Interhemispheric commissurotomy for congenital hemiplegics with intractable epilepsy

Five patients with congenital hemiplegia and intractable epilepsy had interhemispheric commissurotomy (the split-brain operation). After intervals of 2 to 12 years, the response has been excellent in four cases. One patient had moderate benefit. There were no late complications. Commissurotomy seems to be substantially better than hemispherectomy for this syndrome.

Migraine coma. Meningitic migraine with cerebral oedema associated with a new form of autosomal dominant cerebellar ataxia

A family with hemiplegic migraine has been documented for a period of over forty years. From this study and the literature we conclude that (1) migraine is a cause of recurrent coma which may be associated with life-threatening cerebral hemisphere oedema; (2) hyperpyrexia with CSF pleocytosis occurs in hemiplegic migraine, which may thus simulate viral meningoencephalitis; and (3) cerebral angiography is hazardous in hemiplegic migraine and may exacerbate coma and cerebral oedema. In the family reported, cerebellar ataxia was present during recovery from attacks of hemiplegic migraine and affected patients ultimately suffered from persistent ataxia with radiological cerebellar atrophy. This syndrome thus constitutes a distinct form of late-onset autosomal dominant cerebellar ataxia and also of familial periodic ataxia. The status of 'cerebellar migraine' is reviewed.

The relationship of transient hemiparesis following febrile convulsions in infancy to subsequent temporal lobectomy for intractable seizures

Nine patients with transient hemiparesis following a febrile convulsion were part of a group of 71 patients undergoing temporal lobectomy with mesial temporal sclerosis or non-specific changes in the specimen. There was no gross evidence of additional brain damage in tests before surgery and their response to surgery was as good as the 62 patients without this history.

Paralysis and unilateral arthritis: is the association established?

A patient with long-standing upper limb lower motor neurone paresis more recently developed homolateral upper motor neurone hemiplegia. Subsequent primary generalised osteoarthritis spared only the paralysed upper limb. Detailed review of reported cases suggest that the "protective" effect of paralysis against subsequent development of arthritis is not as clearly established as generally believed.

Hip fracture in stroke patients. Epidemiology and rehabilitation

With the purpose of identifying specific features in aged hemiplegic patients, 818 cases referred to a geriatric-rehabilitation hospital after hip fracture were studied. In 66 cases a cerebro-vascular accident had preceded the fracture, which was ipsilateral in 52 cases. No differences were found in incidence of concurrent disease, hospitalization time, mortality and functional recovery between hip fracture patients with and without a history of stroke, except that an interval of less than a week between stroke and fracture was associated with poor functional recovery. We conclude that rehabilitation of the stroke patient with hip fracture is worthwhile.

Surgery for epilepsy

Despite important advances in the treatment of epilepsy over the past several decades, many patients remain uncontrolled. Partial complex (psychomotor) seizures are the largest problem, with less than two thirds of patients successfully managed despite optimal medication use. In these situations, various surgical procedures may be helpful, depending on the type of epilepsy, its cerebral location of origin, and the neurologic status of the particular patient. Intensive investigation including EEG and audiovisual monitoring are utilized to evaluate the medically refractory epileptic. In some instances, specialized recordings from epidural, subdural or intracerebral locations are needed to try to pinpoint onset of focal seizure. When this is possible, and the epileptogenic area is resectable, cortical excision may provide cure or marked reduction of seizures in 60 to 90 per cent of properly selected patients with minimal morbidity. The most common operation is temporal lobectomy; this procedure itself is undergoing modifications as more is learned about the usual locations of seizure foci and the functions of this tissue. Resections in other cortical areas may be more difficult but are possible. When a single focus is not identified or is not resectable, other procedures may be used. Results in seizure control with chronic cerebellar stimulation have been variable. The results of stereotaxic lesions in various locations are difficult to evaluate with the single exception of field H of Forel, which in many reports has been effective for grand mal seizures. Generalized seizures, particularly in patients with infantile hemiplegia or frontal lobe epilepsy, are well controlled with corpus callosotomy. Surgery for epilepsy is currently practiced at several centers in this country and abroad. There is great need for more such centers and more education about this treatment as estimates indicate 100,000 patients in the United States at this time could benefit from such procedures.

