Unilateral occlusion of the middle cerebral artery after varicella-zoster virus infection

We report a 4-year-old child who developed hemiplegia 6 months after varicella-zoster virus (VZV) infection. Cerebral angiography showed complete occlusion of the right middle cerebral artery with basal moyamoya vessels. Elevation of anti-VZV antibody in the cerebrospinal fluid indicated central nervous system involvement. The association between VZV cerebral angitis and unilateral occlusion of right middle cerebral artery is discussed.     

Streptococcus oralis as a risk factor for middle cerebral artery thrombosis

We reported a case of an 8-year-old boy who was presented to the emergency department with left-sided hemiparesis. Computed tomography showed hypodense areas in the territory of the right middle cerebral artery, indicating acute cerebral infarct. Diagnostic evaluation was performed to identify the etiology. On the eighteenth day of hospitalization, cerebrospinal fluid cultures yielded Streptococcus oralis. We hypothesized that the source of the oral pathogen was an abscess belonging to his upper left fourth tooth, which, by a transient bacteremia, had invaded the central nervous system, and skipping the meninges caused local inflammatory arteritis of the carotid artery, leading to cerebral infarction. Sulbactam-ampicillin therapy was initiated for 14 days, and he was discharged with anticoagulation therapy.     

Benign angiopathy of the central nervous system associated with phenytoin intoxication

We report a patient with epilepsy who presented with acute onset of left hemiparesis associated with phenytoin intoxication due to interaction with clobazam. Magnetic resonance angiography of the head revealed stenosis of the M2 segment of the right middle cerebral artery, whereas an erythrocyte sedimentation rate and cerebrospinal fluid analysis were normal, being consistent with a diagnosis of benign angiopathy of the central nervous system. The patient exhibited an elevated plasma level of thrombin-antithrombin III complex along with a marginally increased plasma concentration of soluble E-selectin. The present case suggests that phenytoin intoxication can cause cerebral vasospasm, which may be associated with some inflammatory endothelial injury accompanied by activated intravascular coagulation.     

脑脊液释放试验后脑血流变化对正常压力性脑积水患者临床症状改善的预测作用

目的 探讨经颅多普勒超声(Transcranial Doppler,TCD)评价正常压力性脑积水(normal pressure hydrocephalus,NPH)患者脑脊液释放试验对脑血流速度的影响及脑脊液释放试验的效果。方法 收集2015年5月1日-2017年6月1日于上海长征医院神经内科治疗的NPH患者25例,在脑脊液释放试验前及脑脊液释放试验24 h后评估患者NPH分级量表评分、运动功能及应用TCD测试大脑中动脉和大脑前动脉的血流速度; 根据NPH分级量表评分进行分组,降低≥1分者为改善组,否则为未改善组,观察2组动脉血流速度情况。结果 与脑脊液释放试验前比较,改善组患者脑脊液释放试验24 h后行走时间、行走步数均明显减少,TCD示左右两侧大脑中动脉最大流速、平均流速、最小流速均明显降低; 非改善组则无上述改变。结论 脑脊液释放试验NPH分级量表评分的改善可能与大脑中动脉血流速度有关,而TCD可有效地评测NPH患者脑脊液释放试验的效果。     

Cerebral blood flow velocity in two patients with neonatal cerebral infarction

Cerebral blood flow velocity was measured in the middle cerebral artery of two patients who exhibited unilateral neonatal cerebral infarction during the neonatal period. Doppler studies demonstrated increases in cerebral blood flow velocity but decreases in the resistance index on the affected side of the middle cerebral artery in the neonate who developed hemiplegia with cystic encephalomalacia, although the neonate with normal neurologic outcome exhibited symmetric cerebral blood flow velocity and resistance index. The asymmetry in cerebral blood flow velocity measurements of both middle cerebral arteries may be useful to evaluate the severity of brain damage and predict the neurodevelopmental prognosis of unilateral neonatal cerebral infarction.     

