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Spinal dural arteriovenous fistula (SDAVF) rarely presents as multiple signal-hyperintense intramedullary lesions on T2-weighted imaging, a finding more commonly seen in multiple neoplastic diseases like lymphoma or in demyelinating, inflammatory, infectious, or multilevel degenerative diseases. We report herein a case of SDAVF with tandem intramedullary hyperintense lesions on T2-weighted imaging. ### Case report. A 58-year-old man with an 8-month history of worsening numbness in both legs progressing to gait disturbance within the next 2 months underwent MRI at another hospital. T2-weighted imaging revealed signal hyperintensities in spinal cord parenchyma at the Th6-8 level and conus medullaris. As no compressing spinal cord lesions were found, multiple sclerosis (MS) was suspected and he was referred to us to rule out intramedullary tumor. Neurologic findings were paraparesis (manual muscle test: right, 4/5; left, 3/5), left patellar hyperreflexia, bilateral hypesthesia and hypalgesia below Th6, position sense disturbance in both legs, dysesthesia at S1-2, and bowel and bladder dysfunction. On T2-weighted imaging (figure, A), separate hyperintense lesions were found at Th6-8 and the conus medullaris. Lesions were isointense compared to normal spinal cord on T1-weighted imaging and displayed faint gadolinium enhancement (figure, B). T2-weighted imaging showed tiny, gadolinium-enhanced signal voids on the posterior spinal cord surface at Th8-10 (figure, A and B). Spinal angiography was performed on suspicion of SDAVF. As left Th7 intercostal arteriography (arterial phase) showed …

Editors' Note: Comments in Writ e Click this week were all in reference to “Clinical features of Parkinson disease when onset of diabetes came first: A case-control study” by Cereda et al. Drs. Kawabe et al. question whether differences in ischemic brain lesions, hypertension, or statin use may be affecting the results. The authors respond that patients with macrovascular lesions were excluded and that hypertension was similar between groups, while statin use may have been protective to the diabetic group. Drs. Kotagal et al. suggest that the data indicate that diabetes may be specifically related to postural instability and gait difficulty. The authors agree with the possibility and that the question deserves further study. Megan Alcauskas, MD, and Robert C. Griggs, MD. # {#article-title-2} Cereda et al.1 elucidated the relationship between Parkinson disease (PD) and diabetes. The authors concluded that the onset of diabetes before the onset of PD appeared to be a risk factor for more severe PD symptoms. …

An increased incidence of multiple sclerosis (MS) has been reported in patients with myasthenia gravis (MG). We reviewed records of 214 patients with MG. CNS demyelinating disease (CNSDD) occurred in five patients (2.3%). CNSDD always occurred after the diagnosis of MG. Myelitis (including recurrent myelitis) was the most common CNS manifestation. All patients had antinuclear antibodies. CNSDD occurs more frequently in patients with MG and may be related to immune-modulating treatments including thymectomy.

The causes of ophthalmoplegia in 24 consecutive patients with neurologically isolated, relative pupil-sparing third nerve palsy included infarction in 10 patients, compression by tumors or aneurysms in 10 patients, and miscellaneous disorders in four patients. There was no significant difference in the proportion of patients with pain, degree of external ophthalmoplegia, or degree of internal ophthalmoplegia between the groups with infarction or mass lesions. Therefore, screening for mass lesions using neuroimaging is indicated in patients with this presentation of third nerve palsy.

We read with great interest the article by Pico et al.1 concerning combined dolichoectasia of basilar artery (BADE) and coronary artery (CAE). We also encountered two patients with those arterial abnormalities and considered possible genetic and acquired profile in BADE and CAE. Sixty-four subjects (60 men and 4 women) were diagnosed with BADE on physical and brain check-up, including brain MRI and three-dimensional time-of-flight MR angiography (1.5 T; Hitachi Medical), in PL Tokyo Health Care Center, Japan. Mean age (SD) of subjects was 59.5 (11.2) years. Two non-related men had BADE and CAE without abdominal aortic aneurysm (AAA). Their common clinical aspects revealed younger onset (less than 40 years) and grade 2 of hypertension, hypercholesterolemia, chain smoking, and obesity. An 80-year-old man was treated …

We read the Holroyd et al. article with great interest.1 We evaluated 50 patients with Parkinson disease (PD). All patients had idiopathic PD, none had a previous history of stroke, and all met Diagnostic and Statistical Manual of Mental Disorders–III criteria for dementia. We evaluated depressive state using Zung self- rating depression scale.2 Motor disability (tremor, rigidity, bradykinesia), Hoehn & Yahr stage, age at onset, levodopa dosage, duration of illness, history of depression, and score on Mini-Mental State Examination3 did not correlate with the SDS …

To the Editor: We read with interest the article on cognitive and MRI aspects of corticobasal degeneration (CBD) and progressive supranuclear palsy (PSP) by Soliveri et al.1 They show that cognitive function tests and MRI are beneficial for differentiation between CBD and PSP. We also studied MRI features in 12 patients with clinically diagnosed PSP and 4 patients with CBD. We would like to compare their study with ours and pose several questions. In our study, age (mean ± SD) was 67.4 ± 5.8 years in PSP and 65.2 ± 8.3 years in CBD. Duration from the clinical onset (mean ± SD) was 3.8 ± 2.2 years in PSP and 3.5 ± 2.3 years in CBD. T1-weighted images revealed midbrain atrophy in all patients with PSP. Proton density images disclosed mild hyperintensity in the periaqueductal region in eight patients with PSP. These MRI findings were not present in …

To the Editor: We read with interest the article by Iannaccone et al.1 concerning pompholyx after IV immunoglobulin (IVIg) therapy for neurologic disease. They suggested that pompholyx occurred in 3 of their 23 patients with peripheral neuropathies. This eczema is one of several adverse events following IVIg treatment. In our evaluation of 5 patients with Guillain-Barre syndrome (GBS) and 10 patients with chronic inflammatory demyelinating polyneuropathy (CIDP), they received standard IVIg therapy (0.4 g/kg/day for 5 consecutive days at a slow infusion rate of longer than 10 hours). Of those treated with IVIg, one patient with CIDP developed vesicular eczema 5 days after the last day of therapy. We suggest a relationship between high plasma IgG concentrations and pompholyx in such a patient and discuss eczema after IVIg therapy. A 72-year-old Japanese woman was diagnosed with recurrence of CIDP. She had a clinical history of carbamazepine-induced rashes. At 5 days postinfusion after IVIg (Glovenin-I) …

To the Editor: We read with interest the article by Good et al.1 concerning pulse IV cyclophosphamide (IVCY) therapy in chronic inflammatory demyelinating polyneuropathy (CIDP). They report that IVCY treatment had benefit in most of their patients and warrants further studies. In our evaluation of 21 patients with CIDP between 1985 and 1998, we encountered some patients who did not respond to corticosteroids, other immunosuppressants, plasma exchange, or immunoglobulin therapy. These patients were given IVCY treatment. Of those treated, IVCY therapy had no favorable effect on one patient. We would like to present this patient and discuss monthly IVCY treatment in CIDP patients. The 17-year-old Japanese girl noticed muscle weakness in her upper extremities in October 1996. Neurologic examination revealed muscle weakness (Medical Research Council MRC 3/5) and dysesthesia in the upper extremities. Muscle stretch reflexes were decreased in the four extremities without Babinski signs. One week later, muscle weakness (MRC 3/5) and dysesthesia spread to her lower extremities. CSF studies showed normal cell …