tical perspective. For instance, there are only three passing references to kuru in a book of 650 pages. This edition reflects the renewed interest in the immunological theories of multiple sclerosis. More than half the text is devoted to Professor Lumsden's analysis of the pathoIogy and, in particular, the chemical pathology of the immune response. There is a great deal of original work devoted to the chemistry and behaviour of the immunoglobulins. Much of this appears in specialist journals and one must be grateful for the critical summary provided here. Professor Lumsden unequivocally sees the key to the problem of multiple sclerosis in the study of its immunochemistry, relegating infection by a virus or a slow virus to a quite subsidiary role. The clinical studies drawing on wide practical experience help to get one's prejudices about the illness onto a more reasoned footing. The section on treatment is still sadly limited. Dr. McAlpine found little to add to the regime which he described in 1955. McAlpine, Lumsden, and Acheson's reappraisal is an essential reference for the practising neurologist and the new edition makes important modification of and changes in emphasis from the edition of 1965.

https://jnnp.bmj.com/content/jnnp/36/5/894.3.full.pdf

The assessment of aphasia and related disorders

Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases.

Motor recovery after stroke: A systematic review of the literature

Background and Purpose— In a geographically defined population, we assessed incidence and determinants of aphasia attributable to first-ever ischemic stroke (FEIS). MethodsA 1-year prospective, population-based study among the permanent residents of the canton Basle City, Switzerland, was performed using multiple overlapping sources of information. Results— Among 188 015 inhabitants, 269 patients had FEIS, of whom 80 (30%; 95% CI, 24 to 36) had aphasia. The overall incidence rate of aphasia attributable to FEIS amounted to 43 per 100 000 inhabitants (95% CI, 33 to 52). Aphasic stroke patients were older than nonaphasic patients. The risk of aphasia attributable to FEIS increased by 4% (95% CI, 1% to 7%), and after controlling for atrial fibrillation, by 3% (95% CI, 1% to 7%) with each year of patients’ age. Gender had no effect on incidence, severity, or fluency of aphasia. Cardioembolism was more frequent in aphasic stroke patients than in nonaphasic ones (odds ratio [OR], 1.85; 95% CI, 1.07 to 3.20). Ap...

Epidemiology of aphasia attributable to first ischemic stroke: incidence, severity, fluency, etiology, and thrombolysis

Thrombolytic agents hold theoretical promise as therapy for cerebral infarction This study was designed to evaluate the safety of tissue plasminogen activator, to accomplish urgent patient treatment, and to estimate potential efficacy of tissue plasminogen activatorFollowing neurological evaluation and computed tomography of the brain, patients with acute ischemic stroke were evaluated and treated with intravenous tissue plasminogen activator under an open-label, dose-escalation design within 90 minutes from symptom onset End points examined included symptomatic and asymptomatic intracranial hematoma, systemic hemorrhage, and neurological outcome at 2 hours, 24 hours, and 3 monthsSeventy-four patients were treated within 90 minutes of symptom onset over seven dose tiers of tissue plasminogen activator, ranging from 035 mg/kg to 108 mg/kg Intracranial hematoma with associated neurological deterioration occurred in three patients and was related to increasing doses of tissue plasminogen activator (p 

Urgent therapy for stroke. Part I. Pilot study of tissue plasminogen activator administered within 90 minutes.

We present the results of a 12-year retrospective analysis of 11 patients, eight women and three men, aged 16-76 years, with pathologically documented atrial myxomas. Nine of the 11 patients were found to have a left atrial myxoma; right atrial myxomas were identified in two. Five of the 11 patients (45%) had abnormalities on neurologic examination, and five of five had computed tomographic evidence of nonhemorrhagic cerebral infarction. Neurologic symptoms were the initial presentation in four patients. Six patients reported a history of cardiac disease; eight of the 11 had abnormalities on cardiac auscultation. Echocardiography in 10 patients was diagnostic in all but one. Gated magnetic resonance imaging of the heart in two patients demonstrated myxoma position and movement. Follow-up examinations (varying from 1 month to 7 years after tumor resection) in nine of 11 patients demonstrated no recurrent neurologic symptoms. Cerebral infarction is a common complication of atrial myxomas and may be the presenting feature. Recurrent cerebral emboli before surgery is not uncommon. Cardiac auscultation may be normal, and electrocardiographic changes are often nonspecific. Delayed neurologic events following surgery are rare.

