Cerebral toxoplasmosis in AIDS. Case report

In a patient with AIDS presenting partial epilepsy cerebral toxoplasmosis was diagnosed on the serological and CT evidence. The diagnosis was confirmed by the immediate response to sulfonamide therapy.

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Sommario In un paziente sofferente di AIDS che presentò una crisi epilettica venne diagnosticata una toxoplamosi cerebrale per i dati TAC e neurologici. La diagnosi è stata confermata dall'immediato successo della terapia con sulfamidici.

     

出血性卒中的脑血流自动调节研究进展

脑血流自动调节 （cerebral autoregulation, CA） 是人体在一定血压或脑灌注压波动范围内维持脑血流量 （cerebral blood flow） 相对稳定的能力, 可避免脑组织发生高灌注或低灌注。 CA在出血性卒中中存在不同程度受损, 且与临床因素及预后密切相关。 对出血性卒中患者行CA监测不仅可评估临床预后, 还可为动脉血压及脑灌注压的管理提供参考信息。 本文主要就脑出血 （intracerebral hemorrhage, ICH） 和蛛网膜下腔出血 （subarachnoid hemorrhage, SAH） 的CA相关进展做一综述, 旨在探讨CA在上述疾病中的改变及其临床应用价值。     

Parkinsonism in a patient with AIDS and cerebral opportunistic granulomatous lesions

The localization of opportunistic infections in the basal ganglia in patients with acquired immunodeficiency syndrome (AIDS) can cause movement disorders, such as choreoathetosis, dystonia, hemiballism and, more rarely, parkinsonism. We describe the case of an AIDS patient who developed cerebral opportunistic granulomatous lesions and, subsequently, a parkinsonian akinetic-rigid syndrome. In agreement with cases reported in the literature, the parkinsonian syndrome developed only when the lesions bilaterally involved basal ganglia. The critical localization of the opportunistic lesions in the direct and indirect strio-pallidal pathways possibly associated with the HIV-related neurotoxicity might have contributed to determine this clinical picture. Received: 4 February 2000 / Accepted in revised form: 3 May 2000     

卒中合并脑微出血的影像学研究

目的 探讨ICH和脑梗死患者合并脑微出血（cerebral microbleeds，CMBs）数量分级及部位分布差异。 方法 连续选取2017年8月-2018年12月在北京市大兴区人民医院神经内科病房住院且资料完整的 卒中患者，分为ICH和脑梗死两组。收集患者发病2周内头颅MRI磁敏感加权成像影像，统计ICH与脑梗 死患者中CMBs数量分级及部位分布特点。 结果 共入组患者234例，其中ICH组79例，脑梗死组155例。ICH组合并CMBs 65例（82.3%），其中 CMBs＞5个的患者41例（51.9%）；脑梗死组合并CMBs 73例（47.1%），其中CMBs＞5个的患者21例 （13.6%），两组差异有统计学意义（P＜0.001）。ICH组中，CMBs同时累及脑叶和深部脑组织的患者40例 （50.6%）；脑梗死组中，CMBs同时累及脑叶和深部脑组织的患者25例（16.1%），两组差异有统计学意 义（P＜0.001）。 结论 CMBs病灶＞5个多见于ICH患者；CMBs同时累及脑叶及深部脑组织多见于ICH患者。     

脑出血后癫痫发作患者临床特点分析

目的 分析脑出血急性期伴癫痫发作患者的临床特征。方法 本研究为回顾性研究,纳入2009-2018年住院的既往无癫痫病史的自发脑出血（发病14 d内）患者。根据脑出血急性期是否伴癫痫发作分为脑出血后癫痫发作组和脑出血后无癫痫发作组。比较两组的一般资料及合并高血压、糖尿病、高脂血症、肺部感染、认知功能障碍等疾病的特点,同时分析脑出血后癫痫发作患者的出血部位、侧别、病因等临床特点。结果 共入组2836例脑出血患者,其中脑出血后伴发癫痫发作者106例,无癫痫发作者2730例。与脑出血后无癫痫发作组患者相比,脑出血后癫痫发作患者年龄较小[（50±17）岁 vs（55±15）岁,P <0.001],合并高血压者比例较低（60.4％ vs 86.9％,P <0.001）,合并肺部感染比例较高（42.5%vs 28.5%,P =0.003）。进一步分析脑出血后癫痫发作组脑出血特点,发现脑叶出血比例较高（57.3%）,且非高血压性脑出血比例较高（59.0%）。结论 与脑出血后无癫痫发作患者比较,脑出血后癫痫发作患者年龄较小,合并合并高血压的比例低,住院期间肺部感染比例高;脑出血后癫痫发作患者出血多位于脑叶,多为非高血压性脑出血。     

