats specific language-based cognitive dysfunction and evaluates and treats
dysphagia and dysarthria. The neuropsychologist defines cognitive problems and monitors improvement. The rehabilitation nurse, in addition to providing medical
nursing care, incorporates into the patients' daily routines skills learned in therapy and institutes treatments to restore sphincter continence. The social worker
implements the discharge plan. All team members participate in formulating a discharge plan and in educating and training patient and family in preparation for return
home.
OCCUPATIONAL THERAPY
Neurologic injury that interferes with use of the arms and hands can be profoundly disabling. Weakness, loss of sensation, ataxia, abnormal tone, and involuntary
movements, alone or in combination, can lead to inability to carry out basic activities of daily living, to drive a car, or to work. Occupational therapy promotes recovery
from neurologic injury; prevents permanent disability from complications of temporary neurologic impairments, such as wrist-flexor contractures from a radial nerve
palsy; teaches new techniques to perform self-care and other tasks; prescribes equipment to increase use of the impaired arm and hand; and, when the impairment is
unilateral, teaches performance of one-handed techniques by the normal arm.
The approach to restoring function to the neurologically impaired arm is determined in part by central or peripheral site of injury. For example, treatment of weakness
caused by an upper motor neuron lesion focuses on reestablishing movement at one joint in isolation from movement at other joints; strengthening exercises follow
later. Strengthening programs are usually instituted early for peripheral injuries, but it is important not to overwork muscles recovering from a nerve injury because
weakness may worsen. Wrist and ankle weights can be used to dampen arm and leg ataxia.
Improving motor skills is only one of the important components in enhancing performance of the activities of daily living, such as dressing, toileting, washing,
grooming, feeding, and community skills. Training to overcome visual and perceptual difficulties, unilateral spatial neglect, memory impairment, inattentiveness, and
poor safety judgment may also be important. The occupational therapist selects adaptive equipment and trains patient and family to compensate. Advanced programs
may include learning special occupational skills or to drive with the left hand and foot.
PHYSICAL THERAPY
Interference with mobility by neurologic disease can be reduced or eliminated by strengthening exercises, gait and balance training, spasticity reduction through
stretching or medication, surgical release of shortened tendons, bracing, assistive devices (e.g., cane, walker), and use of a wheelchair. Techniques and orthotics are
chosen to maximize safe and independent mobility; to optimize energy efficiency; to prevent decubitus skin ulcers, tendon contractures, and falls; and to enhance
recovery. Leg and trunk weakness, impaired postural reflexes, ataxia, proprioceptive loss, and hemineglect may all interfere with walking. Even though a person may
not be able to walk immediately after neurologic injury, ambulation usually becomes possible through a combination of bracing at the ankle and sometimes the knee
and use of a walker or cane. When ambulation is not possible, mobility is attained through training in the use of a wheelchair of the correct size and height, with a
special seat to prevent skin breakdown and cushions for trunk support.
DYSPHAGIA THERAPY
Facial, lingual, masticatory, pharyngeal, esophageal, and respiratory muscles participate in swallowing. Neurologic disorders that disturb coordinated contraction of
any of these muscles can cause dysphagia and, secondarily, airway obstruction, aspiration pneumonia, and malnutrition. Dysphagia evaluation is indicated for
patients with any of these complications; who report coughing, choking, or nasal regurgitation while eating; are dysarthric; or have a disease commonly associated
with dysphagia, such as motor neuron disease or myasthenia gravis. This evaluation includes characterization of the neurologic disorder and bedside and
fluoroscopic observation of swallowing foods of different consistencies, from thin liquids to chewy meat. Restriction of the diet to consistencies that can be swallowed
without aspiration reduces the risk of dysphagia complications. The speech therapist teaches techniques that improve coordinated swallowing and reduce the risk of
aspiration, such as tucking the chin before swallowing to close the larynx and open the upper esophagus and swallowing twice after each bite of food to clear the
pharynx.
LANGUAGE AND COGNITIVE THERAPIES
Brain injuries that cause behavioral, language, and other cognitive dysfunctions may be focal and discrete or generalized and diffuse. In focal injuries, the neurologic
dysfunctions may be restricted, with other brain functions preserved, for instance, Broca aphasia with intact attention, memory, and concentration. In contrast, diffuse
injury may affect several areas of cognitive function. The therapeutic approach needs to be tailored to the nature and complexity of the symptoms. The first step in
implementing a cognitive rehabilitation program is to define the neurobehavioral impediments and how they interfere with function. For example, a short attention span
