Section on Psychiatry & Neurology. (Abstracts of Scientific Posters).

PSYNEU1-B. REM-STATUS IN A NARCOLEPTIC PATIENT TAKING RIVASTIGMINE. Fowzia Siddiqui, MD, and Edward Bromfield, MD. Boston, MA.

Narcolepsy is a syndrome characterized by excessive daytime sleepiness, and rapid eye movement (REM) sleep at sleep onset. It is often associated with cataplexy, sleep paralysis, and hypnagogic/hypnopompic hallucinations. Anticholinergics are potent REM inhibitors, and there is abundant experimental data showing that cholinergics promote REM sleep. In the elderly, rivastigmine, a new cholinesterase inhibitor used to treat Alzheimer's dementia, is associated with significantly reduced REM latency (Heuser I 2000). We report the case of a 73-year-old right-handed woman with a long history of narcolepsy and cataplexy, controlled with dextroamphetamine therapy (20mg/day). She complained of trouble with memory and daily activities, was given rivastgmine, and several weeks later, began having multiple falls, described as flaccidity with unresponsiveness and amnesia, with eyes rolled back or closed, and no response to stimuli. MRI showed right basal ganglia and left pontine lacunes. EEG reportedly showed sharp activi ty, and she was given valproate, titrated to levels above 100 without clinical change. On transfer, she was noted to have frequent episodes of staring, with droopy eyelids, open mouth, and occasional jerks of her right face and hand. Video-EEC recording showed no epileptiform activity, and during attacks there were low-voltage alpha and theta activity with eye-movement artifact consistent with REM. Extensive laboratory evaluation was notable only for mildly elevated TSH level. She dramatically improved after discontinuation of rivastigmine therapy and institution of treatment with modafinil, to 300 mg/d, and prontryptiline, 20 mg/d. We caution against the use of rivastigmine in elderly patients with narcolepsy and other sleep disorders.

PSYNEU2-B. DEPRESSION IN SICKLE CELL DISEASE. Shahzad Hashmi, MD, and William E. Matory, MD. Department of Psychiatry, Howard University, Washington, DC.

The purpose of our study was to assess the prevalence of depression and examine the contribution of demographics, disease severity, and health care use variables to depressive symptoms in sickle cell patients who had been in stable state for at least a month. There were 27 men and 23 women. Depression was assessed using Beck Depression Inventory in 50 patients attending sickle cell clinic at Howard University Hospital. Chi-square test was used to determine if independent predictors, such as demographics, disease severity, health care use variables, hydroxyurea use, and history of substance abuse were associated with depression. The results of the analysis indicate that 44% (n = 22) of the sample scored within the mild to severe (> 20) range of depression on the BDI. The results also indicate that depressed sickle cell patients were more frequently treated in emergency departments and were more likely to be hospitalized with vaso-occlusive crises. Those with family income less than $10,000/year, less than high school education, female, poor pain control, inadequate social support, hydroxyurea use, multiple blood transfusions, and history of frequent vaso-occlusive crises were more likely to be depressed. The prevalence of depression in sickle cell patients is high compared to the general population. The results of our study are comparable to those in previous studies (18% to 56.5%) examining the occurrence of depression. The depressive symptoms in patients with SCD appear to be a function of demographics, pain control and disease severity. Analgesics, antidepressants and psychotherapy should be strongly considered to improve the quality of life, and probably disease course, in depressed sickle cell patients.

PSYNEU3-B. PROGRESSIVE SPONGIFORM LEUKOENCEPHALOPATHY IN A CHRONIC HEROIN USER WITH VARIANT RADIOLOGIC AND HISTOLOGIC MANIFESTATIONS. Daniel S. C. Dube, MD, Michael Puruckherr, MD, and John B. Schweitzer, MD. Department of Internal Medicine, James H. Quillen College of Medicine, Johnson City, TN.

A 47-year-old white man was transferred to our facility from a psychiatric hospital, where he presented with confusion, disorientation, ataxia, and incontinence. His symptoms had developed over one month. He had a 20-year history of intravenous heroin abuse, and used cocaine regularly. Physical examination revealed a well-built, restless male. His vital signs were normal. His body was covered in tattoos. He had variable comprehension, with inappropriate responses to simple commands. His speech was nondysarthric but was grossly reduced in volume. There was horizontal nystagmus. Cranial nerve examination was normal. Power, tone, and reflexes were symmetrical and normal. Balbinski sign was positive bilaterally. Cerebellar signs were positive on the right. The rest of the physical examination was unremarkable. A CT scan of the head without contrast showed low-attenuation white-matter changes. An MRI demonstrated florid white-matter changes, less prominent in the posterior fossa and the brain stem. Toxicologic scr een was positive for cannabinoids. His ANA was weakly positive at 1/80. An EEG showed a diffuse slowing. HIV, Lyme disease, HTLV, herpes, and fungal serologies were negative. CSF studies showed a high protein level. Brain biopsy showed myelin and axonal loss, with vacuolation in the white matter and reactive astrocytosis. The patient died of a pulmonary embolism a few days after admission. Autopsy showed spongy myelinopathy, intramyelinic edema, and foamy macrophages, with minimal brain stem and cerebellum involvement. PSL has been described in users of heated forms of heroin. Characteristic neuroradiologic changes involve the posterior fossa. Neuropathologically, there is edematous spongy myelin with diffuse astrogliosis. The mechanisms of PSL are not fully understood, but include inflammatory, circulatory, and degenerative processes, which may be exacerbated in susceptible individuals. The theory that PSL is a toxic metabolic syndrome is supported by the observation that tin causes a very similar picture in experimental animals. The differential diagnosis of dementia in a heroin user should include PSL. White-matter changes should be evaluated with a brain biopsy. Uncharacteristic radiologic features do not preclude the diagnosis of PSL. This case is the first describing variant radiologic manifestations of PSL with a usual clinical presentation.

