We report this case of effort thrombosis of the upper extremity (Paget-Schroetter syndrome) caused by hypertrophied muscles. This unusual cause of extrinsic venous compression and intimal injury leading to thrombosis was treated uniquely with good outcome. Untreated symptomatic patients can sustain long-term disability from venous obstruction resulting in significant loss of occupational productivity and quality of life. For the same reason, early catheter directed thrombolysis followed by anticoagulation and surgical intervention are recommended in much of the recent literature. Thrombolysis is the most common form of treatment, followed by surgery, if needed, after careful diagnostic approach. A majority of the literature supports a multimodal approach, but there is no definite consensus on management. This highlights the need for randomized clinical trials to guide management as well as to assess the safety and efficacy of anticoagulants commonly used and to define the optimal duration of therapy after thrombolysis. (J Am Board Fam Pract 2005;18:314 -9.)

Functional MRI has been widely used to identify the eloquent cortex in neurosurgical/radiosurgical planning and treatment of CNS neoplasms and malformations. In this study we examined the effect of CNS tumours on the blood oxygenation level-dependent (BOLD) activation maps in the primary and supplementary motor cortex. A total of 33 tumour patients and five healthy right-handed adults were enrolled in the study. Patients were divided into four groups based on tumour type and distance from primary motor cortex: (1) intra-axial, near, (2) extra-axial, near, (3) intra-axial, far and (4) extra-axial, far. The intra-axial groups consisted of patients with astrocytomas, glioblastomas and metastatic tumours of mixed histology; all the extra-axial tumours were meningiomas. The motor task was a bilateral, self-paced, finger-tapping paradigm. Anatomical and functional data were acquired with a 1.5 T GE Echospeed scanner. Maps of the motor areas were derived from the BOLD images, using SPM99 software. For each subject we first determined the activation volume in the primary motor area and the supplementary motor area (SMA) and then calculated the percentage difference between the hemispheres. Two factors influenced the activation volumes: tumour type (P<0.04) and distance from the eloquent cortex (P<0.06). Patients in group 1 (intra-axial, near) had the smallest activation area in the primary motor cortex, the greatest percentage difference in the activation volume between the hemispheres, and the largest activation volume in the SMA. Patients in group 4 (extra-axial, far) had the largest activation volume in the primary motor cortex, the least percentage difference in volume between the hemispheres, and the smallest activation volume in the SMA. There was no significant change in the volume of the SMA in any group, compared with controls, suggesting that, although there is a gradual decrease in SMA volume with distance from the primary motor area, the effect on motor reorganisation is minimal. All the tumour patients showed a net loss in total activation volumes (both hemispheres plus SMA) compared with controls. The effect of the tumours on interhemispheric volume differences was: group 1>group 3>group 2>group 4. Within the intra-axial tumours, there was no significant effect of tumour type on the results. We conclude that BOLD-imaged activation volume is affected at least by the interplay of two factors: tumour type and distance from the motor cortex. Further, all tumours may be expected to cause some loss of activation volumes in motor areas. We suggest that, with proper precautions and planning, BOLD functional magnetic resonance imaging (fMRI) maps can be useful in minimising damage to the functional areas.

Levetiracetam (LEV) is a novel antiepileptic drug (AED) approved for the adjunctive treatment of generalized and partial seizures. LEV has no clinically significant drug interactions and has limited adverse effects. The psychiatric adverse effects of LEV include de novo psychosis, affective disorder, and aggression. LEV-induced suicidal behavior has been reported infrequently with a past history of affective disorders. The authors report an apparent dose/concentration-dependent LEV-induced de novo major depression with near fatal suicide attempt in a patient without prior history of affective disorder. Psychiatric evaluation with emphasis on historic/current affective disorders, impulsive–aggressive behaviors, and assessment of risk factors for suicidal behaviors is indicated in treating patients with epilepsy with LEV. Clinicians should consider therapeutic drug monitoring to optimize therapeutic LEV treatment.

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