Subarachnoid-pleural fistula after resection of a pancoast tumor with hyponatremia

Resection of superior sulcus neoplasms is associated with a number of complications resulting from the extensive nature of the resection and the necessity to sacrifice certain adjacent structures. One of the complications of resection is the development of subarachnoid-pleural fistula, with the subsequent appearance of air in the cerebrospinal fluid circulation. We report a case in which a subarachnoid-pleural fistula led to persistent pneumocephaly in a patient who exhibited postoperative hyponatremia, confusion, and gait disturbance.

[Drug-induced extrapyramidal disorders]

We analyze 402 drug-adverse events consisting of movement disorders or aggravation of parkinsonisms, submitted to Sistema Español de Farmacovigilancia until 1994. Our aim is to know patient characteristics and the drugs related with these submissions. Most of them (64) belong to calcium-entry blocker group (31%) and benzamides (27%). Case age intervals more frequent were 11-30 and 60-80 years-old and the events affect predominantly females. The percentage of serious adverse events were near 80%. We think that drug-related parkinsonisms have high prevalence rate and that the role of calcium-entry blockers in these events should be considered at the moment to prescribe groups.

Intrathecal baclofen for motor disorders

To test the efficacy of intrathecal baclofen in various movement disorders, 18 patients with dystonia, head trauma, cerebral palsy, rigidity, or painful spasms underwent a trial of intrathecal baclofen. Ten went on to permanent implantation with an infusion pump to provide long-term treatment. Patients with a component of spasticity, painful spasms, or focal dystonias did best, and no response was seen in patients with rigidity due to anoxic encephalopathy. A videotape of responses is provided.

Delayed neurological symptoms from the spontaneous migration of a bullet in the lumbosacral spinal canal. Case report

In a patient wounded by a gunshot in the abdomen, the bullet was radiologically located intradurally at S1 level. Although she had no neurological deficit at admission, she developed pain and motor weakness a few days later. At operation the bullet was found at L4 level and its removal resulted in complete neurological recovery.

Clinical features of progressive lacunar infarction--retrospective analysis of patients with motor syndromes

The clinical features of progressive lacunar infarction were analyzed in 20 patients with lacunar infarction. Seven of the 20 patients experienced paresis progression and the remaining 13 patients had a stable course. The mean age of progressive lacunar infarction patients (78.6 +/- 4.30 yrs) was significantly higher than that of stable lacunar infarction patients (65.1 +/- 7.68 yrs) (p < 0.01). Patients presenting with pure motor stroke were more likely to have progressive stroke (7/13) than those presenting with sensorimotor stroke (0/7) (p < 0.05). Paresis aggravation began on Day 1 and ceased on Day 2 in most patients. Progressive paresis began to improve after reaching the nadir. Hemiparesis was only slightly worse after 1 month compared with that on admission. Older patients are more likely to have a progressive course. Paresis progression in lacunar patients does not preclude the possibility of recovery and is not necessarily associated with a poor prognosis.

Cerebral gigantism (Sotos' syndrome). A rare cause of delayed walking and awkward gait

A case history of an 8-year-old girl with cerebral gigantism (Sotos' syndrome) has been presented. Throughout her life, this child has demonstrated all of the common features of Sotos' syndrome including large size at birth, excessive growth during childhood, dysmorphic craniofacial features, delay in motor and speech development, generalized clumsiness, and awkward gait. Family history was contributory with delays in early language development and the possibility that the child's father had Sotos' syndrome. When evaluating a pediatric patient for pes planus, delayed walking, and gait problems, the practitioner should consider the entire clinical profile and unusual etiologies.