发作期抑郁症患者脑动脉血流速度与注意力、执行功能关系

目的探讨发作期抑郁症患者脑动脉血流速度及其与注意力、执行功能的关系。方法 70例发作期抑郁症患者及65名健康对照纳入研究。采用24项汉密尔顿抑郁量表(24 items Hamilton depression scale,HAMD-24)评估抑郁症患者抑郁情绪,划销测验(cancellation test,CT)、威斯康星卡片分类测验(Wisconsin card sorting test,WCST)评估的认知功能,采用经颅多普勒超声(transcranial Doppler,TCD)检测脑动脉血流速度。结果与对照组比较,发作期抑郁症患者基底动脉、左侧大脑中动脉、右侧大脑中动脉、左大脑前动脉与右大脑前动脉平均血流速度均减慢,差异具有统计学意义(P0.05)。患者组CT各阶段净分及总净分低于对照组,而WCST总应答数、错误应答数、持续性错误数、完成第一个分类所需应答数均高于对照组,差异具有统计学意义(P0.01)。发作期抑郁症患者大脑基底动脉(r=0.25)、左中动脉(r=0.46)、右中动脉(r=0.25)、右后动脉(r=0.26)平均血流速度与CT总净分呈正相关(P0.05),各大脑动脉平均血流速度与WCST总应答数、持续性错误数呈负相关(P0.05),基底动脉、左右后动脉与错误应答数、完成第一个分类所需应答数呈负相关(P0.05)。结论发作期抑郁症患者大脑动脉平均血流速度普遍降低,注意力与执行功能受损。认知功能受损可能与脑动脉平均血流速度的改变有关。     

3例神经梅毒的临床特征分析

目的分析3例神经梅毒的临床特征为早期诊断提供参考。方法回顾性分析3例神经梅毒患者的临床症状、神经影像学和实验室检查特点。结果(1)脑血管梅毒1例,脊髓痨2例;(2)3例血和脑脊液的梅毒抗体均为阳性;脑脊液蛋白含量增加、细胞数增多(以单核细胞为主);(3)脑血管梅毒患者MRA及DSA显示左大脑中动脉M1段闭塞;左大脑前动脉及左大脑后动脉通过皮层支向左大脑中动脉供血区代偿供血;(4)2例脊髓痨患者头颅及胸髓MRI无特殊发现,肌电图及周围神经活检不支持周围神经受损。结论神经梅毒的临床表现与其分型密切相关;首诊易误诊。临床表现及血和脑脊液梅毒抗体阳性是确诊的依据。     

Transcranial Doppler assessment of cerebral flow velocity during cognitive tasks.

BACKGROUND AND PURPOSE: The purpose of this study was to assess the ability of transcranial Doppler ultrasonography to detect selective circulatory changes during cognitive activity. METHODS: We measured cerebral artery flow velocity in 21 normal volunteers by transcranial Doppler ultrasonography during rest followed by cerebral activation. Mean and peak systolic flow velocities of the anterior, middle, and posterior cerebral arteries were measured during the performance of a commercial video game. We also measured flow velocity of the anterior cerebral arteries in 18 subjects during a mental arithmetic task. Serial measurements of the right and left sides were made with a headband with two probes. RESULTS: We observed a global increase in the flow velocity above baseline measurements during task performance. During the video game, both middle cerebral arteries (t = 2.6, p = 0.02 for the left; t = 3.3, p = 0.004 for the right) and the left posterior cerebral artery (t = 2.2, p = 0.004) had selective increase in mean flow velocity compared with the ipsilateral anterior cerebral artery. This selective activation was most prominent in the right middle cerebral artery, which had a greater degree of activation than the right posterior cerebral artery (t = 2.8, p = 0.013). We did not observe a statistically significant difference between the right and left middle cerebral arteries, but there was a trend toward a greater activation on the right for both the mean velocity (t = 1.7, p = 0.098) and the peak velocity (t = 1.9, p = 0.079). CONCLUSIONS: Our preliminary investigation suggests that this noninvasive technique has the potential to correlate selective cerebral artery flow dynamics with cognitive activity.     