HIV-2 Infection With Cerebral Toxoplasmosis and Lymphomatoid Granulomatosis

A Nigerian man had acute onset of headache and vertigo due to a cerebellar mass. A brain biopsy of the mass revealed toxoplasmosis despite repeated negative HIV-1 serology. The presence of an opportunistic infection and his country of origin raised the suspicion for HIV-2; this was confirmed by positive HIV-2 serology. Despite his preliminary pathological diagnosis, results of physiological magnetic resonance imaging (MRI) (perfusion MRI and proton magnetic resonance spectroscopy) were not typical for toxoplasmosis. The lesion showed a biochemical and perfusion pattern that was intermediate for infectious and neoplastic processes. Further neuropathology confirmed a secondary diagnosis of lymphomatoid granulomatosis.     

脑萎缩并发脑出血的临床研究

目的 探讨脑萎缩并发脑出血的预后。方法 2002年3月～2006年12月我院收治的40例脑萎缩并发脑出血病例中死亡24例，存活16例，对其临床和CT资料进行了对比性研究。结果 研究表明，死亡高峰期为50～80岁，预后与出血量、血肿部位及是否有脑室积血密切相关。血肿破溃形成脑室积血率高。6例大于30mL血肿的脑室积血发生4例。本组40例死亡率为60％，死亡率高的原因可能是脑萎缩并发脑出血易破入脑室，并且脑出血与脑萎缩并存者应激能力差，对伤害性损害的耐受力低，易并发感染或器官衰竭而死亡。结论 脑萎缩并发脑出血预后差、死亡率高。     

成人出血型烟雾病自然病史研究

目的 探讨成人出血型烟雾病的长期自然病史及预后相关危险因素。 方法 回顾性分析115例成人（>17岁）出血型烟雾病患者临床资料,对其中40例行保守治疗患者进 行长期随访,主要观察指标为新发脑出血和死亡事件。 结果 40例保守治疗的患者中有6例失访,34例累计随访398.7年,平均随访（11.7±4.6）年,15例 （44.1%）出现21次脑再出血,平均每年出血率5.3%。5例（33.3%）死于再出血,4例有严重后遗症[改 良Rankin评分（modified Rankin Scale,mRS）≥3]。年再出血率前5年为2.6%,10年后为7.9%。年龄大于 35岁的患者再出血风险高于年龄低于35岁者[风险比（hazard ratio,HR）2.8,95%可信区间（confidence interval,CI）1.1～7.7,P =0.04]。患者性别、出血部位、数字减影血管造影（digital subraction angiography, DSA）分期、高血压、烟雾病家族史以及是否合并脑动脉瘤与再出血不相关。 结论 成人出血型烟雾病再出血风险随着时间延长明显增加;年龄大于35岁患者再出血风险偏高。     

Cerebral toxoplasmosis combined with disseminated tuberculosis

A 24-year-old man presented with mental change, fever, abdominal pain, tenderness and palpable mass on the lower abdomen. He was a non-Korean engineer and did not accompany a legal guardian, so medical history taking was difficult due to his mental status. Brain magnetic resonance imaging showed multiple rim-enhanced lesions of the brain, and abdominal computed tomography showed huge paraspinal abscess. Chest X-ray and computed tomography showed poorly defined nodular opacities. We initially thought that this patient was infected with toxoplasmosis with typical cerebral image finding and immunoglobulin laboratory finding of cerebrospinal fluid and serum study. The abdominal abscess was confirmed as tuberculosis through the pathologic finding of caseous necrosis. We used anti-tuberculosis medication and anti-toxoplasmosis medication for almost 4 months, and then his clinical state and radiological findings were considerably improved.     

Clinical Neuropathological Analysis of 10 Cases of Cerebral Amyloid Angiopathy-Related Cerebral Lobar Hemorrhage

ObjectiveThe clinical and pathological characteristics of 10 cases of cerebral amyloid angiopathy (CAA)-related cerebral lobar hemorrhage (CLH) that was diagnosed at autopsy were investigated to facilitate the diagnosis of this condition.MethodsThe clinical characteristics of 10 cases of CAA-related CLH were retrospectively reviewed, and a neuropathological examination was performed on autopsy samples.ResultsThe 10 cases included two with a single lobar hemorrhage and eight with multifocal lobar hemorrhages. In all of the cases, the hemorrhage bled into the subarachnoid space. Pathological examinations of the 10 cases revealed microaneurysms in two, double barrel-like changes in four, multifocal arteriolar clusters in five, obliterative onion skin-like intimal changes in four, fibrinoid necrosis of the vessels in seven, neurofibrillary tangles in eight, and senile plaques in five cases.ConclusionCAA-related CLHs were located primarily in the parietal, temporal, and occipital lobes. These hemorrhages normally consisted of multiple repeated CLHs that frequently bled into the subarachnoid space. CAA-associated microvascular lesions may be the pathological factor underlying CLH.     