[A case of astrocytoma of corpus callosum presented diagnostic dyspraxia]

A case of astrocytoma whose first clinical presentation was diagnostic dyspraxia was reported. A 38-year-old right-handed male experienced funny motion of his left hand triggered by voluntary movement of his right hand. One day, he tried to insert a coin into the vending machine with his right hand, then the left hand was against the other. One month after that event, he experienced headache and vertigo. On admission, there were no abnormal findings on neurological examination. On neuropsychological examination, he was cooperative, well orientated and attentive, and there were no callosal disconnection symptoms. Frontal lobe function tests were slightly impaired. T1-weighted MRI demonstrated irregular mixed signal intensity mass lesion extending from the genu to the body of the corpus callosum and the cingulate gyrus. This lesion was slightly enhanced with Gd-DTPA. Biopsy was performed and histological diagnosis was fibrillary astrocytoma. After irradiation and chemotherapy, he was discharged from the hospital without evident neurological deficit. About 20 cases of diagnostic dyspraxia have been reported and almost all of them were caused by cerebro-vascular disease. This is the first case of brain tumor who presented diagnostic dyspraxia.

[Neurological involvements with transient gait disturbance in subacute phase of Kawasaki disease; a case report]

A 1-year-and-9-months old boy with gait disturbance during the 3rd week of Kawasaki disease (KD) was described. He had been previously healthy, and developed high fever and rash. The diagnosis of KD was based on 5 of 6 major criteria on the 3rd clinical day. He was initially treated with intravenous gamma-globulin 400 mg/kg/day for five days. On the 17th clinical day, the patient developed gait disturbance after most clinical signs disappeared. His gait was wide- based and unstable. Generalized hypotonia with poor traction response was also seen. Pyramidal tract signs including exaggerated patellar and Achilles tendon reflexes and positive bilateral Mendel-Bechterew reflex were presented. Cerebrospinal fluid was normal. Brain CT, MRI, and 123I-IMP SPECT images were normal without broad hemorrhage or infarction of the cerebral parenchyma. Gait disturbance recovered spontaneously within one month without any sequelae.

The cardiovascular outcome of patients with motor impairment and extensive leukoaraiosis

BACKGROUND AND METHODS

The long-term outcome of patients with motor impairment and extensive leukoaraiosis on computed tomographic scan is unknown. We studied the incidence of stroke, myocardial infarction, and death in 31 such patients (cases) and in 68 neurologic patients without leukoaraiosis (controls). The patients in both groups had a routine neurologic and cardiovascular assessment and were followed up for 51.9 +/- 20.1 (mean +/- SD) months (cases) and 49.5 +/- 18.6 months (controls).

RESULTS

The 6-year risk of cumulative stroke, as determined by life table analysis, was 49% among cases and 16% among controls (hazard ratio, 3.0; 95% confidence interval, 1.2 to 7.5). The risk of stroke or myocardial infarction was 69% vs 36% (hazard ratio, 2.9; 95% confidence interval, 1.4 to 6.2). The stroke risk remained significantly increased among cases after adjustment for age, sex, and any conventional vascular risk factor, while it was reduced (hazard ratio, 2.5; 95% confidence interval, 0.8 to 7.4) after adjustment for history of lacunar stroke was corrected for and was almost halved (hazard ratio, 1.6; 95% confidence interval, 0.5 to 4.6) after adjustment for the presence of lacunar infarction images on computed tomographic scan.

CONCLUSIONS

Patients with motor impairment and extensive leukoaraiosis have a very poor cardiovascular outcome. Lacunar infarction might be the major determinant of the outcome in these patients.

Hemiballismus: CT and MR findings

OBJECTIVE

Our aim was to determine the frequency with which a lesion responsible for hemiballismus was detectable on CT and MR examinations.

MATERIALS AND METHODS

The CT and MR examinations of six patients with hemiballismus were reviewed. Three patients underwent MRI alone, two CT alone, and one underwent both CT and MRI. Sites considered as possible locations for a lesion causing hemiballismus included the subthalamic nucleus on the side contralateral to the movements, contralateral putamen, caudate nucleus, thalamus, corpus striatum, lenticular nucleus, substantia nigra, and the premotor and motor cortex.

