NOTES A N D LETTERS
Chronic Subdural Hematoma Simulating Transient Ischemic Attacks Joseph J. Robin, M D , John A. Maxwell, MD, and David T. Pitkethly, MD Although transient ischemic attacks are common, their symptoms have rarely been reported in patients with chronic subdural hematomas [ I , 21. W e have examined 2 patients with this type of association.
Patient 1 A 64-year-old right-handed man sustained a head injury in July, 1977. Approximately two weeks later, the patient developed left-sided headaches with intermittent apraxia of his right upper extremity. Arteriography revealed a left parietal subdural hematoma, which was drained on September 4. A week later the patient developed transient attacks, including expressive aphasia, right upper extremity paresis, and right facial paresis. T h e episodes lasted one to two hours and then subsided, recurring once a week. In October, examination revealed right-to-left confusion, finger agnosia, and acalculia. He had some difficulty with recent memory, but he was able to gwe most of the history. He had a decreased opticokinetic response to the left and mild agraphia of the right hand. A CAT scan showed residual left parietal subdural hematoma, which was drained. Postoperatively his symptoms subsided completely.
Patient 2 A 65-year-old man had been in good health until three weeks before hospitalization, when he fell, striking the left side of his head. He developed headaches, lethargy, and left hemiparesis. A right subdural hematoma was diagnosed by angiography and was drained. Postoperatively he experienced four transient episodes, including a right hemiparesis with expressive aphasia. These lasted two to three hours and then cleared. He was observed, and he recovered. The cause of these transient neurological abnormalities with chronic subdural hematoma is not known. Melamed e t al [ 11 suggested several possible mechanisms. including mechanical pressure of a mass o n neighboring cerebral vessels, an irritative phenomenon such as epileptic discharges, or the phenomenon of spreading cortical depression. W e could not demonstrate a paroxysmal electroencephalographic abnormality, and angiography showed normal vessels in the area, without spasm.
2. Melamed E, Levy S, Reches A, et al: Chronic subdural hematoma simulating transient cerebral ischemic attacks. J Neurosurg 42: 101-103, 1975
Greater Reliability of Tear versus SAva An ticonvulsant Levels Massimo Tondi, MD, Roberto Mutani, MD, Camillo Mastropaolo, MD, and Francesco Monaco, MD Though the easy and noninvasive accessibility of saliva as a sample medium can be helpful for measurements of the free fraction of anticonvulsant drugs [ 11, several problems hinder reliable results. These include large variations in composition ascribed to, respectively, methods of collection, the particular salivary glands that were secreting, and the varying stimuli employed to augment salivary flow [7]. Furthermore, salivary phenobarbital concentration is p H dependent, and the p H of saliva is influenced by secretion rate 13-51. Different methods have been attempted to compensate for the great variations in p H [ 1-41. but their application requires analytical methods and mathematical calculations hard to perform in routine clinical settings. Tears seem to represent a potentially more stable body fluid since they contain diffusible and nitrogenous materials as well as electrolytes in concentration similar to those of plasma and because they have modest variations in p H . Tears share with cerebrospinal fluid a relatively constant protein content (0.6 to 0.8 gnddl), which assures them a greater osmotic stability [Z]. This note reports phenobarbital and carbamazepine levels determined in a group of epileptic patients by a simple method of tear collection. Samples of plasma, tears, o r saliva (or all three) were collected simultaneously early in the morning in subjects undergoing steady-state treatment with phenobarbital, carbamazepine, or both. Salivary secretion was stimulated by having the patient chew a small piece of paraffin; in some babies it was impossible to obtain a n y sample. Tears were obtained soon after the subjects awakened so as to avoid evaporation and consequent concentration of the fluid. They were collected in a glass capillary tube 5 cm long and 1 m m in internal diameter from either the medial or the lateral canthus of the eye. Lacrimation is frequent in children; in adults, brisk tearing can easily be provoked by cigarette smoke, thus resulting in an isotonic solution [7]. The p H range was 6.9 4 0.5 for saliva and 7.9 f 0.4 for tears. Anticonvulsant levels were determined in triplicate by means of immunoassay EMIT technique (Syva, Palo Alto, CA) which correlates well with results by gas-liquid
R ejerences 1. Groch S, Hurwiu LJ, Wright 1, et al: Cranial lesions simulating
cerebral thrombosis. JAMA 172:1469-1472, 1960 Accepted for publication Mar 20, 1978. Address reprint requests to Dr Robin, Neurological Associates of Washington, Inc, 1200 F 116th Ave NE, Bellevue, WA 98004.
154
From the Neurological Clinic and the Institute of Child Neuropsychiatry, University of Sassari, Sassari, Italy. Accepted for publication Mar 22, 1978. Address reprint requests to Dr Tondi, Istituto di Neuropsichiatria Infantile dell’UniversitH, c/o Villaggio S. Camillo, 07 100 Sassari, Italy.