[Accompanying symptoms in infantile spastic hemiplegia]

Various concomitant disorders in 535 children with infantile hemiplegia were evaluated; 159 of the cases were particularly well documented. The right/left distribution of the hemiplegia was 56 to 44, the ratio of boys to girls 59 to 41. Severe impairments of hand function (lack of function, first grip) were found more frequently in right hemiplegics than left; the ratio of severe to slight disorders was approx. 3 to 1 in right hemiplegics and 3 to 2 in left hemiplegics. Impairment of hand function was closely related to the quality of sensitivity, the tests of this being based on two-point discrimination and stereognosis. Sixty-two percent of the children were of normal intelligence; of the remainder, approximately equal-sized groups suffered from impairment of the learning faculty or were mentally retarded. There was a positive correlation between reduced intelligence and the severity of impairment of hand function. Impaired speech development was found in 7 percent of the children, right and left hemiplegics being equally affected. Thus, there was no evidence that the brain lesion had any special influence on development of speech. Observations of growth in the legs revealed average differences of length of 2 mm and up to 3.5 cm in isolated cases. After eight year of life there was practically no further increase in the differences in length.

Acute childhood hemiplegia

A 10-year-old child presented to the emergency department with a sudden onset of right hemiparesis and dysphasia. A thorough evaluation, including CT scan of the brain and cerebral angiography, resulted in a diagnosis of acute childhood hemiplegia. The diagnosis of acute childhood hemiplegia depends on characteristic cerebral angiographic findings. The treatment of this particular entity is supportive, often with incomplete recovery.

Shoulder pain in hemiplegia

Development of a painful shoulder in the hemiplegic patient is a significant and serious problem, because it can limit the patient's ability to reach his or her maximum functional potential. Several etiologies of shoulder pain have been identified, such as immobilization of the upper extremity, trauma to the joint structures, including brachial plexus injuries, and subluxation of the gleno-humeral joint. A review of the literature explains the basic anatomy and kinesiology of the shoulder complex, the various etiologies of hemiplegic shoulder pain, and the pros and cons of specific treatment techniques. This knowledge is essential for the occupational therapist to evaluate effectively techniques used to treat the patient with hemiplegic shoulder pain. More effective management of this problem will facilitate the patient's ability to reach his or her maximum functional potential.

Spastic hemiplegia in a quadriplegic patient: treatment with phenol nerve block

A quadriplegic patient with a C6 lesion had a stroke with aphasia and right hemiplegia 20 years after his cervical cord injury. The combination of hemiplegia and quadriplegia created unusual rehabilitation problems, the most disabling of which was a painful flexion contracture of the right elbow that prevented any useful right arm function. A sequence of phenol nerve blocks produced almost complete resolution of this contracture and was a key factor in his successful return to independent living. Although phenol block is much less commonly performed in the upper than lower extremities, its judicious use in carefully selected cases may be beneficial to the patient's functional outcome.

[A case of normal pressure hydrocephalus associated with cerebrovascular disorders]

There has been much argument in recent years about the diagnostic and pathogenetic differences between normal pressure hydrocephalus (NPH) and vascular dementia (Multi-infarct dementia) or Binswanger's disease. We experienced an interesting patient, a 54-year-old male, who had left hemiparesis due to two past attacks of cerebral infarction and possible hydrocephalus had been pointed out by CT findings in 1981. He was seen on May 22, 1982, with the chief complaints of dementia, gait disturbance and urinary incontinence. He had the clinical and pathogenetic features, common to NPH and MID or Binswanger's disease. The followings were observed. These symptoms (dementia, gait disturbance, urinary incontinence) and computed tomographic findings (bilateral ventricular dilatation, periventricular lucency), as is often the case in NPH, are at times similar to those of MID or Binswanger's disease and it is difficult to distinguish NPH from MID or Binswanger's disease. We consider that there are probably many patients who are on the borderline of these three diseases. For treatment, the V-P shunt was very effective in combination with the preceding bilateral STA-MCA shunt but it is not clear whether the preceding STA-MCA shunt was required before the V-P shunt. We believe that the clinical symptoms will not appear until the ventricle is dilated to a critical degree. There was a correlation between the degree of dementia and Huckman number, one of the assessment methods for ventricular dilatation.

