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T P Bleck

Publications and source records attributed to T P Bleck.

17 recordsLinked to original sources
PubMed1992

Intravenous midazolam for the treatment of refractory status epilepticus.

OBJECTIVE: To determine the usefulness of midazolam as a therapeutic agent for status epilepticus refractory to conventional treatment. DESIGN: Retrospective study. SETTING: ICUs of two university hospitals. PATIENTS: Seven patients with refractory status epilepticus who failed treatment with diazepam, lorazepam, and phenytoin, with or without phenobarbital. All patients received mechanical ventilation before receiving midazolam. INTERVENTIONS: Intravenous midazolam by bolus administration followed by infusion. MEASUREMENTS AND MAIN RESULTS: Midazolam terminated status epilepticus in all patients in less than 100 secs, as determined by clinical observation (three patients) or electroencephalographic monitoring (four patients). One patient developed mild hypotension. CONCLUSIONS: In this small study, midazolam appears to be an effective and safe alternative to high-dose barbiturate coma for the termination of status epilepticus when conventional agents have failed.

Adult↗
PubMed1991

Tetanus: pathophysiology, management, and prophylaxis.

As tetanus has become a rare disease in the developed world, physicians have become less comfortable with its diagnosis and management. The extent of adequate antitetanus immunity in the adult population, especially the elderly, is waning, in great measure because primary care physicians have not made prophylaxis a priority in their routine encounters with patients. Furthermore, as the population of immunocompromised hosts grows, an increasing percentage of our patients may not respond to standard active immunization routines. Unless these trends are reversed, we face a substantial increase in the incidence of this dread disorder. Tetanus is also of interest as a relatively simple model of disordered motor control that can instruct us in the management of the many more common causes of neurogenic muscular rigidity. The toxin produced by Clostridium tetani finds increasing use in laboratories investigating brain function as well. Clinical tetanus is divided into four symptomatic types: generalized tetanus, local tetanus, cephalic tetanus, and neonatal tetanus. This monograph discusses the diagnostic aspects of each type of tetanus, its pathophysiology, diagnosis, differential diagnosis, and treatment. Preventing tetanus should be a high priority for all primary care physicians. Active immunization with tetanus toxoid is remarkably effective and safe. Passive immunization with human tetanus immune globulin is indicated in certain circumstances, which are discussed below.

Adult↗
PubMed1991

Convulsive disorders: status epilepticus.

Status epilepticus (SE) remains one of the most serious disorders affecting the central nervous system. Recent progress in understanding the mechanisms of the brain damage produced by SE make even more apparent the need to quickly terminate this condition, prevent its recurrence, and treat its complications. Intracellular calcium concentrations rise, prompting a cascade of excitotoxic consequences. Therapy for SE currently consists of agents which stop seizures (benzodiazepines, phenytoin, barbiturates). This review discusses their use in SE.

Anticonvulsants↗
PubMed1991

Prolonged survival following the inadvertent intrathecal administration of vincristine: clinical and electrophysiologic analyses.

A 23-year-old man with a lymphoblastic lymphoma accidentally received 2.0 mg of vincristine intrathecally instead of intravenously. Although he underwent immediate CSF drainage, symptoms of an ascending myeloencephalopathy developed at 48 h. This progressed to coma, initially with a diffusely slow EEG, which evolved into alpha coma. He also developed a left frontal focus of epileptiform activity. He was transferred to our institution 1 month later. His court-appointed guardian refused to allow discontinuation of supportive treatment; therefore, the evolution of the disorder can be followed for 12 months. Although alpha coma remained the predominant pattern, some EEG evolution did occur, with a progressive decrease in amplitude being most prominent. An increase in amplitude in the 10th month was accompanied by the return of some nystagmoid eye movements. The patient's lymphoma then recurred, and further treatment was not attempted. This tragic case, in which transient exposure to a microtubular poison produced severe CNS toxicity, allows some insights into the mechanisms of alpha coma.

Adult↗
PubMed1989

Multiple subpial transection: a new approach to the surgical treatment of focal epilepsy.