PSYNEU4-B. DEVIC'S DISEASE (NEUROMYELITIS OPTICA) PRESENTING AS MONOCULAR VISUAL LOSS AND URINARY RETENTION. Mark E. Braun, MD, and Seth John Stankus, DO. EAMC, Department of Neurology, Fort Gordon, GA.

Devic's disease, thought to be a variant of multiple sclerosis, is a rare entity that carries a poor prognosis. We report the case of a 36-year-old woman who presented with progressive unilateral visual loss and acute urinary retention. At the time of admission, she also reported a history of chronic back pain and chronic bilateral weakness in her upper and lower extremities. MRI of her brain and spinal cord demonstrated an increased T2 signal in the left optic nerve as well as the cervical spinal cord from C2 to C7, consistent with demyelination. Her CSF showed elevated protein level, lyrnphocytic pleocytosis, and negative bacterial cultures and antigens. No oligoclonal bands were detected. Although effective therapy has not been established for Devic's disease, our patient has had a good response to pulse-dose intravenous methylprednisolone, followed by an oral steroid taper. Her back pain, motor weakness and neurogenic bladder have improved, and she has had a mild improvement in her visual symptoms. She is currently undergoing therapy with beta-interferon.

PSYNEU5-B. INTERNAL CAROTID AGENESIS ASSOCIATED WITH SEIZURE ACTIVITY. Captain Brant Lutsi, MD, and Captain Richard Popwell, MD. Keesler Air Force Base Medical Center, Biloxi, MS.

A 29-year-old white woman with a history of migraine headaches presented to Keesler Medical Center with dysarthria, right upper extremity tonic-clonic movements, and left lower extremity weakness that was followed by her usual migraine headache. Computed tomography and magnetic resonance imaging with and without contrast of her brain parenchyma were normal. Magnetic resonance imaging of her cervical spine was also normal. However, an incidental finding of an absent right internal carotid artery was noted and confirmed with magnetic resonance angiography of her aortic arch and carotid arteries. Carotid artery dissection and thrombosis were ruled out by these studies. Laboratory tests for metabolic abnormalities, inflammatory disorders, and infection were unremarkable. A sleep-deprived electroencephalogram to evaluate her tonic-clonic movements showed a right paracentral epileptic focus for which depakote therapy for seizure prophylaxis was started. All of her symptoms had resolved at the time of discharge from the hospital, except for a mild left lower extremity paresis. Unilateral agenesis of the internal carotid artery is a rare developmental anomaly. It was first reported by Tode in 1787 at postmortem examination, and only a little more than a hundred cases have been reported since in the medical literature. Because most of the reported cases have been made in asymptomatic adults, sufficient collateral circulation must have existed. Arterial insufficiency is usually prevented by the contralateral internal carotid artery and the vertebrobasilar system via the circle of Willis. Agenesis is a primary failure of development with absence of the bony carotid canal. It has been associated with cerebral aneurysms, hypopituitarism, seizures, coarcatation of the aorta, and neurofibromatosis. We report a rare case of internal carotid artery agenesis associated with seizure activity.

PSYNEU6-B. INCREASING COMPLIANCE WITH NALTREXONE. Ronald J. Dougherty, MD, FAAFP, ASAM. Tully, NY.

In an article in the Archives of General Psychiatry, 54- December 1997, it was reported that of 74 alcoholic patients in the study who were on 50 mg of naltrexone per day, 15% had discontinued the use of naltrexone because of adverse clinical effects. Most patients gave more than 1 adverse reason for discontinuation. The most common reasons were nausea (6%), headaches (3%), dizziness (3%), fatigue (1.9%), vomiting (1.9%), anxiety (1.9%), and nervousness (1.9%). Three were discontinued from the study because of abnormal liver function tests. At the Tully Hill Alcohol & Drug Rehab Center, Tully, New York, a total of 275 patients were admitted between January 1, 2000 and September 15, 2000. A total of 191 patients met DSM-IV criteria for alcohol dependence. 141 patients elected to begin treatment with Revia after receiving education as to the risks, benefits, and alternatives. 89 patients were male and 52 were female. These patients ranged in age from 17 to 65 years. Common side effects mentioned were vertigo/di zziness (4), decreased appetite (1), sleep disturbance/weird dreams (4), headache (2) and nausea (1). Modifications of protocol to address reported side effects included changing the medication from p.m. to a.m. administration for those who had sleep disturbance, and medication given after a meal for reported GI symptoms. One patient refused all medications, including naltrexone. The starting dose for patients was 12.5 mg/day for 3 days; 25 mg/day thereafter; and then, 1 week prior to discharge, the dose was increased to 50 mg/day. No patient discontinued medication because of adverse clinical events. None were removed from the study because of abnormal liver function tests. It would appear that for inpatients meeting the criteria for alcohol dependence, the old adage of "start low, go slow" might be a better way to increase naltrexone compliance.