RESULTS

A lesion likely to account for hemiballismus was found in five patients (contralateral subthalamic nucleus in four patients, contralateral putamen in one patient). Causes of hemiballismus included infarction (one patient), hemorrhage (two patients), trauma (one patient), and an abscess (one patient). A responsible lesion was detected in all five patients who underwent MRI. In one patient who underwent CT alone, a responsible lesion was not identified.

CONCLUSION

A lesion responsible for hemiballistic movements can generally be found on cross-sectional imaging examinations. Because the multiplanar imaging capability of MR appears to allow for sensitive detection of even small lesions in sites likely to cause hemiballismus, MRI offers the best means of imaging these patients.

Photic headshaking in the horse: 7 cases

Seven horses with headshaking are described. No physical abnormalities were detected in any of the cases. Six of these horses had onset of clinical signs in the spring. The role of light was assessed by application of a blindfold or dark grey lens to the eyes, covering the eyes with a face mask and observing the horse in total darkness outdoors. Cessation of headshaking was observed with blindfolding (5/5 horses), night darkness outdoors (4/4 horses) and use of grey lenses (2/3 horses). Outdoor behaviour suggested efforts to avoid light in 4/4 cases. The photic sneeze in man is suggested as a putative mechanism for equine headshaking. Five of 7 horses had improvement with cyproheptadine treatment (0.3 mg/kg bwt b.i.d.). Headshaking developed within 2 calendar weeks of the same date for 3 consecutive years in one horse. Neuropharmacological alterations associated with photoperiod mechanisms leading to optic trigeminal summation are suggested as possible reasons for spring onset of headshaking.

Intracranial haemorrhage in a dobermann puppy with von Willebrand's disease

Neurological examination of a lethargic, ataxic 12-week-old dobermann revealed decreased conscious proprioception in all its limbs. Haematological examination revealed a low platelet count. Cytological examination of a sample of cerebrospinal fluid revealed evidence of haemorrhage and chronic inflammation. The levels of von Willebrand's factor antigen were extremely low. Skull radiographs were consistent with mild hydrocephalus. Treatment resulted in little clinical improvement and the animal was euthanased. Post mortem examination of the brain revealed an internal hydrocephalus with haemorrhage into the ventricles. It was considered that the animal had suffered severe intracranial haemorrhage as a result of its low level of von Willebrand's factor antigen and that the bleeding may have been potentiated by the low platelet count.

[Hemorrhage in cerebral cavernous hemangioma as a cause of hemiballismus]

A 19 year old righthanded woman, without previous neurological symptoms, was examined in April 1993, because of involuntary movements affecting especially the right hand, but also her right leg and the right side of her face. Magnetic Resonance Imagning (MRI), showed a process located in the area of the left subthalamic nucleus, which was recognized as a cavernous haemangioma. A left carotic arteriography in August was normal. The patient had a complete regression of her symptoms, wherefore there was no indication for neurosurgical intervention. The patient is still being followed without treatment.

Alien hand syndrome without a corpus callosum lesion

A 58 year old right handed woman developed a left alien hand syndrome after a right capsulothalamic haemorrhage with mesencephalic extension. No lesion was detected in the corpus callosum. Positron emission tomography suggested that right cortical dysfunction might account for the absence of recognition of the left hand whereas involuntary motor activity was attributed to the lesion itself. This case shows that the alien hand syndrome is not always the expression of a disconnection syndrome and may occur after a large, strategically located, posterior lesion.

Induction of leg-shaking, knock-down and killing responses by gamma-ray irradiation in Shaker mutants of Drosophila melanogaster

Induction of membrane-associated responses, a leg-shaking, a knock-down and a killing, by gamma-ray irradiation was investigated in Shaker (Sh) mutants of Drosophila melanogaster in which the gene cords for the A-current K+ channel. Sh mutants were more sensitive in the knock-down response after gamma-ray irradiation than wild types. There were a great amount of sex difference in the knock-down response, males being more sensitive than females, but not in the killing response. The sex difference was larger than gene dosage effect on X chromosome in females. Genetical analysis revealed that the sensitivity of the knock-down response is an incompletely dominant character without maternal effects. The leg-shaking response, which had previously been reported to be induced by ether treatment, was demonstrated in the head-removed flies of Sh mutants. It was found to be the most sensitive among the responses tested, and may involve changes in K+ channel. The knock-down response may be related to expansion of the leg-shaking response. The killing response should have causes different from the leg-shaking and the knock-down responses judging from the lack of correlation with them.

