RESUMEN
Basing on the literature, the information on the shoulder-hand syndrome in stroke patients is presented. The syndrome is believed to be a clinical form of algodystrophy of the upper extremity. The main signs and symptoms include pain and considerable reduction of movement in shoulder joint, wrist and hand. The condition usually develops 1-6 months after stroke with pain and loss of range of motion in the shoulder at the beginning; then the distal part of the extremity is involved. The syndrome is considered to develop in three consecutive phases: I--acute, II--dystrophic and III--atrophic. Besides classical clinical form, affecting distal and proximal part of extremity, the incomplete forms confined only to one of this parts may exist. The prevalence of the condition is rated at 12.5-27% in stroke patients. It is believed that the development of the syndrome is related to altered biomechanics of the hemiplegic shoulder. Stability of the joint is considerably affected due to paresis or palsy of shoulder girdle muscles what results in partial subluxation of humeral head. Repeated microtraumas of shoulder joint may cause chronic pain and may initiate development of abnormal, regional sensory-sympathetic reflex arch, or--according to the other concept--it results in "sensitization" of neurons in the dorsal horn; this state may alter dorsal horn central mechanisms processing sensory and painful stimuli. The diagnosis of the syndrome is based on clinical ground. Three-phase bone scintigraphy is believed to be the most useful additional diagnostic test. The diagnostic and predictive value of this technique is presented. For all advantages of scintigraphic examination, it does not need to be performed in the majority of stroke patients since the presence of typical signs and symptoms is usually sufficient to make a diagnosis. The treatment of shoulder-hand syndrome included administration of steroids with satisfactory response. The role of proper physical therapy in improving of the results of treatment as well as in prophylactics of the syndrome is emphasised. Considering the fact that many of stroke patients may have contraindications to steroid therapy, other methods of effective treatment are proposed.
Asunto(s)
Trastornos Cerebrovasculares/complicaciones , Distrofia Simpática Refleja/etiología , Humanos , Cintigrafía/métodos , Distrofia Simpática Refleja/diagnóstico , Factores de RiesgoRESUMEN
A case of shoulder-hand syndrome (algodystrophy, reflex sympathetic dystrophy) in a stroke patient is presented. Six weeks after stroke the condition started with pain, swelling and considerable reduction of movements of the hand and wrist followed by involvement of shoulder joint a few days later. Initially, the complaints were attributed to excessive rehabilitation, however, when cessation of exercises and anti-inflammatory treatment failed to improve, the diagnosis of shoulder-hand syndrome was suspected. Three phase bone scintigraphy performed 2 weeks after the onset of symptoms revealed features of possible algodystrophy. X-ray revealed no significant changes. The patient satisfactory responded to nasal salmon calcitonin treatment 300 units daily during 4 weeks. The reassessment performed 3 months after the onset of disease showed regression of most signs and symptoms as well as satisfactory range of motion of the hand and shoulder. Bone scintigraphy revealed typical algodystrophy pattern (diffusely increased periarticular uptake). The cause of such evolution of scintigraphic changes as well as some implications of nasal calcitonin administration were discussed.