A new operative approach has been designed for the relief of medically intractable focal epilepsy. It is intended particularly to be used in those cases where the epileptogenic lesion lies in "unresectable" cortex; that is, those cerebral regions subserving speech, memory, and primary motor and sensory function. The procedure is based upon experimental evidence indicating 1) that epileptogenic discharge requires substantial side-to-side or horizontal interaction of cortical neurons, and 2) that the major functional properties of cortical tissue depend upon the vertical fiber connections of the columnar units. The technique requires severing of tangential intracortical fibers while preserving the vertical fiber connections of both incoming and outgoing nerve pathways and of the penetrating blood vessels which also have a vertical orientation. In this study, the effect of multiple subpial transection was assessed on both function and seizure control. The effect on function was reviewed in 32 cases; only 20 cases were evaluated with respect to seizure control, since a follow-up period of 5 years or more (5 to 22 years) is required before conclusions can be drawn. Multiple subpial transection was applied to the precentral gyrus in 16 cases, the postcentral gyrus in six, Broca's area in five, and Wernicke's area in five. With respect to function, the major finding was that none of the 32 patients has suffered a clinically significant behavioral deficit (although subtle deficits could be detected by careful neurological examination). Complete control of seizures has been obtained in 11 (55%) of the 20 cases evaluated. Nine patients developed recurrent seizures consequent to progressive disease unsuspected before operation (Rasmussen's encephalitis in five, tumor in three, and subacute sclerosing panencephalitis in one). In none of these cases, however, did the recurrent seizures arise in the transected zone. Thus, the results indicate that multiple subpial transection is about as effective as standard excisional therapy, and can be successfully employed when epileptogenic lesions encroach upon cortical territories, the removal of which would be functionally incapacitating.

Adolescent↗
PubMed1988

Prevalence of psychologic disorders after surgical treatment of seizures.

To investigate whether surgical treatment of refractory epilepsy is associated with increased risk for serious psychopathology, 25 treated patients were compared with 25 current candidates for surgery matched on demographic and neuroepileptic characteristics. Diagnoses were made by the National Institute of Mental Health Diagnostic Interview Schedule. No differences between groups in lifetime or point prevalence rates were significant. The rate of psychosis in the postoperative group (8%) approximated the lower estimates in previous studies. Thus, surgical treatment of seizures did not increase the risk for psychopathology. However, patients with temporal lobe electroencephalogram foci or tumor as the epileptogenic lesion were more likely to have serious disorders than other patients. Also, anxiety disorders were more prevalent in our patient groups than in the general population.

Adolescent↗
PubMed1987

Epilepsy.

"Epilepsy" describes a heterogenous group of disorders bound together by their tendency to produce seizures. Recent advances in the basic neurosciences provide new insights into the pathophysiology and treatment of seizures. In the last decade, revisions of the classification schemata have led to improvements in the recognition of seizure types and of different epilepsies and epileptic syndromes. The clinical utility of these definitions is apparent in diagnosis, therapy, prognostication, and genetic counseling. A plan for the diagnostic evaluation of patients with epilepsy is presented. The therapeutic options for seizure treatment are reviewed including the withdrawal of anticonvulsants. Patients who should probably not be treated with anticonvulsants are identified. Psychological and life-style issues in the management of seizure patients are considered. The concept of adequate control is discussed. Surgical management, an increasingly employed therapeutic modality, is described.

Anticonvulsants↗
PubMed1986

Neurologic emergencies.

This article considers the rapid assessment and initial management of several neurologic emergencies--altered consciousness, increased intracranial pressure, stroke, status epilepticus, acute neurogenic respiratory failure, acute autonomic instability, the neuroleptic malignant syndrome, and spinal cord compression.

Autonomic Nervous System Diseases↗
PubMedDate not supplied

Infarction after surgery for focal epilepsy: manipulation hemiplegia revisited.

The success of surgery for seizure focus resection depends on postoperative reduction or disappearance in number of seizures, improvement in psychosocial functioning, and low morbidity and mortality. Permanent neurologic sequelae are most often not discussed in this context. Deficits more than a superior quadrantanopsia are not expected after temporal lobectomy. Four cases of ischemic stroke after seizure focus resection, each distant from the site of tissue removal, are reported. These are the first such radiologically documented reports of "manipulation hemiplegia." The permanent neurologic deficits are not attributed to resected tissue or edema.

Adolescent↗
PubMedDate not supplied

Possible induction of systemic lupus erythematosus by valproate.

Two patients developed clinical and laboratory evidence of systemic lupus erythematosus (SLE) during treatment with valproate (VPA) preparations. The first patient, a 47-year-old man, had fever, malaise, and thrombocytopenia 1 month after VPA was added to phenytoin (PHT) and primidone (PRM). He developed high titers of antinuclear antibodies (ANA) and anti-DNA antibodies, and hypocomplementemia. After discontinuation of PHT and VPA, steroid and immunoglobulin treatment was required for 4 weeks before his condition improved. The second patient, a 28-year-old woman, had been followed for idiopathic leukopenia for 3 years and had previously experienced fever and lymphadenopathy from PHT. After 4 months of divalproex therapy, she developed confusion, joint pain, and a dramatic increase in seizure frequency. She also developed high titers of ANA and anti-DNA antibodies and hypocomplementemia, along with a further decrease in white blood cell (WBC) count. These responded to steroid therapy and withdrawal of divalproex. Three months later, reintroduction of divalproex was followed by a return of ANA in low titer, which resolved after discontinuation. We believe that VPA may have caused true SLE in these patients, one of whom was probably predisposed.

Adult↗