Cerebral dysfunction in fibromyalgia: evidence from regional cerebral blood flow measurements,otoneurological tests and cerebrospinal fluid analysis

Measurements of regional cerebral blood flow (rCBF), analysis of cerebrospinal fluid, auditory brain stem responses (ABR) and oculomotor tests were performed in 19 patients with fibromyalgia. The results from the rCBF measurements showed a normal flow level with slight but significant focal flow decreases in dorsolateral frontal cortical areas of both hemispheres. The ABR results showed signs dysfunction at least at the brain stem level and the oculomotor tests showed high frequency of pathology. The cerebrospinal fluid analysis showed discrete changes in the cell differential count. Possible explanations for the involvement of the central nervous system in fibromyalgia are discussed.     

IgM immunoglobulin in cerebrospinal fluid in cases of multiple sclerosis (preliminary report)]

In cases of multiple sclerosis, central nervous system syphilis and other neurological diseases the IgM was determined in the cerebrospinal fluid by means of radial diffusion. The control group comprised patients with neurosis. It was found that IgM determinations must be done in concentrated fluid when this method is used. Raised total and percent level of IgM in the cerebrospinal fluid was observed in 8 out of 29 cases of multiple sclerosis in the acute phase of the disease.     

A case report and DSA findings of cerebral hemorrhage caused by syphilitic vasculitis

Syphilis is now rare and easily misdiagnosed because of the wide use of antibiotics in the clinical. We report a case of cerebral hemorrhage in a patient with hypertension who was first diagnosed as hypertensive cerebral hemorrhage. However, treponema pallidum particle agglutination and rapid plasma regain tests of cerebrospinal fluid revealed the existence of neurosyphilis. Interestingly, digital subtraction angiography (DSA) showed severe stenosis in both middle cerebral arteries and right anterior cerebral artery. The case reminded us to pay attention to syphilitic vasculitis in patients with cryptogenic stroke. DSA sometimes may play a critical role in differential diagnosis of neurosyphilis.     

A transcranial Doppler study of blood flow velocity in the middle cerebral arteries performed at rest and during mental activities

While changes in blood velocity in the middle cerebral artery relative to rest were assessed by transcranial Doppler sonography, 70 volunteers with no sign of cerebrovascular disease performed two (left and right middle cerebral artery) series of six cognitive tasks. The tasks are assumed to be processed predominantly by either the left (verbal and mathematical tests performed aloud) or the right hemisphere (dot/distance estimation, spatial perception, and face recognition performed silently). All tasks were shown to increase middle cerebral artery blood flow velocity on both sides, by 1.6-10.6%. After an initial maximum at approximately 8 seconds, velocity decreased then increased again. A steady state was reached after approximately 24-42 seconds. The initial minimum during the following rest phase was reached some seconds later, followed by a slow increase to the reference rest steady state. A difference according to side could be determined only during the three right-hemispheric tasks (right greater than left, 2.5-2.9%). Left-handedness/ambidexterity, familial sinistrality, and profession seemed to have no influence on the results. The middle cerebral artery blood flow velocity increase on both sides was higher in women than in men during the dot/distance estimation and was also higher bilaterally in older than in younger subjects during the dot/distance and the spatial perception tasks. Habituation in performing the tasks was an important factor associated with a decrease of blood flow velocity, especially in the right middle cerebral artery. The habituation more pronounced on the right side possibly reflects the role of the right hemisphere in attention and arousal. The absolute blood velocities at rest decreased bilaterally with age.     

Cerebral blood flow velocity in untreated panic disorder patients: a transcranial Doppler ultrasonography study.

BACKGROUND: The aim of this study was to compare resting cerebral blood flow velocity values of unmedicated patients in the acute phase of panic disorder with resting values of healthy control subjects. METHODS: Nineteen unmedicated panic disorder patients were assessed for degree of anxiety using the Hamilton Anxiety Scale. The patients and 20 healthy age-matched control subjects were then insonated at rest using transcranial Doppler ultrasonography (TCD). For TCD, the anterior, the middle, and the posterior cerebral arteries were insonated bilaterally in all patients. RESULTS: Compared with healthy age-matched control subjects, acute unmedicated panic disorder patients showed a significant increase in cerebral blood flow velocity, bilaterally in the middle and the anterior cerebral artery, and unilaterally in the left posterior cerebral artery. Cerebral blood flow velocity in the right middle cerebral artery correlated positively to the item "Fear" on the Hamilton Anxiety Scale, whereas pulsatility index in the posterior cerebral artery bilaterally and in the left middle cerebral artery correlated negatively to the item "Mood." CONCLUSIONS: Transcranial Doppler ultrasonography agrees well with validated psychometric methods. If follow-up studies confirm our findings, TCD could allow an objective assessment of the mental state of panic disorder patients and reliably discriminate panic disorder patients from normal control subjects.     