Asunto(s)
Trastornos Cerebrovasculares/complicaciones , Distrofia Simpática Refleja/etiología , Administración Intranasal , Anciano , Calcitonina/uso terapéutico , Mano/diagnóstico por imagen , Humanos , Masculino , Radiografía , Cintigrafía/métodos , Distrofia Simpática Refleja/diagnóstico , Distrofia Simpática Refleja/tratamiento farmacológico , Índice de Severidad de la EnfermedadRESUMEN
The influence of the intrathecal methotrexate (IT MTX) prophylaxis on frequency and intensity of lymphomatous infiltrates within the leptomeninges and spinal roots in adults with non-Hodgkin's lymphomas (HGNHL) of high grade malignancy was evaluated. The effect of selected risk factors on the central nervous system (CNS) involvement by infiltrates was also analysed. Based on the results, indications for the prophylactic management were discussed. The post-mortem neuropathological investigations have been performed on 42 deceased patients having the NHL of high grade malignancy, treated and suffered in the Department of Haematology of the Pomeranian Medical Academy between 1980-1994. In all patients, neither apparent neurological complications nor changes in the cerebrospinal fluid during the disease were noted. Generally, lymphomatous infiltrates within the leptomeninges and spinal roots were observed in 64 per cent of cases. They were usually observed as variously sized foci: from single small to large, diffused in many regions. The study group of 21 patients subjected to IT MTX prophylaxis were compared with 21 patients without "CNS prophylaxis" (control group). Frequency and intensity of lymphomatous infiltrates decreased significantly after more than 3 IT MTX injections (Tab. 1) within spinal leptomeninges only (Tab. 2, 3). No benefits of this kind of treatment within cerebellar leptomeninges were noted. A poor penetration of the MTX (given by lumbar injection) into this region, could be a possible explanation of such result. It was disclosed that high white blood cells (WBC) count was the most important risk factor of the CNS involvement by lymphomatous infiltrates. Frequency of lymphomatous infiltrates diminished after IT MTX prophylaxis only in patients with WBC count less than 50 G/1 during the disease (Tab. 4). It was also found that lymphomatous infiltrates within the leptomeninges and spinal roots occurred in high percentage in both groups, and were independent of histological type of the HGNHL (Tab. 5) as well as of patients' age. From the neuropathological point of view, IT MTX prophylaxis seems to be ineffective in patients with the HGNHL, who did not reach a complete heamatological remission. A complete elimination of lymphomatous cells from the intracranial leptomeninges is particularly difficult to achieve. Considering the fact that it is hard to foresee response to polychemotherapy, especially at the beginning of the treatment, and--as present study shows--the lymphomatous infiltrates in the CNS are frequently found soon after the onset of the disease, "CNS prophylaxis" should be initiated simultaneously with the induction of remission. However, the continuation of the prophylaxis without haematological control of the disease seems to be aimless.
Asunto(s)
Aracnoides/patología , Linfoma no Hodgkin/patología , Neoplasias Meníngeas/patología , Metotrexato/administración & dosificación , Piamadre/patología , Raíces Nerviosas Espinales/patología , Adulto , Anciano , Ensayos Clínicos Controlados como Asunto , Femenino , Estudios de Seguimiento , Humanos , Inyecciones Espinales , Recuento de Leucocitos , Linfoma no Hodgkin/sangre , Linfoma no Hodgkin/prevención & control , Masculino , Neoplasias Meníngeas/sangre , Neoplasias Meníngeas/diagnóstico , Neoplasias Meníngeas/prevención & control , Persona de Mediana Edad , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Based on post-mortem neuropathological evaluation the authors analyzed the incidence and distribution of the lymphomatous infiltrates within the leptomeninges and spinal roots in 21 patients with high grade non-Hodgkin's lymphomas (HGNHL) treated with intrathecal methotrexate (ITMTX) prophylaxis. The investigations revealed that lymphomatous infiltrates were most frequent within cerebellar leptomeninges and around spinal roots. In spinal leptomeninges and roots the infiltrates occurred significantly rare after more than 3 ITMTX injections, but further ITMTX applications did not diminish infiltrates incidence in the mentioned regions. In the remaining regions infiltrates incidence was similar, irrespective of the number of ITMTX injections. From the neuropathological point of view ITMTX prophylaxis isn't able to prevent the development of the infiltrates in the mentioned regions. In an attempt to determine the clinical usefulness of the ITMTX prophylaxis in adult patients with HGNHL and to elaborate optimal prophylactic management, the more detailed clinical and pathological evaluations are required.
Asunto(s)
Neoplasias Encefálicas/tratamiento farmacológico , Encéfalo/metabolismo , Infiltración Leucémica , Linfoma no Hodgkin/tratamiento farmacológico , Metotrexato/farmacocinética , Metotrexato/uso terapéutico , Adolescente , Adulto , Encéfalo/patología , Neoplasias Encefálicas/patología , Femenino , Humanos , Inyecciones Espinales , Linfoma no Hodgkin/patología , Masculino , Metotrexato/administración & dosificación , Persona de Mediana EdadRESUMEN
The clinical and neuropathological investigations have been done on 133 autopsied patients died of leukemia or non-Hodgkin's lymphoma of high malignancy. A study was performed to analyse the role of various factors particularly with respect to adhesion and aggregation in the CNS leukostasis development. The findings were also designated to evaluate the distribution of leukostasis in different CNS regions and to recognize its intensity in various CNS vessels. Basing on the studies the authors conclude that the risk of CNS leukostasis increases evidently when the leukocyte counts are elevated above 50 G/l. The adhesion and aggregation of leukemic and lymphomatous cells as well as local anatomical factors in the CNS vessels play and important role in the CNS leukostasis development, which is more intensive in the white matter and leptomeninges. The medium-sized vessels are much involved, whereas cortical capillaries are relatively less affected by leukostasis. The CNS leukostasis appears to be dynamic and reversible phenomenon, which undergoes fluctuations according to the leukocyte counts increase or decrease.
