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BACKGROUND: Clostridium tetani is a gram-positive spore-forming bacterium that produces toxins and grows under anaerobic conditions. Infections with this bacterium can lead to local or generalised forms of tetanus. CASE DESCRIPTION: An 83-year-old man presented to the acute cardiac care unit with a painful left arm and jaw. Because the patient had a hypertonic left arm and was unable to open his mouth fully, the neurologist was consulted. The patient had been to the emergency department 9 days earlier for an infected wound after falling in the garden. He had not been actively or passively immunised against tetanus at that time. On inquiry, it appeared that the patient had also not been vaccinated as a child. We made a clinical diagnosis of tetanus. The patient was admitted and treated with tetanus immunoglobulin, metronidazole, diazepam and painkillers. He was also administered tetanus toxoid and the wound was cleaned. After 1 month and 7 months, the patient was again administered tetanus toxoid. CONCLUSION: Patients with a wound that may have come into contact with road grime, dirt or manure, should always be asked for their vaccination status, especially people from high-risk groups, such as the elderly.

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A healthy woman aged 56 was vaccinated for the second year in succession against influenza. Three days afterwards she developed a strange sensation in the legs and lower abdomen, accompanied by difficulties of urinating and defaecation. Motor strength and reflexes were normal at neurological examination. There was, however, an altered sensibility below the dermatome T7. Additional investigations were all normal, and the diagnosis of myelopathy after influenza vaccination was made. Over six months there was gradual amelioration.

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The frequency of silent infarction is an important issue because it is a marker of vascular disease. We studied the occurrence of silent infarction in a sample of patients from the Dutch TIA trial, in which patients were randomized between 30 and 283 mg of aspirin. A total of 91 patients with TIA or non-disabling ischemic stroke and who did not suffer a stroke during a period of one to four years (mean 32 months) underwent CT scanning both on entry and at the end of the study. A cardiac source of embolism was an exclusion criterion for the trial. We found only one patient with a possibly silent infarction; in four patients a previously detected symptomatic infarct on CT was no longer visible. The rarity of silent infarction in this study may have several explanations; (1) the relatively short period of follow-up, (2) the selection of patients (no cardiac source of embolism), (3) the clinical monitoring at four monthly intervals aimed at detection of focal ischemia, (4) the use of aspirin. Given these circumstances, silent infarction is an infrequent problem.

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BACKGROUND AND PURPOSE: We studied silent stroke (i.e., infarcts on computed tomographic scan not related to later symptoms) in patients after transient ischemic attack or minor ischemic stroke. METHODS: Ours is a cross-sectional study of 2,329 patients who were randomized in a secondary prevention trial after transient ischemic attack or minor ischemic stroke and had no residual deficit after the qualifying event. RESULTS: Silent stroke was observed in 13% of the 2,329 patients. Lacunes formed 79%, cortical lesions 14%, and border zone lesions 7% of all silent strokes. Silent lacunes were most often located in the basal ganglia and symptomatic lacunes most often in the corona radiata. Age, hypertension, and current cigarette smoking were related to the presence of silent stroke. Silent stroke was equally common in different types of transient ischemic attack, including transient monocular blindness. Residual symptoms of any kind were more common in patients with silent stroke than in those without. CONCLUSIONS: Because only the sites of silent stroke infarcts differed slightly from those of symptomatic infarcts and the frequency of vascular risk factors was similar to that of symptomatic infarcts, silent stroke may have the same bearing on future risk as known prior stroke.

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A retrospective follow-up study was performed on a cohort, which took part in a secondary prevention trial after transient ischemic attack (TIA) or small stroke, to study variables relevant to the cessation of smoking. Of 100 patients, 57 smoked, 1 was lost to follow-up and 18 stopped smoking. Age, gender, amount of cigarettes, hospital admission, and persistence of symptoms were not statistically significant factors in the cessation of smoking in this group, which reported regularly for follow-up in the Dutch TIA trial. Directly after the event 11 patients stopped indefinitely and another 18 patients tried, but resumed smoking later on. During follow-up another 7 stopped. The important factor in the cessation of smoking was the event itself, as most people stopped directly after it, but enforcement was difficult, as half of those who stopped resumed smoking.

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We treated five patients with hemispheric ischemic stroke with intravenous recombinant tissue plasminogen activator (rtPA), within 3-6 h after stroke onset. Regional cerebral blood flow was evaluated with single photon emission computed tomography (rCBF-SPECT) before and after treatment. One patient with aphasia and a moderately severe hemiparesis, who had a small flow deficit, was treated 5 h and 30 min after the onset of his stroke and had a prompt and complete recovery. The post treatment rCBF-SPECT showed normal flow. One patient with a very large flow deficit died of transtentorial herniation. In three other patient clinical condition remained unchanged, in one of them despite restoration of flow, demonstrated by transcranial doppler examination. In all these patients the rCBF-SPECT remained abnormal. rCBF-SPECT is a valuable tool in the explanatory analysis of fibrinolytic treatment in ischemic stroke.

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Two patients with angiographically proved basilar artery occlusion were treated with systemic recombinant tissue plasminogen activator (rtPA) according to protocol. The first patient was in a locked-in state and gradually deteriorated. On repeat angiography the basilar artery remained occluded. He died and necropsy revealed a pontine haemorrhagic infarction. The second patient, who was comatose and with decerebrate posturing, made a remarkable recovery. Angiography showed reperfusion. Therapy was initiated in the first patient after six hours and in the second after two hours. Treatment with rtPA is promising but probably not feasible for every patient. Success may depend on duration of occlusion and composition of occluding thrombus.

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An unusual mode of presentation of lymphomatoid granulomatosis is reported. A 19-year-old man developed spinal cord symptoms, and magnetic resonance imaging of the spinal cord disclosed a compatible lesion. Despite medical therapy the outcome was fatal.

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