Cerebral hemodynamic patterns during stimuli tasks in multi-infarct and Alzheimer types of dementia

Objectives – To examine differences in cerebrovascular reactivity between multi-infarct and Alzheimer types of dementia. Patients and methods – Using transcranial Doppler, measurements of flow velocity in the middle cerebral arteries during apnea, thumb-to-finger opposition and verbal and design discrimination tasks were recorded in patients with multi-infarct ( n = 10; mean age 68 + 7.5 years) and Alzheimer types of dementia ( n = 10; mean age 62±9.1 years). Controls were 20 healthy subjects matched for age and sex. Results – Cerebral reactivity to apnea was significantly lower ( P <0.0001) in the multi-infarct group compared to the other 2 groups. During the motor task, a nearly selective increase of mean flow velocity in the middle cerebral artery contralateral to the hand performing the task occurred in both controls and Alzheimer patients. A bilateral increase, without side-to-side differences, of flow velocity during movement of each hand was observed in multi-infarct patients. With respect to baseline values, the cognitive tasks produced significant and distinct effects on the left and right side in the controls but not in the patients. Controls showed a significant increase of left middle cerebral artery mean flow velocity during a verbal task ( P <0.0001), and of the right middle cerebral artery mean flow velocity during a design discrimination task ( P <0.001) when side-to-side comparisons were done. Differently, a bilateral and comparable increase of flow velocity was observed in all patients during performance of the same cognitive tasks. Conclusion – These data suggest that cerebrovascular reactivity to apnea could be an additional criterion for discriminating between MID and DAT patients. Transcranial Doppler assessment during cognitive and motor tasks could provide useful complementary information for comprehension changes in cerebral activity in patients with dementia.     

Eosinophilic meningitis in Thailand. Clinical and epidemiological characteristics of 162 patients with myeloencephalitis probably caused by Gnathostoma spinigerum

The clinical and epidemiological characteristics of 162 patients with eosinophilic myeloencephalitis, believed to be caused by invasion of the central nervous system by Gnathostoma spinigerum, are described. The case mortality rate was at least 12%, and probably higher. Single live young adult G. spinigerum were recovered from the brains of 2 patients at autopsy and from the eye lids of 2 other living patients. The disease caused by this parasite can be distinguished from that caused by Angiostrongylus cantonensis by characteristic acute nerve root pain, signs of spinal cord and cerebral involvement, and the presence of bloody or xanthochromic cerebrospinal fluid. As judged by its prevalence and mortality, central nervous system disease caused by G. spinigerum is the most important parasitic disease of the central nervous system in Thailand. Since invasion of the nervous system by this parasite is a significant cause of intracranial hemorrhage in Thailand, it should be kept in mind by internists, neurologists, neurosurgeons, and pathologists who care for patients residing in, or who have visited, areas where G. spinigerum occurs.     

Transcranial Doppler ultrasonography of the middle cerebral artery in the hemodynamic assessment of internal carotid artery stenosis

We performed transcranial Doppler ultrasonography of the middle cerebral arteries in 43 patients who underwent cerebral angiography. Twelve patients had normal arteriograms, 18 had internal carotid artery stenosis, and 13 had complete occlusion. Parameters measured included: flow velocity (mean, maximum, and peak systolic), flow acceleration, systolic-to-diastolic ratio, and pulsatility index. Patients with 75% to 100% stenosis had lower average ipsilateral flow acceleration and mean velocity than did normal subjects. Correlation analysis revealed an inverse relationship between degree of stenosis and ipsilateral flow acceleration, as well as ipsilateral mean velocity. These correlations were no longer significant when we excluded normals, however. There was a linear relationship between right and left velocity values for both normal subjects and patients with occlusion but not for patients with stenosis. This technique has potential for the reliable assessment of the hemodynamic effect of carotid stenosis on intracranial circulation.     