Asunto(s)
Encefalopatías/patología , Leucemia/complicaciones , Leucostasis/patología , Linfoma no Hodgkin/complicaciones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Encefalopatías/sangre , Encefalopatías/etiología , Capilares/patología , Humanos , Recuento de Leucocitos , Leucostasis/sangre , Leucostasis/etiología , Persona de Mediana EdadRESUMEN
The authors report the clinical course and neuropathological findings in the case of hemiballismus due to leukemic infiltration of the subthalamic nucleus. The symptoms were observed in a 19-year-old patient with blastic phase of chronic myelogenous leukemia, two weeks before death, when what is called the "critical point" developed (white cell count beyond 100 G/l and thrombocytopenia less than 50 G/l). The investigation are considered to confirm the role of the "critical point" in the development of central nervous system leukemic complications.
Asunto(s)
Crisis Blástica , Neoplasias Encefálicas/patología , Tractos Extrapiramidales/patología , Leucemia Mieloide de Fase Crónica/patología , Adulto , Edad de Inicio , Neoplasias Encefálicas/ultraestructura , Hemorragia Cerebral/etiología , Resultado Fatal , Lóbulo Frontal/patología , Lóbulo Frontal/ultraestructura , Lateralidad Funcional , Humanos , Leucemia Mieloide de Fase Crónica/complicaciones , Infiltración Leucémica , Masculino , SíndromeRESUMEN
The reported analysis comprised 81 patients dying of acute non-lymphoblastic leukaemia type M1, M2, M4 and blastic crises in chronic myelocytic leukaemia. It was observed that the number of cases of cerebellar granular layer atrophy rose markedly in the years 1984-1990 as compared with 1976-1983 (45.4% vs 16.2%). It is suggested that this was due to the introduction of cytostatic treatment schedules with higher doses of cytosine arabinoside (ARAC), especially TAD (6-thioguanine, ARAC, daunorubicin). Cerebellar granular layer atrophy seems to be dependent rather on the cumulative dose of ARAC and not on a single high dose of that drug.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Crisis Blástica/tratamiento farmacológico , Corteza Cerebelosa/patología , Citarabina/efectos adversos , Leucemia Mielógena Crónica BCR-ABL Positiva/tratamiento farmacológico , Leucemia Mieloide Aguda/tratamiento farmacológico , Adolescente , Adulto , Anciano , Aminoglutetimida/administración & dosificación , Atrofia/inducido químicamente , Crisis Blástica/patología , Corteza Cerebelosa/efectos de los fármacos , Ciclofosfamida/administración & dosificación , Citarabina/administración & dosificación , Danazol/administración & dosificación , Relación Dosis-Respuesta a Droga , Doxorrubicina/administración & dosificación , Femenino , Humanos , Leucemia Mielógena Crónica BCR-ABL Positiva/patología , Leucemia Mieloide Aguda/patología , Masculino , Persona de Mediana Edad , Prednisolona/administración & dosificación , Prednisona/administración & dosificación , Tamoxifeno/administración & dosificación , Vincristina/administración & dosificaciónRESUMEN
On the basis of clinical neuropathological evaluation of 48 patients with acute myeloblastic leukaemias the authors analyse the risk factors of leukemic infiltrations developing in the brain. The investigations revealed that the distinct dissemination of leukemic cells in blood is the most important risk factor of such infiltrations. The risk increases significantly in older patients. Survival time and maintenance of high leukocytosis do not intensify the risk of leukemic infiltrations in the brain.