Changes in presence of a segmental dysfunction pattern associated with hypertension: Part 2. A long-term longitudinal study

The short-term portion of this study (part 1) showed an association between somatic dysfunction and the regulation of blood pressure. To study long-term relationships, follow-up examinations were made of 61 subjects studied 3 to 10 years earlier. They were heterogeneous Family Practice Clinic patients with a mean age of 45 years. By methods used in part 1 and in our previous studies of systemic interactions, palpatory examination was done to support presence or absence of a C6T2T6 pattern of segmental motion dysfunctions, and blood pressure status was established by the medical history. The C6T2T6 pattern persisted in 16 of 16 subjects with grade 2 or greater hypertension and 4 of 9 normotensive subjects who had shown the pattern initially. At follow-up, the pattern first appeared in 7 subjects who had hypertension previously diagnosed and who remained hypertensive; the pattern disappeared in 5 normotensive subjects who remained normotensive. The C6T2T6 pattern's long-term persistence in hypertensive subjects and changes in its presence corresponding to the subjects' hypertensive status indicate an important relationship between this pattern of segmental motion dysfunctions and disturbances in regulation of blood pressure.

Comparison of surgeries for removal of primary vestibular inputs: a combined anatomical and behavioral study in rats

Unilateral removal of Scarpa's ganglion and neurectomy of the peripheral vestibular nerve branches were compared in rats as methods to eliminate primary vestibular input. Ocular nystagmus was consistently observed after both types of lesion, but it completely disappeared within 4 to 7 days. Imbalance and rotation were more serious and prolonged after ganglionectomy than after peripheral neurectomy. Corresponding with these differences in symptoms were differences in terminal degeneration. After ganglionectomy, degenerated axons and terminals were distributed throughout all terminal regions of primary vestibular fibers on the lesioned side, while after peripheral neurectomy, the degeneration was more limited. The results of this study suggest that vestibular ganglionectomy is a more successful approach than peripheral vestibular neurectomy for removing the primary vestibular input.

Alien hand syndrome: interhemispheric motor disconnection due to a lesion in the midbody of the corpus callosum

The neuroanatomic substrate of the alien hand syndrome has remained controversial due to the noncircumscribed nature of cerebral injuries present in most cases. There have been few cases studied in which damage was restricted to portions of the body of the callosum, and most of those involved surgical callosotomy for tumors or epilepsy. We report the case of a woman with a transient alien hand syndrome caused by a stroke limited to the middle and posterior portions of the body of the corpus callosum. This case provides supportive evidence for damage to the midbody of the corpus callosum as the anatomic basis of nondominant alien hand syndrome and conforms to a model of interhemispheric motor disconnection as the essential component of this unusual behavioral syndrome. This disconnection can occur with injuries involving interhemispheric premotor and motor fibers traveling in the midportion of the callosum in individuals with left hemisphere dominance for motor activities.

Heavy metals and the etiology of Parkinson's disease and other movement disorders

Heavy metals, such as iron and manganese, are involved in neurologic disease. Most often these diseases are associated with abnormal environmental exposures or abnormal accumulations of heavy metals in the body. There is increasing recognition that heavy metals normally present in the body also may play a role in disease pathogenesis through free radical formation. When a part of the brain known as the basal ganglia is affected, movements become disordered. Parkinson's disease is one of the most common movement disorders and is related to destruction of neurons in the substantia nigra pars compacta (SNpc) of the basal ganglia. The combination of high concentration of iron and the neurotransmitter, dopamine, may contribute to the selective vulnerability of the SNpc. Dopamine can auto-oxidize to produce free radicals particularly in the presence of iron and other heavy metals.