980 Matters arising

can not only show "some abnormality that 6 Mas JL, Henin D, Bousser MG, Chain F, Hauw 1 Hinse P, Thie A, L. Dissection of Lachenmayer J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.55.10.980-b on 1 October 1992. Downloaded from encourages angiographic examination" but JJ. Dissecting aneurysm ofthe vertebral artery the extracranial vertebral artery: report of and cervical manipulation: a case report with four cases and review of the literature. Jf can also diagnose dissections involving the autopsy. Neurology 1989;39:512-5. Neurol Neurosurg Psychiatry 199 1;54:863-9. pretransverse, C6-C5 and C5-C4 intertrans- 7 D'Anglejan-Chatillon J, Ribeiro V, Mas JL, Youl 2 Mokri B, Houser OW, Sandok BA, Piepgras verse segments of the VA.5 The diagnosis is BD, Bousser MG. Migraine-A risk factor for DG. Spontaneous dissections of the vertebral dissections of cervical arteries. Headache arteries. Neurology 1988;38:880-5. based on the association of a localised 1989;29:560-1. 3 Mas JL, Bousser MG, Hasboun D, Laplane D. increase in arterial diameter with haemody- Extracranial vertebral artery dissections: a namic signs of stenosis or occlusion and/or review of 13 cases. Stroke 1987;18:1037-47. decreased pulsatility and intravascular echoes Hinse and Thie reply: 4 Mokri B. Traumatic and spontaneous extrac- ranial internal carotid artery dissections. J at the same level. Furthermore, ultrasonic We thank Dr Mas and colleagues for their Neurol 1990;237:356-61. examination is an excellent tool for the follow interest in our recent paper,' and we appre- 5 Touboul PJ, Mas JL, Bousser MG, Laplane D. up of dissection. ciate the opportunity to comment on a few of Duplex scanning in extracranial vertebral 6) Among other diagnostic procedures, the the issues raised by them. artery dissection. Stroke 1987;18: 116-21. authors did not mention thin-section con- Our paper did not deal with the incidence trast-enhanced dynamic CT scan and MRI. of vertebral artery (VA) dissection which By virtue of its sensitivity to both blood flow remains unknown. Better diagnosis and sys- and thrombus formation, its multiplanar tematic study will hopefully shed more light Late onset globoid cell leukodystrophy imaging capability, and its noninvasiveness, on incidence of this condition in the future. MRI (and soon MR angiography) is becom- In our analysis, we have included only case I read with great interest the paper by Grewal ing the imaging modality of choice for the reports providing sufficient detail of the et al.' I would like to add a few comments. evaluation of suspected carotid or vertebral individual patient, but not summarised First, the authors suggest that their dissection (fig). At present, however, MRI series, thus the results of Mokri et al2 were patient's late onset (at age 14) distinguishes does not assist in distinguishing between not considered. We apologise for not includ- his disease from globoid cell leukodystrophy intraluminal and intramural thrombus and ing the well documented patients by Mas et (GLD) distinct from the infantile and late therefore does not allow the diagnosis of a1.3 infantile onset types. This may be true for the occlusive forms of vertebral dissection. The question of internal carotid artery first type, but the latter can occur within one 7) The relation of trauma to dissection is a (ICA) dissection was not the subject of our family together with a later onset type.2 complex issue. Hinse et al' considered their paper. We agree that angiographic visual- Second, it would be interesting to know patient 4 as an example of traumatic (chiro- isation of all four brain-supplying vessels whether the white matter hyperintensities on practic manipulation) dissection. We recently should be attempted in acuteVA dissection in the MRI were diffuse or rather restricted to reported6 the case of a woman with a 3 week order not to miss concomitant asymptomatic the occipito-parietal white matter, as des- history of cervical pain who developed iscae- ICA dissection. This point is of particular cribed in other late onset GLD.2 3 If so, this mia in the basilar artery territory following importance in spontaneous VA dissection: in posterior white matter involvement on MRI cervical manipulation. Necropsy revealed 2 5 of 29 reviewed patients concomitant ICA would seem to be very useful to distinguish VA dissections, a recent one probably due to dissection was documented, but not in 28 GLD from other cerebral white matter dis- cervical manipulation and a second one, a patients with traumatic VA dissection. eases. few weeks old, accounting for the initial Mas et al correctly state that dissection as a PETER VERDRU cervical pain. This case demonstrates that cause of arterial occlusion Neurologie, may