may prevent participation in group activities such as business meetings, or memory impairment may lead to failure at school.
Speech therapy for aphasia is a specialized part of cognitive rehabilitation. The speech therapist defines receptive and expressive dysfunction and identifies areas of
strength and weaknesses in language. Areas of strength may then be used for compensatory purposes. For instance, if an aphasic patient's written language skills
are preserved better than verbal expression, writing may be useful for communication. Training in use of visual imagery as an internal cue may help to overcome the
word blocking of Broca aphasia. A picture board may circumvent an expressive language deficit. The use of computer-assisted communication for aphasia is an area
of active rehabilitation research. Visual imagery to create memory cues may improve performance on memory tests. Breaking a task into individual steps and then
teaching one step at a time helps to overcome constructional problems.
In diffuse or multifocal brain injury that impairs attention and behavior and many aspects of cognition and language, a structured program that permits few distractions
is necessary. Speech and occupational therapists collaborate on program development and implementation, and all members of the rehabilitation team contribute.
Several strategies may compensate for multiple problems. For example, sensory reduction minimizes distractions by controlling the noise and activity in the
environment; development of a rigidly structured daily routine helps to overcome poor planning and organizational skills. Education of patient and family about
aphasia and other cognitive problems helps to reduce frustration with impaired communication, memory, and abnormal behavior.
INCONTINENCE THERAPY
Loss of control of bladder or bowel emptying is a devastating condition and should be addressed by any comprehensive neurorehabilitation program. The cause of
impaired emptying or sphincter incompetence, and therefore the treatment, depends on the site of the neural injury. Evaluation includes clinical observations about
incontinence and retention; search for nonneurologic factors, such as cystitis or mechanical problems, particularly urethral obstruction by prostatic enlargement; and
cystometrographic measurements of bladder and sphincter functions. The neurorehabilitation nurse plays a crucial role in the treatment of bladder and bowel
disorders, including implementation of voiding programs and training patient and family to use urethral catheters.
Incontinence characterized by bladder hyperreflexia, in which the bladder contracts at low urine volumes and voluntary inhibition of bladder contraction and sphincter
relaxation fails, commonly complicates cerebral, particularly frontal lobe, injury. Lack of awareness or indifference may impede achievement of continence, but
neurologic recovery usually reduces incontinence. Scheduled voidings at 2-hour intervals contribute to regaining continence. Bladder dyssynergia, in which bladder
contraction and sphincter relaxation are dissociated and the bladder contracts against a closed sphincter, is usually a consequence of lower brainstem or spinal cord
disorders. Bladder emptying, if it occurs at all, is incomplete and occurs at high pressure. Treatment includes bladder antispasmodic drugs and intermittent
catheterization. Hydronephrosis and renal failure are potential complications. Peripheral nerve diseases involving the nerves innervating the bladder may cause
bladder flaccidity. Bladder emptying, at low pressures, is incomplete, and incontinence occurs between voluntary voidings. Cholinergic agents may improve emptying,
but intermittent catheterization is often necessary.
Immobility from any neurologic disorder and loss of cortical control over bowel movements due to spinal cord injury may cause severe obstipation and even bowel
obstruction. Prevention combines a high-fiber diet and stool softeners with laxatives or enemas timed to stimulate evacuation on a regular schedule.
SUGGESTED READINGS
Bennett L, Knowlton GC. Overwork weakness in partially denervated skeletal muscle. Clin Orthop 1958;12:2229.
Goldstein LB, Matchar DB, Morgenlander JC, Davis JN. Influence of drugs on the recovery of sensorimotor function after stroke. J Neurol Rehab 1990;4:137144.
Good DC, Couch JR, eds. Handbook of neurorehabilitation. New York: Marcel Dekker, 1994.
International classification of impairments, disabilities, and handicaps. Geneva: World Health Organization, 1980.
Kalra L, Dale P, Crome P. Improving stroke rehabilitation: a controlled study. Stroke 1993;24:14621467.
Kramer AM, Steiner JF, Schlenker RE, et al. Outcomes and costs after hip fracture and stroke. A comparison of rehabilitation settings. JAMA 1997;277:396404.
Selzer ME. Neurological rehabilitation. Ann Neurol 1992;32:695699.
Taub E, Miller NE, Novack TA, et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 1993;74:347354.
Visintin M, Barbeau H, Korner-Bitensky N, Mayo NE. A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. Stroke 1998;29:11221128.
Walker-Batson D, Smith P, Curtis S, Unwin H, Greenlee R. Amphetamine paired with physical therapy accelerates motor recovery after stroke. Stroke 1995;26:22542259.
CHAPTER 165. END-OF-LIFE ISSUES IN NEUROLOGY
MERRITTS NEUROLOGY
XXV. ETHICAL AND LEGAL GUIDELINES

