The association between headache presentation, normal examination and neuroimaging findings: a retrospective analysis of patients presenting to a tertiary referral centre

Background: There is a high worldwide burden of headaches. Selection of patients with headaches for neuroimaging, in the absence of traditional red flags, is imperative in guiding further management. Objectives: Determine the yield of neuroimaging findings in patients with headache and normal examination; and potentially identifying additional red flags. Methods: A retrospective consecutive chart review of patients with a main complaint of headaches and normal clinical examination were assessed at a tertiary hospital, over a 10-year period. Results: Cohort consisted of 114 patients. Unexpected or normal variants found in 20.2% of patients (23/114) and 11.4% (13/114) required change in management. The absence of nausea and vomiting (p=0.009) and absence of sharp type headaches in unexpected or normal variants group (p=0.03) were statistically significant. There was a higher chance of an abnormal neuroimaging study in men and HIV seropositive patients. Conclusions: Decision to neuroimage should be determined on an individual basis (demographic factors, history of headache and examination) as normal examination cannot preclude patients from unexpected findings on neuroimaging. Headache with nausea and vomiting in isolation may be associated with normal neuroimaging reflecting primary type headaches. Findings support a lower threshold to neuroimage men and HIV seropositive patients with headaches despite normal clinical examination. Keywords: Headache; normal clinical examination; neuroimaging; headache red flags

Motor neuron disease in blacks

A series of 86 black, Indian and white patients with motor neuron disease were analysed retrospectively. Although the material does not allow statistically valid conclusions, there are sufficient cases among blacks to allow two prima facie observations in this population group: (i) motor neuron disease has an earlier age of onset than in whites and Indians; and (ii) more patients come from peripheral and rural areas than would be expected in prevailing circumstances.S Af Med J 1989; 76: 155-15

Autoimmune encephalitis: a missed diagnostic and therapeutic opportunity

Encephalitis is a common clinical problem affecting 5 cases per 100 000 population annually. After exclusion of the usual infective causes, a number of cases remain unexplained. It has been observed that many such cases have an autoimmune basis resulting in disruption of synaptic and ion channel function. This diagnosis should be suspected based on subacute onset, short term memory loss, altered mental status or psychiatric symptoms in combination with new focal neurological deficits, new onset seizures, CSF pleocytosis or MRI features suggestive of encephalitis. As this is a treatable condition, with a good prognosis if recognised early, it is important not to miss the diagnosis.Keywords: Autoimmune encephaliti

Sensitivity and specificity of neuropsychological tests for dementia and mild cognitive impairment in a sample of residential elderly in South Africa

BACKGROUND. Neuropsychological tests can successfully distinguish between healthy elderly persons and those with clinically significant cognitive impairment. Objectives. A battery of neuropsychological tests was evaluated for their discrimination validity of cognitive impairment in a group of elderly persons in Durban, South Africa. METHOD. A sample of 117 English-speaking participants of different race groups (9 with dementia, 30 with mild cognitive impairment (MCI) and 78 controls) from a group of residential homes for the elderly was administered a battery of 11 neuropsychological tests. Kruskal-Wallis independent sample tests were used to compare performance of tests in the groups. Sensitivity and specificity of the tests for dementia and MCI were determined using random operating curve (ROC) analysis. RESULTS. Most tests were able to discriminate between participants with dementia or MCI, and controls (p<0.05). Area under the curve (AUC) values for dementia v. non-dementia participants ranged from 0.519 for the digit span (forward) to 0.828 for the digit symbol (90 s), with 14 of the 29 test scores achieving significance (p<0.05). AUC values for MCI participants ranged from 0.754 for controlled oral word association test (COWAT) (Animal) to 0.507 for the Rey complex figure test copy, with 17 of the 29 scores achieving significance (p<0.05). CONCLUSION. Several measures from the neuropsychological battery had discrimination validity for the differential diagnosis of cognitive disturbances in the elderly. Further studies are needed to assess the effect of culture and language on the appropriateness of the tests for different populations.Web of Scienc

Importance of contrast-enhanced fluid-attenuated inversion recovery imaging to detect paradoxical expansion of tuberculoma

SummaryTuberculosis is a significant public health problem that continues to be a major cause of morbidity and mortality worldwide. Tuberculous meningoencephalitis (TM) is the most common extrapulmonary lesion in tuberculosis. A 41-year-old female was thought to have TM. Tests to confirm the TM diagnosis were initially negative, including tuberculosis PCR and adenosine deaminase level in serum and cerebrospinal fluid (CSF). Anti-tuberculous medication and intravenous steroids were administered to her on the basis of brain imaging and lactate dehydrogenase electrophoresis in CSF, suggestive of the diagnosis of TM. Her neurological problems improved rapidly following treatment. Serologic and CSF markers were positive in PCR and culture after 60 days. Radiological findings are often nonspecific and TM is difficult to diagnose without an increased index of suspicion. The detection of paradoxical expansion of tuberculoma is very important in the maintenance of medication. Magnetic resonance imaging was used to detect paradoxical expansion of the tuberculoma using various methods, such as contrast-enhanced fluid-attenuated inversion recovery (CE-FLAIR) imaging. CE-FLAIR imaging conspicuously showed paradoxical expansion of the tuberculoma. If patients present with clear meningitis, without any identified pathogen, there is a need to constantly and scrupulously check for TM, including with the use of CE-FLAIR brain imaging

Treatment of tuberculous meningitis in adults: Is the duration of intensive-phase therapy adequate?

