Four men, aged 67-72 years, had 4-month to 6-year histories of injuring themselves or their spouses with aggressive behaviors during sleep, often during attempted dream enactment. A 60-year-old woman had disruptive though nonviolent sleep and dream behaviors. Polysomnography did not detect seizures but did document REM sleep pathology with variable loss of chin atonia, extraordinarily increased limb-twitch activity, and increased REM ocular activity and density. A broad range of REM sleep behaviors was recorded on videotape, including stereotypical hand motions, reaching and searching gestures, punches, kicks, and verified dream movements. Stage 3-4 slow wave sleep was elevated for age in all patients. NREM sleep was devoid of harmful behaviors, although three men had periodic myoclonus. There was no associated psychiatric disorder, whereas serious neurologic disorder was closely associated in four cases: olivo-ponto-cerebellar degeneration, Guillain-Barre syndrome, subarachnoid hemorrhage, and an atypical dementia. Two patients had immediate and lasting sleep behavioral suppression induced by clonazepam, and another patient had the same response with desipramine. All instances of drug discontinuation prompted immediate relapse. In four cases there was associated dream hyperactivity, which resolved with behavioral control. These REM sleep neurobehavioral disorders constitute another category of parasomnia, replicate findings from 21 years ago in cats receiving pontine tegmental lesions, and offer additional perspectives on human behavior, neurophysiology, pharmacology, and dream phenomenology.

We treated 64 emergency room patients with a primary vascular headache with dihydroergotamine (DHE), meperidine, or butorphanol. Post-treatment pain scores were lowest in the DHE group (p less than 0.01). Eight of 21 patients receiving DHE had greater than 90% reduction in pain compared with three of 19 patients receiving butorphanol and none of 22 receiving meperidine.

Abstract:Coagulation A bnormalities in Subarachnoid Hemorrhage

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Thromboelastographic Studies in Cerebral Infarction• Blood coagulability in patients following cerebral infarction was studied utilizing the thromboelastograph (TEG). Cerebral infarction patients from two separate institutions were studied within 24 to 48 hours after onset of stroke. Ninety-four stroke patients from one institution and 109 from another yielded a total stroke population of 203 patients for this study. Fifty-nine agematched normals were used as a control group. Frequency distribution curves were determined for a TEG ratio of ma/(r + k). The 59 controls exhibited a normal frequency distribution between the values of 1.6 and 4.0. Both groups of stroke patients revealed an increased number of patients with a ratio exceeding 4.0, suggesting a hypercoagulable state exists following cerebral infarction in approximately 29% to 38% of the patients studied.Additional Key Words clot lysis hypercoagulability platelet function fibrinolysis cerebrovascular disease• Our laboratory has been investigating abnormalities of blood clotting, clot lysis and platelet function in various categories of cerebrovascular disease. One of our objectives has been to identify a simple, reliable and clinically relevant test of blood or plasma which accurately identifies the overall consequences of the separate, yet simultaneously occurring reactions, which collectively result in the balance between clot formation and clot dissolution. A number of "global" tests of coagulation have been described, including the plasma recalcification test, partial thromboplastin time (PTT), the activated partial thromboplastin time, and the whole blood clotting time. All have their limitations with respect to reliability, sensitivity, and lack of correlation with clinically significant clotting or bleeding events. A somewhat different approach to a laboratory measurement of overall coagulation and fibrinolysis, which also is sensitive to platelet dysfunction, has been the development of the thromboelastograph. The thromboelastograph (TEG) provides a continuous recording of the process of blood coagulation and subsequent clot retraction. The instrument is capable of analyzing three blood samples simultaneously ( fig. 1). Stainless steel sample containers maintained at 37°C are set in motion around a vertical axis. A cylindrical dragbar is lowered into the . slowly oscillating metal containers and remains im- This investigation was supported by Research Grant NS03364 from the National Institute of Neurological Diseases and Stroke.Presented at the 46th Scientific Session of the American Heart Association, November 9, 1973, in Atlantic City, New Jersey. mobile as long as the blood or plasma sample is fluid. As the clot forms, the dragbar, suspended by the torsion wire, becomes dynamically coupled to the cup resulting in transmission of the oscillatory rotation of the cup to the cylinder. The cylinder then oscillates with an amplitude governed by the specific mechanical properties of the clot ( fig. 2). A mirror, coupled to the cylinder tors...

Attentional selection in the context of goal-directed behavior involves top-down modulation to enhance the contrast between relevant and irrelevant stimuli via enhancement and suppression of sensory cortical activity. Acetylcholine (ACh) is believed to be involved mechanistically in such attention processes. The objective of the current study was to examine the effects of donepezil, a cholinesterase inhibitor that increases synaptic levels of ACh, on the relationship between performance and network dynamics during a visual working memory (WM) task involving relevant and irrelevant stimuli. Electroencephalogram (EEG) activity was recorded in 14 healthy young adults while they performed a selective face/scene working memory task. Each participant received either placebo or donepezil (5 mg, orally) on two different visits in a double-blinded study. To investigate the effects of donepezil on brain network dynamics we utilized a novel EEG-based Brain Network Activation (BNA) analysis method that isolates location–time–frequency interrelations among event-related potential (ERP) peaks and extracts condition-specific networks. The activation level of the network modulated by donepezil, reflected in terms of the degree of its dynamical organization, was positively correlated with WM performance. Further analyses revealed that the frontal–posterior theta–alpha sub-network comprised the critical regions whose activation level correlated with beneficial effects on cognitive performance. These results indicate that condition-specific EEG network analysis could potentially serve to predict beneficial effects of therapeutic treatment in working memory.

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Estazolam is a new benzodiazepine hypnotic agent with an intermediate half-life of 12 to 15 hours. The authors designed an investigation to compare its hypnotic efficacy to that of flurazepam, generally considered the reference standard. The hypnotic efficacy of estazolam at two doses (1 mg and 2 mg) was compared with that of flurazepam (30 mg) in a double-blind, placebo-controlled, multicenter, 7-night study that involved 223 outpatients with insomnia. On subjective assessments of the patients, no differences were noted between estazolam 2 mg and flurazepam 30 mg on any of six sleep parameters. Patients who were receiving estazolam 1 mg rated their sleep significantly better than did patients who were receiving placebo on all parameters except sleep latency. Global evaluation of the physicians indicated significant improvement in quality of sleep, sleep depth, sleep duration, and nocturnal awakenings in all three active treatment groups; estazolam 2 mg and flurazepam also decreased sleep latency significantly. The percentage of patients who reported any adverse experience was 68% for flurazepam, 58% for estazolam 2 mg, and 54% for estazolam 1 mg; the incidence of adverse events in the placebo group was 43%. In conclusion, estazolam 2 mg was found to be as effective a hypnotic as flurazepam 30 mg. Estazolam 1 mg is also effective in the treatment of outpatients with insomnia, but to a lesser degree.