CHAPTER 165. END-OF-LIFE ISSUES IN NEUROLOGY
LEWIS P. ROWLAND
Informed Consent
Advance Directives
Refusal of Life Sustaining Treatment
Double Effect
Palliative Care
Physician Assisted Suicide
Terminal Sedation
Euthanasia
An Overall View
Suggested Readings
Neurologic diseases have been at the center of discussions on issues at the end of life. The American Academy of Neurology has set standards for the determination
of cerebral death and for the persistent vegetative state (see Chapter 4). Amyotrophic lateral sclerosis and Alzheimer disease have been the focus of debates about
assisted suicide. Neurologic intensive care units face the issue of discontinuing mechanical ventilation. Presymptomatic diagnosis is available for incurable conditions
like Huntington disease, creating an ethical challenge.
These ethical issues could fill a separate book. Here, we set forth some principles and definitions as an introduction for students and physicians as they learn to deal
with the problems. The fundamental ethical and legal guidelines are the basis for actions taken or avoided.
INFORMED CONSENT
One basis for patient autonomy in decision making is informed consent. A patient may accept or refuse a treatment or diagnostic test after learning about the
anticipated benefits and risks and alternative choices. This requires accurate information about prognosis.
ADVANCE DIRECTIVES
Individuals may prepare legal documents that specify their preferences for end-of-life treatments under specific circumstances, and they may also appoint surrogate
decision makers if the individual is not competent to make decisions at some future time. Most states recognize living wills as instruments for these advance
directives, which usually provide a prohibition against life-sustaining treatments that prolong the dying process if the person is in a terminal condition and can no
longer make decisions. In the interim, a competent person can change the advance directive at any time.
REFUSAL OF LIFE SUSTAINING TREATMENT
The doctrine of informed consent includes the patient's right to refuse life-sustaining treatment. Refusal is a decision not to provide consent, without which the
physician usually cannot continue treatment. Respect for patients' autonomy does not require acceptance of all decisions; the decision must be based on adequate
understanding of the nature and consequences of the choice ( informed consent) without coercion and with capacity to make a reasoned decision.
The patient's right to consent or refuse is not abrogated when the patient loses the capacity to make decisions. It becomes transferred to a legally authorized
surrogate decision maker and the physician must ask the surrogate for consent or refusal on behalf of the patient.
The surrogate must follow the patient's previously expressed wishes as expressed in advance directives or other reliable statements. If the patient's expressed wishes
have not been explicitly stated, the surrogate must use the doctrine of substituted judgment, based on knowledge of the patient's general values and preferences. If
the surrogate has no such information, the surrogate must assess the anticipated benefits and burdens, based on the doctrine of best interest. This may be
problematic, however, because it is not based on the desires of the patient.
Despite widely held beliefs to the contrary, it is not necessary to consult legal counsel before withdrawing life-sustaining therapy.
DOUBLE EFFECT
Some actions are morally and ethically acceptable and may have foreseeable but unintended and undesirable outcomes; the morality of the action depends on the
morality of the intended outcome, not the unintended one. According to the American Academy of Neurology Ethics Committee statement on assisted suicide, several
conditions must be met: the action to be carried out must be morally or ethically acceptable or at least neutral, the good effect must not depend on the undesired or
bad effect, and the good effect must be sufficient to justify the risk of the unintended outcome.
In practice, this principle makes it possible to administer sufficient analgesic and sedative medication to keep a patient comfortable even though the treatment will not
prolong life. The principle of double effect is the basis of the hospice program.
PALLIATIVE CARE
According to the World Health Organization definition, palliative care is the active total care of patients whose disease is not responsive to curative treatment, where
the control of pain, of other symptoms and of psychological, social, and spiritual problems is paramount, and where the goal is the achievement of the best quality of
life for patients and their families. More directly stated, palliative care is comfort care or treatment intended to relieve pain and suffering rather than to cure the