Chronic Subdural Hematoma Simulating Transient Ischemic Attacks Joseph J. Robin, M D , John A. Maxwell, MD, and David T. Pitkethly, MD Although transient ischemic attacks are common, their symptoms have rarely been reported in patients with chronic subdural hematomas [ I , 21. W e have examined 2 patients with this type of association.
Patient 1 A 64-year-old right-handed man sustained a head injury in July, 1977. Approximately two weeks later, the patient developed left-sided headaches with intermittent apraxia of his right upper extremity. Arteriography revealed a left parietal subdural hematoma, which was drained on September 4. A week later the patient developed transient attacks, including expressive aphasia, right upper extremity paresis, and right facial paresis. T h e episodes lasted one to two hours and then subsided, recurring once a week. In October, examination revealed right-to-left confusion, finger agnosia, and acalculia. He had some difficulty with recent memory, but he was able to gwe most of the history. He had a decreased opticokinetic response to the left and mild agraphia of the right hand. A CAT scan showed residual left parietal subdural hematoma, which was drained. Postoperatively his symptoms subsided completely.
Patient 2 A 65-year-old man had been in good health until three weeks before hospitalization, when he fell, striking the left side of his head. He developed headaches, lethargy, and left hemiparesis. A right subdural hematoma was diagnosed by angiography and was drained. Postoperatively he experienced four transient episodes, including a right hemiparesis with expressive aphasia. These lasted two to three hours and then cleared. He was observed, and he recovered. The cause of these transient neurological abnormalities with chronic subdural hematoma is not known. Melamed e t al [ 11 suggested several possible mechanisms. including mechanical pressure of a mass o n neighboring cerebral vessels, an irritative phenomenon such as epileptic discharges, or the phenomenon of spreading cortical depression. W e could not demonstrate a paroxysmal electroencephalographic abnormality, and angiography showed normal vessels in the area, without spasm.
2. Melamed E, Levy S, Reches A, et al: Chronic subdural hematoma simulating transient cerebral ischemic attacks. J Neurosurg 42: 101-103, 1975
Greater Reliability of Tear versus SAva An ticonvulsant Levels Massimo Tondi, MD, Roberto Mutani, MD, Camillo Mastropaolo, MD, and Francesco Monaco, MD Though the easy and noninvasive accessibility of saliva as a sample medium can be helpful for measurements of the free fraction of anticonvulsant drugs [ 11, several problems hinder reliable results. These include large variations in composition ascribed to, respectively, methods of collection, the particular salivary glands that were secreting, and the varying stimuli employed to augment salivary flow [7]. Furthermore, salivary phenobarbital concentration is p H dependent, and the p H of saliva is influenced by secretion rate 13-51. Different methods have been attempted to compensate for the great variations in p H [ 1-41. but their application requires analytical methods and mathematical calculations hard to perform in routine clinical settings. Tears seem to represent a potentially more stable body fluid since they contain diffusible and nitrogenous materials as well as electrolytes in concentration similar to those of plasma and because they have modest variations in p H . Tears share with cerebrospinal fluid a relatively constant protein content (0.6 to 0.8 gnddl), which assures them a greater osmotic stability [Z]. This note reports phenobarbital and carbamazepine levels determined in a group of epileptic patients by a simple method of tear collection. Samples of plasma, tears, o r saliva (or all three) were collected simultaneously early in the morning in subjects undergoing steady-state treatment with phenobarbital, carbamazepine, or both. Salivary secretion was stimulated by having the patient chew a small piece of paraffin; in some babies it was impossible to obtain a n y sample. Tears were obtained soon after the subjects awakened so as to avoid evaporation and consequent concentration of the fluid. They were collected in a glass capillary tube 5 cm long and 1 m m in internal diameter from either the medial or the lateral canthus of the eye. Lacrimation is frequent in children; in adults, brisk tearing can easily be provoked by cigarette smoke, thus resulting in an isotonic solution [7]. The p H range was 6.9 4 0.5 for saliva and 7.9 f 0.4 for tears. Anticonvulsant levels were determined in triplicate by means of immunoassay EMIT technique (Syva, Palo Alto, CA) which correlates well with results by gas-liquid
R ejerences 1. Groch S, Hurwiu LJ, Wright 1, et al: Cranial lesions simulating
cerebral thrombosis. JAMA 172:1469-1472, 1960 Accepted for publication Mar 20, 1978. Address reprint requests to Dr Robin, Neurological Associates of Washington, Inc, 1200 F 116th Ave NE, Bellevue, WA 98004.
154
From the Neurological Clinic and the Institute of Child Neuropsychiatry, University of Sassari, Sassari, Italy. Accepted for publication Mar 22, 1978. Address reprint requests to Dr Tondi, Istituto di Neuropsichiatria Infantile dell’UniversitH, c/o Villaggio S. Camillo, 07 100 Sassari, Italy.