be hard to Universitaire Ziekenhuizen, cervical pain that precedes and motivates diagnose. However, the angiographic appear- Herestraat 49, chiropractic manipulation may be the first ance of tapering occlusion is highly sugges- 3000 Leuven, Belgium symptom of a hitherto unrecognised sponta- tive of dissection.4 In our patients, complete neous (or traumatic) dissection and illus- recanalisation of a formerly occluded VA 1 Grewal RP, Petronas N, Barton NW. Late onset trates the difficulty in classifying with (cases 2 and 3) and visualisation of a small globoid cell leukodystrophy. J Neurol Neu- certainty whether dissection is spontaneous pseudoaneurysm (case 2) made the diagnosis rosurg Psychiatry 1991;54:1011-2. or traumatic. ofVA dissection probable. 2 Verdru P, Lammens M, Dom R, Van Elsen A, highly Carton H. Globoid cell leukodystrophy: a Apart from trauma and fibromuscular dys- The value of ultrasound method in the family with both late-infantile and adult type. plasia, other conditions implicated as risk diagnosis of VA dissection remains to be Neurol 1991;41:1382-4. factors for dissection include migraine, oral determined. Our own experience' and the 3 Shapiro EG, Lockman LA, Krivit W. Correla- tion of Magnetic Resonance Imaging and contraceptives, and chronic high blood pres- work of Touboul et al' on three patients Neuropsychological Abnormalities in Late- sure. In a case control study,7 we found a examined by duplex scan are too preliminary onset Leukodystrophies. Ann Neurol 1991; significant positive association of dissection to allow any firm conclusions. As we have 30:466-7. with and migraine current oral contraceptive pointed out in our paper, ultrasound meth- http://jnnp.bmj.com/ use but not with hypertension. However, the ods may be suitable for diagnosis of recanal- mechanisms leading to this association isation, possibly obviating the need for remains speculative. repeated angiography in some patients. The 8) Finally, we agree that anticoagulants are same holds true for modern neuroimaging Aseptic meningitis associated with high not harmful in extracranial VA dissection and methods. Contrast-enhanced CT scan and dose intravenous immunoglobulin may even be of benefit although no conclu- MRI may corroborate the diagnosis of VA therapy sion can be drawn from the comparison of dissection, and are also increasingly recom- nonrandomised treatment groups. mended for follow up studies. However, both We read with great interest the report by JEAN-LOUIS MAS methods do not allow on October 1, 2021 by guest. Protected copyright. Hpital Ste-Anne, examination of the Watson et al' and we would like to draw the 75674 Paris Cedex 14, affected vessels in their entire length. These authors attention to a similar case we pub- France neuroimaging techniques will have to prove lished last year.2 M G BOUSSER their value in a systematic study against the Our patient was a seven year old boy with P J TOUBOUL present "gold standard" (angiography). idiopathic thrombocytopenic purpura who Hopital Saint-Antoine, The role of many presumably predisposing had 75571 Paris Cedex 12, well-documented episodes of acute asep- France conditions, in particular migraine, use of oral tic meningitis on two occasions after the contraceptives or hypertension, remains second intravenous dose ofimmune globulin. totally obscure. It is speculative whether On these two occasions, the patient devel- 1 Hinse P, Thie A, Lachenmayer L. Dissection of some of these factors might act by merely oped aseptic meningitis on day three; quite the extracranial vertebral artery: report of facilitating the occurrence of stroke after identical to the two four cases and review of the literature. _7 patients reported by Neurol Neurosurg Psychiatry 1991;54:863-9. dissection, but not dissection itself. It is also Watson, whereas Kato's patient developed 2 Mas JL, Bousser MG, Hasboun D, Laplane D. unknown why minor trauma may induce the aseptic meningitis two days after a five Extracranial vertebral artery dissections: a cervical dissections in some patients at any day course of intravenous immune review of 13 cases. Stroke 1987;18:1037-47. globulin 3 Mokri B, Houser OW, Sandok BA, Piepgras particular time, but why recurrences in these therapy.3 DG. Spontaneous dissections of the vertebral patients are rare. In our patient the immune globulin prep- arteries. Neurology 1988;38:880-5. P HINSE aration used was Sandoglobulin IV (Sandoz), 4 Hart RG. Vertebral artery dissection. Neurology A THIE which is a formulation prepared by cold 1988;38:987-9. Department ofNeurology, 5 Touboul PJ, Mas JL, Bousser MG, Laplane D. University of Hamburg, ethanol fractionation. It was given at a dose Duplex scanning in extracranial vertebral Martinistr 52, of 0 4 g per kilogram of body weight infused artery dissection. Stroke 1987;18: 116-21. 2000 Hamburg 20, Germany over a 11 hour period. Matters arising 981