disease, restore the patient to health, or prolong life at all costs. Oral or parenteral morphine is used in amounts sufficient to control pain and maintain comfort.
A hospice program is often the venue for palliative care. This is sometimes carried out in a hospital or separate physical facility but is increasingly a home care
program. In the United States, a Medicare Disease-Related Group (DRG) provides reimbursement for the care of patients who are not expected to survive for more
than 6 months. However, hospice care is used by only 17% of people who are dying, and three reasons are adduced: physicians are uncomfortable about talking with
patients about terminal events long enough in advance, sometimes it is difficult to determine precisely the expected time of death, and hospices emphasize home care
and family members may not be able to commit the time required or there may be no family members. Most Americans die in hospitals (61%) or nursing homes (17%).
Another drawback to the use of home or hospice care is the insensitivity of U.S. physicians to the advance directives of their patients, as detected by the Study to
Understand Prognoses and Preferences for Outcomes and Risks of Treatment (support). Fifty percent of the physicians polled did not respect or did not know the
advance directives; most do-not-resuscitate (DNR) orders were not written until 24 hours before death; and 40% of the patients had severe pain for several days
before death. In a follow-up study, there was no improvement in communication about patients' desires for resuscitation; in the time before death in an intensive care
unit; or the incidence or timing of do not resuscitate orders, which were not written in 50% of the patients surveyed. Physicians misunderstood the desires of their
patients against do not resuscitate (80%) or the level of pain.
PHYSICIAN ASSISTED SUICIDE
As specified by law in the state of Oregon, it is permissible for a physician to prescribe medication to be used by a patient for the purpose of suicide. The physician
may not actually administer the drug. This law is restricted to Oregon and the practice is not legal in any other state.
Neurologic diseases generate problems for this policy. Patients may be incompetent with Alzheimer disease and would be unable to give consent. Other patients may
lose the use of their hands from multiple sclerosis or amyotrophic lateral sclerosis. Under these circumstances, the patients themselves cannot fill the prescription and
take the drug; someone else must assist them physically, which would be euthanasia and specifically banned by the Oregon law.
Many authorities have debated the desirability of assisted suicide. Medical and nursing organizations have uniformly opposed legalization.
TERMINAL SEDATION
The right to forgo treatment includes food and water. Pain or other discomfort can be ameliorated by standard palliative measures that may include sedation to
unconsciousness. The patient then dies as a result of the underlying disease, dehydration, or both. It is believed that some form of terminal sedation is applied in up
to 40% of deaths in U.S. hospitals. Discontinuing mechanical ventilation in an intensive care unit is another situation that calls for prevention or relief of suffering.
Some believe that terminal dehydration has a stronger moral basis than assisted suicide, based as it is on the right to refuse treatment. A physician is morally
obligated to honor a competent patient's refusal of food and water but is not obligated by a request for a lethal drug. Nevertheless, detractors consider terminal
sedation a form of slow euthanasia.
EUTHANASIA
If in compliance with a patient's request a physician administers a lethal drug by injection or other means, the act is euthanasia, which is illegal in the United States.
The public, physicians, and courts have had difficulty separating refusal or discontinuation of therapy, which are legal, from assisted suicide and euthanasia, which
are not. The distinction between assisted suicide and euthanasia is the most controversial of all. The Supreme Court concluded that palliative care and terminal
sedation are permissible but referred the question of physician-assisted suicide back to legislation by the states.
AN OVERALL VIEW
The issues discussed here are among the most controversial in modern life. Consensus is not easy to achieve, but views are changing and current practices are likely
to change as well. Already, pain control and palliative care have come to the fore and provide effective alternatives to assisted suicide. Legal changes may be
anticipated but do not seem imminent.
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Merritt - Neurology 10th Ed

