Clinical Neuroscience

[About granulomas in the dorsal root ganglia of the spinal cord]

BALÓ József1

OCTOBER 01, 1969

Clinical Neuroscience - 1969;22(10)

[In the study of spinal ganglion cysts, we have monitored granulomas that occur in the posterior gyri of the spinal cord. Although these granulomas also contain a chronic inflammatory component, they are also populated by endothelial, or more recently meningothelial, cells of the arachnoid. According to Verga and Rexed and Wennström, these granulomas are important as causative factors in the formation of cysts in spinal ganglia. Veith has observed granulomas in the root nerves in connection with chronic infectious diseases of other organs (chronic polyarthritis, chronic cholecystitis, and malignant tumours), which he considers to be of non-specific origin. He raised the question of whether Richter's tabes granulomas are specific or non-specific. In cases of pemphigus, granulomas similar to those described by Veith in various chronic infectious diseases occur in the dorsal root ganglia of the spinal cord. The question of whether Richter's specific syphilitic granulomas are identical to Veith's non-specific granulomas due to chronic infectious diseases needs further investigation. A similar finding was reported on the subject raised, that of a disease which started with chronic inflammation (tuboovarial abscess) and was associated with granulomas in the root nerves, the clinical course leading to death in the form of multiple neurotic gangrene of the skin.]

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  1. Budapesti Orvostudományi Egyetem I. Kórbonctani Intézete

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Clinical Neuroscience

[Choosing how to explore in lumbar hernia operations, based on 373 cases over four years - 1965-1968]

ANDRÁSOFSZKY T., MÁTHÉ Á., NAGY P., ROTH Gy., KOMJÁTSZEGI S., SZABÓ Á., KISGYÖRGY Á.

[It is the authors' understanding that the most important criteria for the successful surgical treatment of lumbar hernias are the correct indication and timing of surgery, avoidance of myelography, minimal bone resection, but always complete root decompression. These criteria were applied in 373 operations between 1965 and 1968, with inter-arch exploration in 87.64% of cases. The situations which make each type of exploration possible or necessary are analysed. It is stressed that inter-arch exploration can be used to remove hernias causing cauda-unusual hernias and that this method of exploration can also be used in reoperations. ]

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Mélanoblastose et neurofibromatose

LUDO Van Bogaert

Les observations cliniques et génétiques rapportées indiquent que la blastomatose méningée et cutano-méningée, lorsqu'elle se présente comme une blastomatose isolable et sévère, entretient un lien, en apparence et surtout en familiarité, avec les dysplasies génétiques du système nerveux central. La conception mésoectodermique de l'ontogenèse de la mélanine explique non seulement l'apparition des neurinomes, des gliomes et des méningiomes, mais aussi la possibilité d'observer des processus mélaniques dans des phacomatoses telles que la neurofibromatose, la sclérose tubéreuse et l'angiomatose.

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[Encephalodystrophy progressiva paranatalis]

CSERMELY Hubert

[The author analyses the histopathological picture of the subacute and chronic stages of paranatal asphyxia based on 3 observations. In the chronic stage, he suggests the name "status microcysticus" for the spongy loosening of the cortex and cortical bone, which should be distinguished from the van Bogaert and Leigh type "status spongiosus". The status microcysticus is the result of a functional or organic vascular lesion. Finally, he discusses Alpers' disease and considers that the majority of the findings to date do not correspond to Alpers' disease.]

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Oro-lingual dyskinesia: a neurological enigma

MACDONALD Critchley

Author draws attention to a specialised dystonic syndrome involving mainly the muscles of the mouth, lips and tongue. Spasms can become so extensive that they can prevent the patient from writing, walking and standing. In particular, the muscles of the face and tongue may be affected. The pathogenesis and pathogenesis are not uniform. In the past, most cases of the disease were late complications of encephalitis. Nowadays this pathology is unlikely. Some cases strongly suggest a psychogenic origin, others are more likely to be of degenerative or ischaemic origin. This is particularly the case in elderly patients. Finally, in a proportion of cases, an organic syndrome due to unusual sensitivity to prolonged use of phenothiazides or other medications is likely.