Neurologic manifestations of atrial myxoma. A 12-year experience and review.

Recent clinical studies emphasize the importance of early (less than 12 hours after onset) treatment of patients with acute ischemic stroke. Therapies have been proposed as being effective because of early clinical improvement. The frequency and degree of spontaneous improvement in such patients, however, is unknown. We prospectively evaluated the course of 29 patients (19 men, 10 women) aged 33-82 years who were seen less than or equal to 12 hours after the onset of acute ischemic stroke. Seventeen patients were first evaluated less than or equal to 6 hours and the remaining patients at 6-12 hours after onset. All patients were examined using a modified National Institutes of Health Stroke Scale at baseline, 1, 2, 3, and 6 hours. No specific treatment for acute ischemic stroke was given during this time. Improvement (defined as a decrease of greater than or equal to 2 points from baseline score) was noted at 1 hour in seven patients (24%). By 6 hours 15 patients (52%) had improved, 12 (41%) were unchanged, and two (7%) were worse. Our results suggest that spontaneous, often dramatic improvement occurs in patients with acute ischemic stroke and should be taken into consideration in the design of any trial of acute treatment.

Spontaneous improvement after acute ischemic stroke. A pilot study.

We reviewed 49 patients with Wernicke's aphasia resulting from a stroke. Their aphasia was classified on the basis of comprehensive neuropsychological testing. Wernicke's aphasia was more common in older patients and in men. Cerebral infarction occurred in 38 patients (78%) and intracerebral hemorrhage in seven (14%); the remaining four patients (8%) developed aphasia after surgery for aneurysmal subarachnoid hemorrhage. Embolic events were the most common etiology of Wernicke's aphasia in the 38 patients with cerebral infarction, with cardiac emboli in 40% and large-vessel atheroemboli from a carotid source in 16%. In patients with Wernicke's aphasia secondary to infarction, an embolic source should be sought. Patients with Wernicke's aphasia should have computed tomography to exclude intracerebral hemorrhage before institution of anticoagulant therapy.

https://www.ahajournals.org/doi/pdf/10.1161/01.STR.20.12.1730

Etiology of stroke in patients with Wernicke's aphasia.

Cerebral ventriculitis is an uncommon site and manifestation of infection of the central nervous system. We report the magnetic resonance findings in two patients with cytologic and CSF culture proof of ventriculitis. The findings included abnormal signal intensity of the ependyma and CSF on T2-weighted images. In addition, ependymal, meningeal, and dural enhancement was seen in one case, on T1-weighted images, after administration of Gd-diethylenetriamine pentaacetic acid.

Cerebral ventriculitis: MR findings.

We studied six patients with basilar artery occlusion using magnetic resonance imaging. Two patients also had arteriography. All had signs consistent with pontine infarction; three had a "locked in" syndrome. Magnetic resonance imaging (five done within 24 h of onset of progression of neurologic symptoms) revealed a linear structure of increased signal intensity in the pontine cistern on T1-weighted parasagittal images and absence of flow void phenomena. Hyperintense signals at various brain stem levels corresponding to the course of the basilar artery were noted on T2-weighted images. Multiple parenchymal abnormalities were noted in the brain stem (six), cerebellum (four), occipital lobes (two), and thalamus (two). Magnetic resonance performed early in the course of basilar artery occlusion is a high-yield, safe procedure and might eliminate the need for arteriography.

Laurie E. Knepper

Papers

Neurologic manifestations of atrial myxoma. A 12-year experience and review.

Spontaneous improvement after acute ischemic stroke. A pilot study.

Etiology of stroke in patients with Wernicke's aphasia.

Cerebral ventriculitis: MR findings.

MR imaging of basilar artery occlusion.