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Merritt's Neurology 10th Edition (June 2000): by H. Houston Textbook of Neurology Merritt (Editor), Lewis P.

Rowland (Editor), Randy Rowland By Lippincott

SECTION I. SYMPTOMS OF NEUROLOGIC DISORDERS

Chapter 1. Delirium and Dementia

Chapter 2. Aphasia, Apraxia, and Agnosia

Chapter 3. Syncope and Seizure

Chapter 5. Diagnosis of Pain and Paresthesias

Chapter 6. Dizziness and Hearing Loss

Chapter 7. Impaired Vision

Chapter 9. Involuntary Movements

Chapter 10. Syndromes Caused by Weak Muscles

Chapter 11. Gait Disorders

Chapter 12. Signs and Symptoms in Neurologic Diagnosis

SECTION II. HOW TO SELECT DIAGNOSTIC TESTS

Chapter 13. Computed Tomography and Magnetic Resonance Imaging

Chapter 14. Electroencephalography and Evoked Potentials

Chapter 15. Electromyography and Nerve Conduction Studies in Neuromuscular Disease

Chapter 16. Neurovascular Imaging

Chapter 17. Lumbar Puncture and Cerebrospinal Fluid Examination

Chapter 18. Muscle and Nerve Biopsy

Chapter 19. Neuropsychologic Evaluation

Chapter 20. DNA Diagnosis

SECTION III. INFECTIONS OF THE NERVOUS SYSTEM

Chapter 21. Bacterial Infections

Chapter 22. Focal Infections

Chapter 23. Viral Infections

Chapter 24. Acquired Immunodeficiency Syndrome

Chapter 25. Fungal and Yeast Infections

Chapter 26. Neurosarcoidosis

Chapter 27. Spirochete Infections: Neurosyphilis

Chapter 28. Spirochete Infections: Leptospirosis

Chapter 29. Spirochete Infections: Lyme Disease

Chapter 30. Parasitic Infections

Chapter 31. Bacterial Toxins

Chapter 32. Reye Syndrome

Chapter 33. Prion Diseases

Chapter 34. Whipple Disease

SECTION IV. VASCULAR DISEASES

Chapter 35. Pathogenesis, Classification, and Epidemiology of Cerebrovascular Disease

Chapter 36. Examination of the Patient with Cerebrovascular Disease

Chapter 37. Transient Ischemic Attack

Chapter 38. Cerebral Infarction

Chapter 39. Cerebral and Cerebellar Hemorrhage

Chapter 40. Genetics of Stroke

Chapter 41. Other Cerebrovascular Syndromes

Chapter 42. Differential Diagnosis of Stroke

Chapter 43. Stroke in Children

Chapter 44. Treatment and Prevention of Stroke

Chapter 45. Subarachnoid Hemorrhage

Chapter 46. Cerebral Veins and Sinuses

Chapter 47. Vascular Disease of the Spinal Cord

SECTION V. DISORDERS OF CEREBROSPINAL AND BRAIN FLUIDS

Chapter 48. Hydrocephalus

Chapter 49. Brain Edema and Disorders of Intracranial Pressure

Chapter 50. Superficial Siderosis of the Central Nervous System

Chapter 51. Hyperosmolar Hyperglycemic Nonketotic Syndrome

SECTION VI. TUMORS

Chapter 52. General Considerations

Chapter 53. Tumors of the Skull And Cranial Nerves

Chapter 54. Tumors of the Meninges

Chapter 55. Gliomas

Chapter 56. Lymphomas

Chapter 57. Pineal Region Tumors

Chapter 58. Tumors of the Pituitary Gland