出血性脑血管病患者不同时期内分泌功能的变化

出血性脑血管病在我国发病率高,有报道显示脑出血急性期以及蛛网膜下腔出血发病1年后会有不同程度的内分泌功能改变,改变程度与病情严重程度、出血部位等相关。本文将从几个已报道的试验出发,阐述在出血性脑血管病中相关内分泌激素的具体改变。     

脑梗死后出血性转化的研究进展

本文综述了脑梗死后出血性转化的类型和预后以及可能的机制,并讨论了溶栓剂组织型纤溶酶原激活物(t-PA)对脑梗死后出血性转化的影响以及出血性转化的干预措施,为脑梗死的临床治疗和研究提供参考。     

自发性脑出血患者肺部感染的影响因素及其对策分析

目的 探讨自发性ICH患者肺部感染（pulmonary infection，PI）的影响因素及其对策。 方法 回顾性分析2015年6月-2018年6月黄石市中心医院收治的228例自发性ICH患者的临床资料， 分析患者PI情况及其影响因素。 结果 228例自发性ICH患者有100例（43.67%）发生PI，共分离病原菌148株，其中革兰氏阴性菌128株 （86.48%）、革兰氏阳性菌10株（6.76%）、真菌10株（6.76%）；单因素分析结果显示，年龄、吸烟、吞 咽困难、GCS评分、出血量、气道侵入性操作、鼻饲、合并糖尿病、肺疾病、低蛋白血症与自发性ICH后 PI发生有关（P＜0.05）；Logistic多元回归分析结果显示，年龄≥60岁、吸烟、吞咽困难、GCS评分＜8分、 出血量≥100 mL、气道侵入性操作、鼻饲、合并糖尿病、肺疾病、低蛋白血症是自发性ICH后PI的独立危 险因素（P＜0.05）。 结论 自发性ICH后PI发生率高，以革兰氏阴性菌感染为主，其发生与多种因素有关，尤其应重视年 龄≥60岁、吸烟、吞咽困难、GCS评分＜8分、出血量≥100 mL、气道侵入性操作、鼻饲、合并糖尿病、 肺疾病、低蛋白血症等患者人群的病情监测与干预。     

Even in Patients with a Small Hemorrhagic Volume, Stereotactic-Guided Evacuation of Spontaneous Intracerebral Hemorrhage Improves Functional Outcome

Objective

The decision to adopt a conservative or surgical modality for a relatively small volume of spontaneous intracerebral hemorrhage (SICH) is difficult and often controversial, especially when consciousness is tolerable. The authors examined the results of stereotactic-guided evacuation of SICH for relatively small volumes with respect to functional outcome.

Methods

This prospective study was performed on 387 patients with SICH who underwent stereotactic-guided evacuation (n = 204, group A) or conservative treatment (n = 183, group B) during the past 8 years. The primary end-point was recovery of functional status, which was estimated using the Modified Barthel Index (MBI) and the modified Rankin Scale (mRS).

Results

All patients had a Glasgow coma scale (GCS) score of ≥ 13 and unilateral hemiparesis of less than motor power grade 3. Group demographic characteristics and initial neurological statuses were similar. In all cases, the volume of SICH involved was < 30 cm³ and location was limited to basal ganglia and thalamus. At 6-month follow-ups, MBI was 90.9 in group A and 62.4 in group B (p < 0.05), and MRS was 1.2 in group A and 3.0 in group B (p < 0.05). Better motor function and stereotactic-guided evacuation had a significant effect on a functional recovery in regression analyses.

Conclusion

Even in patients with a small volume of SICH, stereotactic-guided evacuation improved functional recovery in activities in daily life than conservative treatment did.     

