Naltrexone and Tourette's syndrome.
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Adolescent↗
Biomedical subjects
R J Lederman
Publications and source records attributed to R J Lederman.
Neurological complications following liver transplantation.
Neurological complications occurred in 4 (19%) of 21 consecutive patients (Group II) undergoing orthotopic liver transplantation, compared with a 47% (9/19) incidence in our initial series (Group I). In Group II, the neurological problems included new recurrent headaches and delayed intracerebral hemorrhage (1 patient), partial third nerve palsy and brachial plexopathy (1 patient), and ataxic dysarthria with encephalopathy (2 patients). Seizures, noted in 8 of 9 neurologically affected Group I patients, were not encountered in Group II. Of the 4 patients in the entire series with the cerebrocerebellar syndrome, 2 had partial recovery after stopping treatment with cyclosporine, 1 stabilized when cyclosporine was discontinued but later worsened when rechallenged, and 1 had full recovery but died following a second transplantation. Brain magnetic resonance images appeared normal in 3 of the 4 patients. Complications affecting vision included cortical blindness in 2 patients and occipital lobe hemorrhage in 1. All completely recovered. Survival was comparable for patients with and those without neurological complications (69% and 63%, respectively). Immediate withdrawal of cyclosporine at the onset of a change in mental status or dysarthria and improvement in intra- and postoperative management may have contributed to the decreased incidence of neurological complications.
Adult↗
Alternating sequential intracarotid BCNU and cisplatin in recurrent malignant glioma.
The authors entered 43 patients with recurrent malignant glioma in a trial of alternating sequential intracarotid BCNU and cisplatin. Protocol design was alternating courses of BCNU (2 doses, 300 to 400 mg each) and cisplatin (2 doses, 150 to 200 mg each) each at 4-week to 6-week intervals. Eight of 40 patients (20%) evaluable after the first course of BCNU showed partial or minor response. Only 18 patients were evaluable after the first course of cisplatin, and 5 were evaluable after the second course of BCNU. Median survival was 9 months (range, 2 weeks to 6 years). Cerebral or ocular toxicity unique to this method of chemotherapy administration and failure to show clinical improvement were the most common reasons for removal from study. Because of the high attrition rate, the authors were unable to determine a meaningful response to alternating sequential BCNU and cisplatin or to test the clinical degree of cross-resistance to these agents in human malignant glioma.
Adult↗
Spinal accessory nerve palsy.
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Accessory Nerve Injuries↗
Peripheral nerve disorders in instrumentalists.
I evaluated 226 instrumentalists for playing-related symptoms. There were 103 players (46%) of string instruments, 7 keyboard instrumentalists (32%), 44 players (19%) of wind instruments, and 6 percussionists (3%). The mean age was 32 years; 58% were women. Sixty-five patients (29%) had a peripheral nerve disorder; 27 had symptoms of thoracic outlet syndrome; 12 had median neuropathies (carpal tunnel syndrome in 9); 9 had ulnar neuropathies; 6 had cervical radiculopathy; 5 had digital neuropathies; 3 had cranial neuropathies; and 3 had other peripheral nerve disorders. Treatment consisted of modification of playing schedules and technique, plus physical and occupational therapy in 51 and surgical procedures in 9 patients; 5 were not treated. Follow-up at 1 to 8 years showed 74% had a satisfactory result, 14% had slight or minimal improvement, and 12% had no improvement. At the time of writing, all but 4 patients remained in the music profession. It is concluded that playing-related symptoms among instrumentalists are frequently neurological in origin and that the large majority can be helped by conservative or, on occasion, surgical means.
Adolescent↗
Primary biliary cirrhosis in a patient with multiple sclerosis.
A 47-yr-old patient with primary biliary cirrhosis and multiple sclerosis is reported. Although primary biliary cirrhosis has been associated with numerous other autoimmune disorders, it has not, to the authors' knowledge, previously been reported in association with multiple sclerosis.
Autoimmune Diseases↗
Neurologic complications of liver transplantation.
Nineteen adult patients underwent 21 orthotopic liver transplants at the Cleveland Clinic between November 1984, and August 1986. Eight of 19 (42%) patients developed seizures. One patient suffered a single seizure, and seven patients had multiple, generalized seizures. Two of these seven patients became comatose after several days of seizure activity. Over several weeks, both of these patients regained consciousness--however, they exhibited a cerebellar-type syndrome, manifested as severe ataxia, weakness, and dysarthria. Both patients have improved, but remain neurologically impaired. Laboratory evaluation included serum electrolytes, magnesium, osmolality, and cyclosporine levels. Neurologic testing consisted of cerebrospinal fluid (CSF) analysis, computed tomographic (CT) scanning, and electroencephalography (EEG). Although the CSF protein was mildly elevated in two patients, all cultures remained sterile. None of the CT scans demonstrated any abnormalities. In five patients, the EEG showed generalized slowing consistent with diffuse encephalopathy. Other factors associated with seizures in transplant patients were analyzed, including fluid retention, hypertension, high-dose steroids, hypomagnesemia, graft dysfunction, and demyelinization. Many of our patients had the first three of these factors, since all but one developed their seizures within the first ten postoperative days. Only one patient had mild hypomagnesemia. Trough cyclosporine levels (whole blood, HPLC) were not in the toxic range (greater than 500 ng/mL). The serum osmolality was elevated in all four patients in whom it was measured, ranging from 309 to 341 mOsm/kg. Only three patients exhibited graft dysfunction--two moderate and one severe. The cause of neurologic toxicity following transplantation is unclear. Although many factors have been implicated, no common denominator has emerged. Several reports have linked cyclosporine with seizures and other neurologic problems, such as the cerebellar-type syndrome exhibited in two of our patients. Future studies should include magnetic resonance (MR) imaging of the head and measuring osmolality and cyclosporine levels in the blood and CSF.