PSYNEU7-B. VERTEBRAL ARTERY DISSECTION: AN UNUSUAL CAUSE OF RESPIRATORY FAILURE IN THE ELDERLY. Halim Abou Faycal, MD, Michael Puruckherr, MD, Mehran Tavacoli, MD, Ryland P. Byrd, Jr., MD, and Thomas M. Roy, MD. Department of Internal Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

An 86-year-old white man with a history of atherosclerotic cardiovascular disease and hypertension, complained of a severe occipital headache that radiated into his neck. He had suffered no recent head trauma. The headache was associated with nausea, vomiting, and a near syncopal episode. While being evaluated in the emergency department, he suffered respiratory arrest, necessitating endotracheal intubation and support with positive pressure mechanical ventilation. His blood pressure was 159/78 mm Hg; heart rate, 78 beats/mm; and temperature, 97[degrees]F. Physical examination revealed a holosystloic murmur (2/6) heard best at the apex with radiation to the axilla. His Babinski was up-going on the left side. Serum electrolyte levels, cardiac isoenzyme values, and EKG were unrewarding. Computerized tomography of the patient's head demonstrated no evidence of an acute ischemic event or bleed. Analysis of his cerebral spinal fluid was normal. Magnetic resonance imaging/angiogram (MRI/A) documented dissection of the right vertebral artery. The patient was treated with aspirin and was subsequently successfully extubated. He was taking aspirin and blood pressure control medication at the time of his discharge home. Vertebral artery dissection (VAD) typically afflicts patients in the 4th or 5th decade of life. There is no sex predilection but females present at a younger age. VAD is responsible for up to 22% of strokes in patients younger than 30 years of age. VAD is categorized as either spontaneous or traumatic. Spontaneous VAD is associated with Marfan's syndrome, vasculitis, cystic medial necrosis, homocystinuria, and fibromuscular dysplasia. Hypertension is a strong risk factor for VAD. An ipsilateral occipital headache and neck pain are the presenting symptoms in 60% to 80% of cases. Ischemic neurologic symptoms depend on the arteries or branches affected by the VAD. VAD may also present as a subarachnoid hemhorrage. MRI/A is a very useful for diagnostic tool. However, angiography may be required at times to confi rm the diagnosis. Ischemic VAD cases typically have a good prognosis. Interestingly, 90% of patients with an ischemic VAD make a full recovery and return to their previous lifestyle. Treatment with heparin followed by warfarin therapy has been recommended for patients with VAD unless there is a contraindication to anticoagulation. Surgery is not indicated in patients with ischemic neurologic injury due to VAD. This report serves as a reminder to the clinician that while unusual VAD, can occur in the elderly, and should alert physicians to consider this diagnosis in patients who present with headaches and respiratory failure.

PSYNEU8-B. THE RELATIONSHIP BETWEEN GLASGOW COMA SCALE SCORE AND CLINICAL OUTCOME IN PATIENTS WITH SPONTANEOUS INTRACRANIAL BLEED. Lenworth Ellis, MD, Alice Adams, MD, and William E. Matory, MD. Department of Neurology, Howard University Hospital, Washington, DC.

The purpose of this study was to determine the role of the initial Glasgow Coma Scale score in predicting clinical outcome in patients with spontaneous intracranial bleed. This is a retrospective study in which the charts of 101 patients admitted to the Howard University Hospital with spontaneous intracerebral bleed were reviewed. The initial Glasgow Coma Scale score, age, and sex of each patient were recorded. In addition, a clinical outcome score was derived by determining the patient's capacity to ambulate and ability to perform activities of daily living. The relationship between the initial Glasgow Coma Scale score and functional outcome was determined. When the total number of patients was analyzed, there was no significant relationship between the Glasgow Coma Scale score and the functional outcome. There was a significant relationship between the initial Glasgow Coma Scale score and functional outcome in patients older than 60 years. Patients with higher Glasgow Coma Scale scores had a significantly l ower mortality rate than patients with lower Glasgow Coma Scale scores.

Glasgow Coma Scale score may predict functional outcome in patients older than 60 years, and predicts mortality rate irrespective of age in patients with spontaneous intracranial hemorrhage. The Glasgow Coma Scale score is a simple, easy to perform assessment that can be used to predict clinical outcome in patients with spontaneous intracranial bleed.