Carcinoembryonic antigen in patients with untreated central nervous system tumors.

This study was designed to determine whether immunological examination of carcinoembryonic antigen (CEA) levels in blood serum and cerebrospinal fluid would be helpful in detecting central nervous system tumors. Forty patients with tumors of the central nervous system were compared with 108 control patients. The findings suggest that: 1) CEA determinations are not helpful as a screening test in detecting preclinical central nervous system tumors; 2) Serum CEA determinations may be useful in determining the presence of a malignant tumor in patients with a circumscribed uptake on brain scan or a nonspecific mass lesion at cerebral angiography; 3) Cerebrospinal fluid CEA determinations were of no value in detecting central nervous system tumors; 4) Further study on a larger population of malignant central nervous system tumors is warranted.     

1727例脑脊液细胞学检查结果分析

目的:探讨脑脊液细胞学(CSFC)检查在中枢神经系统疾病中的诊断价值。方法:采用玻片离心法收集脑脊液细胞,经瑞-姬染色后在显微镜油镜下观察。结果:总结分析1727份CSFC检查结果,中枢神经系统感染性疾病207例(其中包括新型隐球菌感染6例),脑出血7例,中枢神经系统白血病和淋巴瘤19例,中枢神经系统肿瘤20例。结论:CSFC检查对于中枢神经系统疾病的诊断和鉴别诊断具有重要意义。     

Perfusion insufficiency in limb-shaking transient ischemic attacks

We describe a 63-year-old man with severe bilateral internal carotid artery disease who presented with repeated, brief attacks of left limb shaking precipitated by his standing up. Cerebral blood flow measured by xenon-133 inhalation showed reduced resting flows and a focal perfusion deficit in the right dorsofrontal and upper rolandic regions. Blood flow velocity and pulsatility index of the right middle cerebral artery measured by transcranial Doppler ultrasonography were also reduced. With hypercapnic challenge, both hemispheric tissue perfusion and blood flow velocity showed impaired reactivity. With induced hypotension, the focal perfusion deficit in the right dorsofrontal region was accentuated. Following right internal carotid endartectomy, resting cerebral blood flow and blood flow velocity improved, as did hypercapnic vasoreactivity. These reversible deficits in cerebral blood flow and vasoregulation, which were maximal in the dorsofrontal region, are consistent with low perfusion in the border zone territory or the distal fields and demonstrate that hemodynamic failure is the likely mechanism for limb-shaking transient ischemic attacks from severe carotid artery disease.     

Autoregulatory cerebral vasodilation occurs during orthostatic hypotension in patients with primary autonomic failure

It is unclear whether patients with autonomic failure autoregulate cerebral blood flow during hypotension. The objective in this study was to examine cerebral autoregulatory capacity in patients with autonomic failure by studying changes in middle cerebral artery blood flow velocity using transcranial Doppler ultrasonography before, during, and after tilt-induced hypotension. Nine patients with primary autonomic failure were evaluated. Mean arterial pressure and middle cerebral artery blood flow velocity were simultaneously recorded while the patients were in the supine position, during 60^o head-up tilt, and after they were returned to the horizontal position. The results were as follows: during tilt-induced hypotension, mean arterial pressure decreased significantly more than middle cerebral artery mean blood flow velocity (58% versus 36%, p<0.0002). After return to the horizontal position, mean arterial pressure returned to baseline, and middle cerebral artery blood flow velocity transiently increased above pretilt value (p<0.02). It is concluded that cerebral autoregulatory vasodilation occurs in patients with autonomic failure. This was demonstrated by a more pronounced decline in mean arterial pressure than in middle cerebral artery blood flow velocity during hypotension and by a transient increase in middle cerebral artery blood flow velocity (ie, hyperemic response) after blood pressure was restored.