Our study in four patients shows fMRI can be performed safely in patients with an implanted vagal nerve stimulator. The successful use of fMRI during VNS offers potential advantages over PET imaging by allowing rapid image acquisition and the ability to repeatedly study patients over time. Our preliminary results differ from previous PET or SPECT studies in failing to detect changes in subcortical areas. This finding could be due to the smaller n in this study compared with the other studies.

Heatstroke is a syndrome consisting of life-threatening central nervous system and multiple organ dysfunction from complications of hyperthermia. Additionally, there is an associated complex immunological and inflammatory component to the illness that resembles sepsis. Core body temperature exceeds 40 degrees C with associated mental status changes such as delirium and coma. Generalized tonic/clonic seizures can occur. A variable degree of organ involvement is present that contributes to the severity of the medical picture. Heatstroke can be viewed as a tropical neurological disorder especially for unacclimated travelers going to warm climates. Heatstroke can be categorized into two types depending on the cause. Classic heatstroke is nonexertional, environmentally related and exertional heatstroke occurs in the setting of strenuous exercise. Heatstroke is actually the most severe of a continuum of heat-related illnesses that carries a high incidence of mortality. Treatment is directed at rapidly reducing core body temperature and the management of life-threatening systemic complications.

We report a case of a 6-year old girl with ring chromosome 20 syndrome whose medically intractable seizures were successfully treated with vagal nerve stimulation therapy. Medically intractable seizures are an expected part of this rare syndrome, and the dramatic improvement in seizure control with vagal nerve stimulation is emphasized. Earlier use of vagal nerve stimulation in similar cases should be considered.

he induction of sudden death in laboratory animals for experimental study is accomplished by T presenting repeated noxious stimuli to the anatomically predisposed animals while providing the animals with no means of control or escape.' The case described below inadvertently parallels this process, both in circumstances and outcome: a confused older gentleman, predisposed to arrhythmia, experienced significant stress from forced immobilization and, shortly thereafter, developed a fatal ventricular arrhythmia. The purpose of this case is to point out the animal and human evidence for the creation of significant psychological stress through physical restraint and the well developed link between psychological stress and sudden death. CASE REPORTP. W. was an 83-year-old man with a 12-year history of slowly progressive cognitive impairment from Alzheimer's type dementia. He presented to his doctor's office with a 4-week history of cough, leg swelling, dyspnea on exertion, and paroxysmal nocturnal dyspnea. He had no history of cardiac disease and was on no medications. His blood pressure was 170/62 sitting, his pulse 45 per minute and regular; he refused to allow his temperature to be taken. He was mildly anxious and suspicious of the staff. The examination of the chest revealed bibasilar rales with good air movement and no wheezes. He was comfortable lying flat. Cardiac examination revealed a III/VI systolic murmur at the apex, radiating to the axilla. There was 3+ peripheral edema. Electrocardiography revealed a sinus rhythm with an atrial rate of 84/min. and two to one A-V conduction, with a ventricular rate of 42. Hospitalization was arranged.On arrival in the telemetry unit at 5 pm, an intravenous catheter was inserted despite the patient's objections. He struggled against the placement effort, which required that he be held down by staff and family. Four-point limb and vest restraints were then placed to keep the intravenous line in place. Agitation and struggling against the restraints continued. At 8:42 pm premature ventricular beats with "R on T" phenomenon appeared, and a 4-beat run of ventricular tachycardia was noted. At 9:45 pm sustained ventricular tachycardia occurred, with loss of pulse and blood pressure. Lidocaine 75 mg was administered IV, and cardiopulmonary resuscitation was begun but stopped