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[Cerebrovascular accidents with psychiatric symptoms]

CSIKY Kálmán, CSIKY-WAGNER Rózsa, STRÖMPEL Ilona

[We have described and illustrated it with "model" cases: a) The acute reversible psychotic symptom complex of hypertensive encephalopathic meningo-cerebral oedema, which we reported in 1956, which presents as a cerebral vascular catastrophe and can be distinguished from the progressive form of meningo-cerebral oedema, the latter being known from an earlier date. b) Psychotic episodes of shorter or longer duration in the Binswanger-Grünthal form of cerebral vascular atherosclerosis, which, although presenting as cerebral vascular catastrophes, are considered to be a form of generalised circulatory insufficiency, beginning with cerebral circulatory insufficiency. c) We have also isolated, on the basis of clinical and EEG features, the temporal lobe Korsakow variant. In our case, we also found a diffuse cerebral small vessel sedation with acute onset and recurrent psychotic symptomatology over many years.]

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EVRAN Sevket, KATAR Salim

Far lateral lumbar disc herniations (FLDH) consist approximately 0.7-12% of all lumbar disc herniations. Compared to the more common central and paramedian lumbar disc herniations, they cause more severe and persistent radicular pain due to direct compression of the nerve root and dorsal root ganglion. In patients who do not respond to conservative treatments such as medical treatment and physical therapy, and have not developed neurological deficits, it is difficult to decide on surgical treatment because of the nerve root damage and spinal instability risk due to disruption of facet joint integrity. In this study, we aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) on the improvement of both pain control and functional capacity in patients with FLDH. A total of 37 patients who had radicular pain caused by far lateral disc herniation which is visible in their lumbar magnetic resonance imaging (MRI) scan, had no neurological deficit and did not respond to conservative treatment, were included the study. TFESI was applied to patients by preganglionic approach. Pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared with the 3rd week, 3rd month and 6th month scores after the procedure. The mean initial VAS score was 8.63 ± 0.55, while it was 3.84 ± 1.66, 5.09 ± 0.85, 4.56 ± 1.66 at the 3rd week, 3rd month and 6th month controls, respectively. This decrease in the VAS score was found statistically significant (p = 0.001). ODI score with baseline mean value of 52.38 ± 6.84 was found to be 18.56 ± 4.95 at the 3rd week, 37.41 ± 14.1 at the 3rd month and 34.88 ± 14.33 at the 6th month. This downtrend of pa­tient’s ODI scores was found statistically significant (p = 0.001). This study has demonstrated that TFESI is an effective method for gaining increased functional capacity and pain control in the treatment of patients who are not suitable for surgical treatment with radicular complaints due to far lateral lumbar disc hernia.

Clinical Neuroscience

Comparison of direct costs of percutaneous full-endoscopic interlaminar lumbar discectomy and microdiscectomy: Results from Turkey

ÜNSAL Ünlü Ülkün, ŞENTÜRK Salim

Microdiscectomy (MD) is a stan­dard technique for the surgical treatment of lumbar disc herniation (LDH). Uniportal percutaneous full-endoscopic in­terlaminar lumbar discectomy (PELD) is another surgical op­tion that has become popular owing to reports of shorter hos­pitalization and earlier functional recovery. There are very few articles analyzing the total costs of these two techniques. The purpose of this study was to compare total hospital costs among microdiscectomy (MD) and uniportal percutaneous full-endoscopic interlaminar lumbar discectomy (PELD). Forty patients aged between 22-70 years who underwent PELD or MD with different anesthesia techniques were divided into four groups: (i) PELD-local anesthesia (PELD-Local) (n=10), (ii) PELD-general anesthesia (PELD-General) (n=10), (iii) MD-spinal anesthesia (MD-Spinal) (n=10), (iv) MD-general anesthesia (MD-General) (n=10). Health care costs were defined as the sum of direct costs. Data were then analyzed based on anesthetic modality to produce a direct cost evaluation. Direct costs were compared statistically between MD and PELD groups. The sum of total costs was $1,249.50 in the PELD-Local group, $1,741.50 in the PELD-General group, $2,015.60 in the MD-Spinal group, and $2,348.70 in the MD-General group. The sum of total costs was higher in the MD-Spinal and MD-General groups than in the PELD-Local and PELD-General groups. The costs of surgical operation, surgical equipment, anesthesia (anesthetist’s costs), hospital stay, anesthetic drugs and materials, laboratory wor­kup, nur­sing care, and postoperative me­dication diffe­red significantly among the two main groups (PELD-MD) (p<0.01). This study demonstrated that PELD is less costly than MD.