From these three reports, we conclude: during five consecutive days, a total of 370 At present I would therefore feel comfort- J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.55.10.980-b on 1 October 1992. Downloaded from 1 Intravenous immune globulin can induce infusions. These infusions were all performed able in calling schizophrenia a brain dysfunc- aseptic meningitis in children as well as in during the acute phase of the Guillain-Barre tion, but I do not think there is yet sufficient adults: the strong temporal association (on syndrome in patients of all ages. During the evidence to call it a brain disease. It is day three in our patient and in Watson's infusion period patients were scored every possible that the term disease, if commonly patients) and the repetitive occurrence in the other day and questions about complications applied to schizophrenia, may in the percep- same patient (on two occasions in Kato's were included in the datasheets. A treatment tion of some clinicians limit the range of patient and in our patient) are both strong form was also filled out, and this included viable therapeutic options. arguments in favour of this. It should no questions about any unusual event during NARINDER KAPUR longer be a hypothesis. treatment. Wessex Neurological Centre, Southampton 2 Several preparations of intravenous im- Five time-related events occurred during mune globulin can induce aseptic meningitis. these 370 infusions; blood pressure dropped 1 Ron MA, Harvey I. The brain in schizophrenia. Up till now it has been reported with four but did not need any treatment (2), dyspnoea J Neurol Neurosurg Psychiatry 199 1;53: 725-6. different preparations: with immunoglobulin treated with a diuretic (1), temperature 2 Boyle M. Schizophrenia: a scientific delusion. prepared with polyethylene glycol and with a increase treated with clemastine (1) and London: Routledge, 1990. sulphonated preparation,' with a formulation transient macroscopic haematuria (1). The prepared by cold ethanol fractionation (San- treatment course was not interrupted in any doglobulin)' and with a low PH formulation of the cases. The last event may have been prepared with ethylene glycol (Intragam).' coincidental, but the others may have been 3 As with many other iatrogenic diseases, the caused by the IgIV infusions. They were, aseptic meningitis in itself is rather benign however, mild and transient. Aseptic menin- ( Tc)-HM-PAO SPECT and dementia and resolves rapidly with cessation of the gitis was not observed in any of the patients. in Parkinson's disease therapy. But not recognising this complica- We conclude that the incidence of side effects tion as such might result in potentially ofhigh dose IgIV is low and that IgIV may be With great interest we read the article from dangerous and/or unnecessary explorations safely applied in neurological patients. Spampinato et al' and we would like to (lumber puncture in a thrombocytopenic FGA VAN DER MECHE comment on some aspects of the article. CT RP KLEYWEG We performed single photon emission patient;4 scan) Coordinatiecentrum Guillain-Barri Trial, The possible occurrence of aseptic menin- Afdeling Neurologie, Kamer Ee 2222, computed tomography (SPECT) using gitis following immune globulin infusion Medische Faculteit, (99'Tc)-HM-PAO as a tracer in 5 clinically should thus be known by all physicians and Erasmus University, Rotterdam, demented and 6 non-demented patients with should be mentioned by the pharmaceutical The Netherlands Parkinson's disease (PD). HM-PAO uptake firms. was measured in the frontal, parietal and M CASTEELS-VAN DAELE 1 Watson JDG, Gibson J, Joshua DE, Kronenberg temporo-parietal cortex and was expressed as L WIJNDAELE H. Aseptic meningitis associated with high cortical/cerebellar activity ratio. None of our P BROCK dose intravenous immunoglobulin therapy. J M KRUGER Neurol Neurosurg Psychiatry 199 1;54:275-6. patients had a reduction of HM-PAO uptake Department of Paediatrics, 2 Van der Meche FGA, Kleyweg RP, Meulstee J, of more than 20%, which seems to be in University Hospital Gasthuisberg, Schmitz PIM and the Dutch Guillain-Barre concordance with Spampinato et al. In con- 3000 Leuven, Belgium Study Group. The Dutch GuiUain-Barre trial trast to Spampinato et al, however, we found Ph GILLIS comparing high-dose immunoglobulins with plas- no difference between the demented and Department of Paediatrics, ma-exchange; preliminary results. Oxford: Per- Virga Jesse Ziekenhuis, ipheral Neuropathy Association of America non-demented PD patients. We investigated 3500 Hasselt, Belgium (PNAA), 1990. whether there was a relation between 3 Van der Meche FGA, Kleyweg RP, Meulstee J, Schmitz PIM and the Dutch Guillain-Barre SPECT-scan data and neuropsychological in a = 1 1 Watson JD G, Gibson J, Joshua DE, Kronen- Study Group. The Dutch Guillain-Barre trial tests our group as whole (n 1). Using berg H. Aseptic meningitis associated with comparing high-dose immunoglobulins with plas- the Spearman rank correlation test, we found high dose intravenous immunoglobulin ther- ma-exchange. VII Int Congress on Neuromus- no significant correlations between neuro- apy. J Neurol Neurosurg Psychiatry 1991; cular Diseases, Munich, 1990. psychological perfomance and SPECT data 54:275-76. 