脑静脉/静脉窦血栓形成伴颅内出血患者的临床特点及相关因素

目的探讨脑静脉/静脉窦血栓形成(Cerebral venous sinus thrombosis CVST)伴颅内出血患者的临床特点及相关因素。方法回顾性分析80例CVST患者,将其分为出血及未出血两组,分析比较两组患者的一般资料、既往病史、潜在病因、临床表现及血栓部位。结果入组80例CVST患者中,出血患者35例(43.75%)。其临床表现以癫痫发作(P0.001)、感觉及运动障碍(P=0.001)、失语(P=0.033)、意识障碍(P0.001)更常见,视力下降患者(P=0.012)较少。单因素分析显示,与未出血组相比,出血组患者发病年龄较大(P=0.023),自症状出现至首次就诊时间较短(P0.001),妊娠/产褥期(P=0.037)更多,直窦/深静脉更易受累(P=0.037)。出血组与未出血组患者的CVST评分差异无统计学意义。多因素分析发现,年龄偏大、急性期入院及直窦/深静脉受累与CVST伴出血的独立相关。结论年龄较大、妊娠/产褥期和直窦受累的CVST患者更易发生颅内出血。合并出血患者局灶性神经功能障碍、癫痫和意识障碍发生率高。     

高血压脑出血术后脑梗塞临床救治分析

目的探讨高血压脑出血术后脑梗塞的发病原因及临床救治措施。方法回顾性分析我院2000年1月至2007年1月间收治的11例高血压脑出血术后脑梗塞病例的临床资料。结果本组所有病例治疗后按日常生活能力分级：Ⅲ级5例,Ⅳ级2例,Ⅴ级1例,死亡3例。结论脑梗塞是高血压脑出血术后严重并发症之一,潜在致病因素复杂。完善综合治疗措施对降低患者死亡率、伤残率,提高其生存质量十分重要。     

脑血流自动调节功能在卒中应用的研究进展

【摘要】 脑血流自动调节（cerebral autoregulation,CA）是大脑维持脑血流量（cerebral blood flow,
CBF）相对恒定的主要机制,对于大脑各种生理功能的正常发挥和多种疾病的发生、发展和转归均有
至关重要的意义。随着测量技术的不断发展,CA逐渐走入临床各个领域,并逐渐开始为临床提供更
多的参考信息。本文就卒中对CA的影响及CA与疾病预后的关系进行了总结。     

Mollaret Meningitis may be Caused by Reactivation of Latent Cerebral Toxoplasmosis

Mollaret meningitis (MM) occurs mainly in females and is characterized by recurrent episodes of headache, transient neurological abnormalities, and the cerebrospinal fluid containing mononuclear cells. HSV-2 was usually identified as the causative agent. Recently, we found that recurrent headaches in non-HIV-infected subjects were due to acquired cerebral toxoplasmosis (CT). The aim of the study was therefore to focus on molecular pathomechanisms that may lead to reactivation of latent CT and manifest as MM. Literature data cited in this work were selected to illustrate that various factors may affect latent CNS Toxoplasma gondii infection/inflammation intensity and/or host defense mechanisms, i.e., the production of NO, cytokines, tryptophan degradation by indoleamine 2,3-dioxygenase, mechanisms mediated by an IFN-γ responsive gene family, limiting the availability of intracellular iron to T. gondii, and production of reactive oxygen/nitrogen species, finally inducing choroid plexitis and/or vasculitis. Examples of triggers revealing MM and accompanying disturbances of IFN-γ-mediated immune responses that control HSV-2 and T. gondii include: female predominance (female mice are more susceptible to T. gondii infection than males); HSV-2 infection (increased IFN-γ, IL-12); metaraminol (increased plasma catecholamine levels, changes in cytokine expression favoring T_H2 cells responses); probably cholesterol contained in debris from ruptured epidermoid cysts (decreased NO; increased TNF-α, IL-6, IL-8). These irregularities induced by the triggers may be responsible for reactivation of latent CT and development of MM. Thus, subjects with MM should have test(s) for T. gondii infection performed obligatorily.     

Two cases of cerebral toxoplasmosis in AIDS patients mimicking HIV-related dementia

Summary Two unusual cases of cerebral toxoplasmosis in AIDS patients are presented. Two homosexual males aged 33 and 52 years in CDC stage IV C1 complained of memory loss during the past 6 months, as well as weight loss and mild fever. They showed severe intellectual deterioration and discrete basal ganglia dysfunction. Motor performance and cognitive function as well as the conventional EEG findings were grossly abnormal. MRI was normal in the younger patient but showed signalintensive zones in the basal ganglia and cortical atrophy in the older one. CSF and serological antibody tests were normal; immunological function was severely impaired. The patients were diagnosed as late HIV-related dementia. Both deteriorated rapidly and died within a few weeks. Neuropathological examination revealed histologically severe Toxoplasma gondii encephalitis, involving the basal ganglia in particular. It is concluded that in AIDS patients with a severely impaired immune status cerebral opportunistic infection may present as dementia with mild basal ganglia impairment in the absence of other focal neurological signs or the characteristic radiological findings.