Clinical Neuroscience

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Vaccines against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been rapidly developed to prevent coronavirus disease 2019 (COVID-19) pandemic. There is increasing safety concerns regarding COVID-19 vaccines. We report a 78-year old woman who was presented with tetraparesis, paresthesias of bilateral upper extremities, and urinary retention of one-day duration. Three weeks before these symptoms, she was vaccinated with CoronaVAC vaccine (Sinovac Life Sciences, China). Spine magnetic resonance imaging showed longitudinally extensive transverse myelitis (TM) from the C1 to the T3 spinal cord segment. An extensive diagnostic workup was performed to exclude other possible causes of TM. We suggest that longitudinally extensive TM may be associated with COVID-19 vaccination in this case. To the best of our knowledge, this is the first report of longitudinally extensive TM developing after CoronaVac vaccination. Clinicians should be aware of neurological symptoms after vaccination of COVID-19.

Clinical Neuroscience

[Consensus statement of the Hungarian Clinical Neurogenic Society about the therapy of adult SMA patients]

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[Background – Spinal muscular atrophy (SMA) is an autosomal recessive, progressive neuromuscular disorder resulting in a loss of lower motoneurons. Recently, new disease-modifying treatments (two drugs for splicing modification of SMN2 and one for SMN1 gene replacement) have become available. Purpose – The new drugs change the progression of SMA with neonatal and childhood onset. Increasing amount of data are available about the effects of these drugs in adult patients with SMA. In this article, we summarize the available data of new SMA therapies in adult patients. Methods – Members of the Executive Committee of the Hungarian Clinical Neurogenetic Society surveyed the literature for palliative treatments, randomized controlled trials, and retrospective and prospective studies using disease modifying therapies in adult patients with SMA. Patients – We evaluated the outcomes of studies focused on treatments of adult patients mainly with SMA II and III. In this paper, we present our consensus statement in nine points covering palliative care, technical, medical and safety considerations, patient selection, and long-term monitoring of adult patients with SMA. This consensus statement aims to support the most efficient management of adult patients with SMA, and provides information about treatment efficacy and safety to be considered during personalized therapy. It also highlights open questions needed to be answered in future. Using this recommendation in clinical practice can result in optimization of therapy.]

Clinical Neuroscience

Life threatening rare lymphomas presenting as longitudinally extensive transverse myelitis: a diagnostic challenge

TOLVAJ Balázs, HAHN Katalin, NAGY Zsuzsanna, VADVÁRI Árpád, CSOMOR Judit, GELPI Ellen, ILLÉS Zsolt, GARZULY Ferenc

Background and aims – Description of two cases of rare intravascular large B-cell lymphoma and secondary T-cell lymphoma diagnosed postmortem, that manifested clinically as longitudinally extensive transverse myelitis (LETM). We discuss causes of diagnostic difficulties, deceptive radiological and histological investigations, and outline diagnostic procedures based on our and previously reported cases. Case reports – Our first case, a 48-year-old female was admitted to the neurological department due to paraparesis. MRI suggested LETM, but the treatments were ineffective. She died after four weeks because of pneumonia and untreatable polyserositis. Pathological examination revealed intravascular large B-cell lymphoma (IVL). Our second case, a 61-year-old man presented with headache and paraparesis. MRI showed small bitemporal lesions and lesions suggesting LETM. Diagnostic investigations were unsuccessful, including tests for possible lymphoma (CSF flow cytometry and muscle biopsy for suspected IVL). Chest CT showed focal inflammation in a small area of the lung, and adrenal adenoma. Brain biopsy sample from the affected temporal area suggested T-cell mediated lymphocytic (paraneoplastic or viral) meningoencephalitis and excluded diffuse large B-cell lymphoma. The symptoms worsened, and the patient died in the sixth week of disease. The pathological examination of the presumed adenoma in the adrenal gland, the pancreatic tail and the lung lesions revealed peripheral T-cell lymphoma, as did the brain and spinal cord lesions. Even at histological examination, the T-cell lymphoma had the misleading appearance of inflammatory condition as did the MRI. Conclusion – Lymphoma can manifest as LETM. In cases of etiologically unclear atypical LETM in patients older than 40 years, a random skin biopsy (with subcutaneous adipose tissue) from the thigh and from the abdomen is strongly recommended as soon as possible. This may detect IVL and provide the possibility of prompt chemotherapy. In case of suspicion of lymphoma, parallel examination of the CSF by flow cytometry is also recommended. If skin biopsy is negative but lymphoma suspicion remains high, biopsy from other sites (bone marrow, lymph nodes or adrenal gland lesion) or from a simultaneously existing cerebral lesion is suggested, to exclude or prove diffuse large B-cell lymphoma, IVL, or a rare T-cell lymphoma.