Tuberculous meningitis (TBM) results in considerable morbidity and mortality, especially in developing countries such as South Africa. Treatment regimens have been extrapolated from treatment for pulmonary tuberculosis, and the intensive-phase duration of 2 months may be inadequate for treatment of patients with TBM. We highlight this situation with a case report of a patient with TBM whose illness progressed after institution of the maintenance phase of treatment. We propose that the intensive-phase treatment of TBM be revisited with regard to duration of treatment, choice of drugs during continuation-phase therapy, or both

The sensitivity and specificity of subjective memory complaints and the subjective memory rating scale, deterioration cognitive observee, mini-mental state examination, six-item screener and clock drawing test in Dementia Screening.

Background: The effectiveness of dementia screening depends on the availability of suitable screening tools with good sensitivity and specificity to confidently distinguish normal age-related cognitive decline from dementia. The aim of this study was to evaluate the discriminant validity of 7 screening measures for dementia. Methods: A sample of 140 participants aged ≥60 years living in a residential facility for the aged were assessed clinically and assigned caseness for dementia using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revised diagnostic criteria. Sensitivity and specificity of a selection of the following screening measures were tested using receiver operating characteristic (ROC) analysis for individual and combined tests: the Mini-Mental State Examination (MMSE), Six-Item Screener (SIS), Subjective Memory Complaint, Subjective Memory Complaint Clinical (SMCC), Subjective Memory Rating Scale (SMRS), Deterioration Cognitive Observee (DECO) and the Clock Drawing Test (CDT). Results: Using ROC analyses, the SMCC, MMSE and CDT were found to be ‘moderately accurate' in screening for dementia with an area under the curve (AUC) >0.70. The AUCs for the SIS (0.526), SMRS (0.661) and DECO (0.687) classified these measures as being ‘less accurate'. At recommended cutoff scores, the SMCC had a sensitivity of 90.9% and specificity of 45.7%; the MMSE had a sensitivity of 63.6% and a specificity of 76.0%, and the CDT had a sensitivity of 44.4% and a specificity of 88.9%. Combining the SMCC and MMSE did not improve their predictive power except for a modest increase when using the sequential rule. Conclusion: The SMCC is composed of valid screening questions that have high sensitivity, are simple to administer and ideal for administration at the community or primary health care level as a first level of ‘rule-out' screening. The MMSE can be included at a second stage of screening at the general hospital level and the CDT in specialist clinical settings. Sequential use of the SMCC and MMSE will improve the specificity of the former and the sensitivity of the latter.Department of HE and Training approved lis

Mild cognitive impairment and dementia in a heterogeneous elderly population: prevalence and risk profile

OBJECTIVE: To describe the demographic, clinical and risk profile of Mild Cognitive Impairment and dementia in a sample of elderly South Africans within a residential setting. METHOD: One hundred and forty participants residing in a group of residential homes for the elderly were assessed by psychiatrists and assigned diagnoses of dementia or Mild Cognitive Impairment (MCI). Participants diagnosed with dementia were also offered haematological investigations and a CT scan of the brain. RESULTS: The sample consisted of 140 participants comprising 46.4% White, 29.3% Coloured, 20% Asian and 4.3% Black participants. There were 97 (69.3%) females and 106 (75.7%) participants had less than 12 years of education. Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Increasing age was associated with cognitive impairment (MCI and dementia) (p=.020) but there was no association between gender and cognitive impairment (p=.165). MCI was significantly associated with a lower education level (p=.036) and no association was found between depression (current-p=.646; past-p=.719) and dementia or MCI. The presence of vascular risk factors (n=140) ranged from 66.4% (hypertension) to 14.3% (stroke). Subjective memory complaints were significantly associated with cognitive impairment (p=.001). Except for the use of the telephone (p=.225) and the television (p=.08), impairment in all domains of instrumental activities of daily living that were assessed were significantly associated with a dementia diagnosis. CONCLUSION: The study showed that cognitive impairment was associated with increasing age and low education levels. The presence of vascular risk factors places this population at risk for future cognitive decline.Web of Scienc

Some aspects of HTLV-1 infection in Natal, South Africa.

Doctoral Degree. University of KwaZulu-Natal, Durban.Abstract available in PDF.Publications listed on page v-vi