2 Casteels-Van Daele M, Wijndaele L, Hunninck on any test. K, Gillis Ph. Intravenous immune globulin One of the main problems in our research and acute aseptic meningitis. N EngI J Med was the estimation of dementia in PD. Of the 1990;323:614-5. 5 who fulfilled the criteria for 3 Kato E, Shindo S, EtoY, et al. Administration of patients immune globulin associated with aseptic dementia as described in the DSM-III-R, all

meningitis. JAMA 1988;259:3269-71. The brain in schizophrenia lacked typical cortical features. All of our http://jnnp.bmj.com/ 4 Scott EW, Cazenave CR, Virapongse C. Spinal patients were able to undergo the neuro- subarachnoid hematoma complicating lum- bar puncture: diagnosis and management. The excellent editorial by Ron and Harvey' psychological tests. In the study by Spampi- Neurosurgery 1989;25:287-93. notes that "to have forgotten that schizo- nato et al, diagnosis ofdementia was based on phrenia is a brain disease will go down as one neuropsychological assessment, according to of the great aberrations of twentieth century which the PD patients were divided into two Dr Watson et al' described two patients who medicine". However, I think it is open to groups of 15 patients. However, five of their developed aseptic meningitis after high dose question as to whether schizophrenia can be patients could not be tested, probably due to intravenous immunoglobulins (IgIV). Both considered as a brain disease in the same way severe dementia. It was not stated by the had mild symptoms and recovered com- as established brain diseases such as viral or investigators whether their demented PD on October 1, 2021 by guest. Protected copyright. pletely within 14 and seven days, respectively. atrophic disorders of the CNS. There may be patients were free from cortical features. We consider it important that this side effect more general reservations with the validity of In our opinion, one of the possible expla- has been noted. It improves detection of the concept of schizophrenia itself,2 but I nations for the differences in results is that future similar effects and places it in the have four specific reservations with calling patients had no cortical dysfunction and appropriate pathogenetic context. The obser- schizophrenia a brain disease: therefore no Alzheimer-like pathology. Fur- vations on these two patients, however, do 1) Unlike most brain diseases, there is as yet ther elucidation of dementia as seen in PD not give any clue about the incidence of this no diagnostic pre- or post-mortem seems mandatory. biological MA KUIPER side effect. or other physical marker for schizophrenia. HC WEINSTEIN* In the Dutch Multi Centre Guillain-Barre 2) Compared to most brain diseases, there is PLM BERGMANS trial we compared high dose IgIV with no predictable pattern of deficit in sensory or Ph SCHELTENS E Ch WOLTERS plasma-exchange (PE). Based on the main motor functions or in "primitive" reflexes. Department of Neurology and Psychiatry* outcome criterion-functional improvement 3) Unlike most brain diseases, psychological of the Free University Hospital Amsterdam, four weeks after randomisation-IgIV was or psychosocial variables play a significant Amsterdam, The Netherlands superior to PE.2 ' As a result of this study part in the aetiology and stability of outcome IgIV may well be used more often in neuro- of many patients with schizophrenia. 1 Spampinato U, Habert MO, Mas JL, Bourdel logical patients after detailed publication of 4) The relationship between neurobiological MC, Ziegler M, de Recondo J, Askienazy S, the results. We would therefore like to report features of patients with schizophrenia and Rondot P. ("Tc)-HM-PAO SPECT and cog- nitive impairment in Parkinson's disease: a our experiences on the side effects of IgIV. the pattern or severity of psychiatric disturb- comparison with dementia of the Alzheimer In 74 patients 0 4 g/kg of IgIV (Gamma- ance is much more equivocal than in the case type. J7 Neurol Neurosurg Psychiatry 1991; gardR, Hyland Division, Baxter) was infused of analagous relationships in brain diseases. 54:787-92.