Adult↗
Solitary primary lymphoma of the sciatic nerve: case report.
An unusual case of a solitary extranodal primary lymphoma of the sciatic nerve in a patient presenting with sciatica and a left footdrop is described. Magnetic resonance imaging was successful in identifying a fusiform lesion in the sciatic nerve in the left infragluteal region. Surgical exploration and biopsy confirmed this as a B cell lymphoma. An extensive metastatic work-up has not identified other sites of lymphomatous involvement.
Humans↗
Ocular and orbital toxicity following intracarotid injection of BCNU (carmustine) and cisplatinum for malignant gliomas.
Eleven patients treated with intracarotid BCNU, cisplatinum, or BCNU and cisplatinum in combination for recurrent malignant gliomas were followed with serial ophthalmologic examinations for 2 to 11 months. Eight patients developed significant visual loss ipsilateral to the side of infusion. Secondary glaucoma and internal ophthalmoplegia were new complications observed after BCNU treatment. An unusual pigmentary retinopathy, previously unreported, was seen in patients treated with cisplatinum. One patient also developed a cavernous sinus syndrome after the intracarotid administration of cisplatinum.
Adult↗
Evidence for conduction delay in thoracic-outlet syndrome is challenged.
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Humans↗
Focal inflammatory myopathy.
We report three patients with inflammatory myopathy who presented clinically with weakness and wasting of only one limb. The myopathy progressed over 6 months and 5 years, respectively, in two patients and was stable after 8 years in the third patient. One patient had a skin rash. Serum CK was elevated in the two patients with progressive disease. Electromyography showed brief duration, small amplitude motor unit potentials and fibrillations in the affected limbs. Muscle biopsy revealed variable fiber size, degenerating and regenerating fibers, and inflammatory foci. Vasculitis was seen in the patient with skin lesions and marked fibroblastic proliferation in the patient with the most chronic course. Immunosuppressive therapy has arrested the progression in the two patients treated; both have regained strength.
Adult↗
Brachial plexopathy: recurrent cancer or radiation?
We reviewed clinical and electrodiagnostic features of 16 patients with neoplastic brachial plexopathy (NBP) and 17 patients with radiation-induced plexopathy (RBP). The groups were similar in symptom-free interval after cancer diagnosis and location of the plexus lesions. NBP patients had pain and Horner's syndrome; RBP patients had paresthesias, but rarely Horner's. NBP patients presented earlier after symptom onset and had a shorter course. RBP patients more frequently had abnormal sensory and normal motor nerve conduction studies and characteristically had fasciculations or myokymia on EMG.
Adult↗
Progressive facial and cerebral hemiatrophy.
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Adult↗
Hearing loss in multiple sclerosis.
Hearing loss in an uncommon symptom in multiple sclerosis (MS). In nine patients with MS, seven with unilateral hearing loss and two with bilateral impairment, accompanying symptoms and signs included facial numbness, hemifacial paresis or spasms, ipsilateral limb ataxia, nystagmus, vertigo, tinnitus, and spastic-ataxic gait. Central auditory dysfunction was suggested by audiometric findings and/or by brainstem auditory evoked potentials in all nine patients. Clinical improvement in two was accompanied by return toward normal in the results of audiometric or electrophysiologic studies. Hearing impairment should be sought in patients with MS and appropriate studies pursued.
Adult↗
Mechanism and frequency of brachial plexus injury in open-heart surgery: a prospective analysis.
A computer-assisted prospective analysis of 531 patients undergoing open-heart operations revealed that 26 patients (5%) sustained brachial plexus injury. In 22 of the 26 patients (85%), the lesion involved the lower trunk or C8-T1 nerve roots. Electromyograms confirmed the clinical impression in 13 patients. In 19 of the 26 patients (73%), the side on which the plexus lesion was found correlated with the side of internal jugular vein cannulation. Because of the anatomical proximity of the lower trunk to the internal jugular vein and the preponderance of lower trunk lesions, we postulate that traumatic cannulation may be a major mechanism of plexus injury. Thus, the resulting syndrome of pain, dysesthesias, and hand weakness may sometimes be preventable.
Adult↗
Peripheral nervous system complications of coronary artery bypass graft surgery.
Among 421 patients undergoing coronary artery bypass graft surgery, 55 (13%) developed 63 new peripheral nervous system (PNS) complications postoperatively. Most common was a brachial radiculoplexopathy, which occurred in 23 patients. Of these, 21 involved lower trunk or medial cord fibers. In 17 there was a correlation between the site of jugular vein cannulation and the side affected, suggesting that needle trauma played a role. Stretching from chest wall retraction may have caused some cases. Other deficits included 13 saphenous, 8 common peroneal, and 5 ulnar mononeuropathies. Six patients had persistent singultus, suggesting phrenic nerve involvement. Unilateral vocal cord paralysis was found in 5. An isolated partial Horner syndrome and a facial neuropathy were also identified. Males were more likely to develop PNS complications. Hypothermia during surgery was associated with increased risk. Most PNS deficits were transient, and lasting disability was rare.
Adult↗