[Action of trazodone on pyramidal hypertension. Clinical study]

18 patients with severe stabilized pyramidal hypertonia were treated with Trazodone for a minimum period of 60 days with a daily oral dose of 200-300 mg. The reduction of hypertonia was assessed using the Ashworth Scale to evaluate symptoms and signs. On the whole 12 patients showed a clinical improvement; eight of them showed an improvement of at least 2 items on the Ashworth Scale. The reduction of hypertonia began on the 4-5th day of therapy, progressing until the 10-12th day of treatment and then remained constant. Tolerance was very good. Despite the low number of patients in the study the authors obtained good results suggesting that Trazodone should be studied further in this field.

Migraine

The most widely accepted classification of the migraine syndrome includes common, classic, complicated and cluster migraines. Migraine variants refer to episodic dysfunctions of an organ or system which either occur in the migraine sufferer, or replace the headache. While migraine appears to be a primary disorder of the cerebral vessels, there is current experimentation into the role of circulating serotin, prostaglandins, platelet abnormalities and estrogen levels. Both nonnarcotic and narcotic treatments are available, and prophylactic measures may be indicated.

Rehabilitation after spinal cord injuries complicated by previous lesions

Since Sir Ludwig Guttmann introduced the comprehensive modern clinical approach to the rehabilitation of spinal cord injured patients much experience has been accumulated. Modern spinal cord injuries centres have opened throughout the world, treating mainly acute spinal cord injuries in young patients. At Stoke Mandeville Hospital we have had the opportunity to treat several spinal patients who had suffered previous neurological or orthopaedic disorders. These complicated combinations affected the rehabilitation process and the presentations show clearly different aspects of the problem.

[Electromyographic analysis of the leg muscles in the hemiplegic patients with equinovarus deformity of the foot]

A series of EMG study of the leg muscles was carried out with a wire electrode in 86 hemiplegic patients of stroke to visualize the role of each muscle either in the development of equinovarus deformity of the foot or in correcting the deformity through tendon transfer. The muscles examined were anterior tibialis, posterior tibialis, gastrocnemius, soleus, flexor digitorum longus and peroneus brevis of the affected side. Tonic discharge of those muscles was recorded as the patients were elevating the affected leg in supine, sitting or standing posture or were standing on legs. On lifting up the affected limb, most patients showed electrical activity of anterior tibialis with or without simultaneous activity of other muscles, most frequently with that of flexor digitorum longus or gastrocnemius. When the patient stood on legs electromyographic discharge appeared most frequently in soleus. Varus deformity of the foot significantly correlated to the lack of the electrical activity of peroneus brevis. Both such abnormal activity of anterior tibialis and the lack of activity of peroneus seemed to be the main causes for the varus deformity. Postoperative EMG study in the patients who underwent Watkins-Barr procedure of anterior transfer of the posterior tibialis tendon, showed that the posterior tibialis was rather inactive both in elevating the leg and in standing on legs. Varus deformity was corrected independent of the discharge of posterior tibialis. The author concluded that the correction of the varus deformity after Watkins-Barr procedure was mainly obtained from the tenodesis effect. The tenodesis provides the checkline effect on the equinus and varus deformity, which reinforces the dorsiflexing action of anterior tibialis and attenuates its inverting action of the same muscle.

[Persistent atrial paralysis. Observation of a clinical case and review of the literature]

A total, primitive, persistent, non-familial auricular standstill was observed in a twenty-two year old female with right hemiplegia and aphasia. The diagnosis was confirmed by electrocardiogram, fluoroscopy, echocardiography and intra-atrial recording and pacing. The patient was treated with permanent pacemaker and anticoagulant drugs. The various clinical presentations, diagnostic criteria, and therapeutic choices are reviewed.