Infantile bilateral striatal necrosis. Clinicopathological classification

Two cases of infantile bilateral striatal necrosis (IBSN) were studied retrospectively, and the literature was reviewed. The two children had presented with progressive neurologic signs of involuntary movements or muscle hypertonia from infancy. Initial computed tomography scans showed mild atrophy of the caudate nuclei or basal ganglia, and the neuropathologic examination revealed diffuse neuronal loss with some patchy preservation and marked astrogliosis in the striatum and globus pallidus. The 27 reported cases of IBSN were divided into three groups with characteristic clinical and pathologic features: early, acute onset (four cases); early, gradual onset (16 cases); and late onset (seven cases). Although metabolic changes in the developing corpus striatum may be important in the pathogenesis of IBSN, the origin is uncertain.

Prevalence of cognitive impairment in systemic lupus erythematosus

We administered a battery of neuropsychological tests to 62 female patients with systemic lupus erythematosus (SLE), 12 female patients with rheumatoid arthritis (RA), and 35 normal control subjects. By applying objective decision rules to individual test protocols, an overall prevalence of cognitive impairment of 66% was obtained in the SLE patient sample. Independent clinical, radiological, and laboratory data were used to determine neuropsychiatric (NP) symptomatology and to group SLE patients as 1) "active" (N = 21), 2) "inactive" (N = 15), and 3) "never" (N = 26) NP-SLE. More than 80% of the patients in groups 1 and 2 and 42% in group 3 showed significant cognitive impairment as compared with 17% of the RA patients and 14% of the normal control subjects. Neither steroid medication nor psychological distress could account for these findings. The unexpectedly high prevalence of cognitive impairment in SLE patients with either inactive or absent neuropsychiatric symptomatology provides evidence for subclinical nervous system involvement in SLE.

Skull base lesions: a classification and surgical approaches

An anatomic classification of lesions affecting the skull base is proposed according to which this region can be divided into a midline compartment and two lateral compartments: a petrotemporal and an infratemporal. The majority of lesions studied radiographically in 56 patients were confined to one of these anatomic subdivisions. The advantages of such a classification are discussed. The surgical approaches to these compartments and to the anterior middle and posterior cranial fossae are described relative to the lesions we have encountered.

The relationship between perinatal hypoxia and newborn encephalopathy

Newborn encephalopathy was observed in 30% of 303 selected high-risk preterm and term newborn infants. The newborn encephalopathy was mild or moderate in 65 children and severe in 27. The predictive significance of newborn encephalopathy to motor and cognitive deficits at 1 year was evident from the incidence of deficits in the children with no encephalopathy (17%), in children with mild or moderate encephalopathy (25%), and in children with severe encephalopathy (55%). The biologic risk factors with a significant association with newborn encephalopathy included severe intrapartum fetal hypoxia, moderate and severe newborn respiratory complications, and major infections. Perinatal hypoxia was associated with, and may have contributed to, 26% of the cases of mild and moderate newborn encephalopathy and 66% of the cases of severe newborn encephalopathy. Fetal and newborn hypoxia occurred with equal frequencies in cases of mild and moderate encephalopathy; however, newborn hypoxia was twice as frequent as fetal hypoxia in cases of severe newborn encephalopathy.

Ependymal cyst of the subarachnoid space. Cytologic diagnosis and developmental considerations

Fluid aspirated from a subarachnoid cystic lesion that covered and compressed part of the left frontal lobe was examined cytologically and compared with histologic sections of the cyst wall. The fluid contained epithelial and histiocytelike cell populations. The epithelial cells were tall columnar, occurring singly or in clusters or sheets. Many cells were ciliated and their cytoplasm showed characteristic refractile granules. The differential diagnosis of this rare type of subarachnoid cyst and the mechanism of the development are discussed. Cytologic evaluation of the fluid of the subarachnoid cysts is potentially a more accurate method of classification of these lesions than is random biopsy of the cyst wall. It is of particular importance in cases with a history of growth, in which the progressive expansion results in attenuation of the diagnostic epithelial lining of the cyst.

Incidence and prognostic value of spindles in post-traumatic coma

One hundred and thirty-three EEGs were analysed from 80 comatose patients with signs of brain stem impairment due to head/brain injury. Seventy EEGs were taken in acute coma on day 1 or 2 after brain injury. Sixty-three EEGs were recorded in prolonged coma 3-12 days after brain injury. Brain stem involvement was divided by neurological signs and by CT scan into secondary lesions due to supratentorial mass displacement and primary lesions due do direct violence to the brain stem. Different EEG patterns were observed, but spindle activity was of special interest. Spindles were classified as typical (easily recognizable, well organized, 12-14 c/sec activity) or atypical (hardly recognizable, distorted form, 6-11 c/sec activity). Furthermore, asymmetries of spindles were noted. The spindles and their alterations were related to different stages of outcome. Spindles were seen in 91% of the EEGs in acute coma and in 30% in prolonged coma. In acute coma due to secondary brain stem involvement a good outcome was heralded by the occurrence of typical symmetrical spindles combined with early stages of secondary brain stem impairment at neurological examination. In cases of primary brain stem involvement typical spindles also suggested a good prognosis despite the observation of serious clinical signs (decerebrate posturing). The percentage of spindle activity decreased, and distortion and asymmetry of spindles increased with the worsening of outcome. Severe intracerebral lesions (confirmed by clinical and CT scan examinations) led to distortion, asymmetry and finally disappearance of spindles. In prolonged coma spindle activity was markedly reduced regardless of the final outcome. When spindles were present atypical and asymmetric forms significantly increased in patients with bad outcome. There were no significant differences in spindle activity in the different outcome categories, if primary and secondary brain stem lesions were compared.

Bilirubin encephalopathy

In babies of low birth weight dying in the first week of life, bilirubin encephalopathy involving the thalamus only or the thalamus and one or two other areas occurred in nineteen of 376 cases examined over a 10 year period. Although coexistent germinal layer haemorrhage was present in sixteen, this was not thought to be an aetiological factor. Bile stained hyaline membranes in nine of the nineteen were considered to indicate the possibility of protein-bound bilirubin traversing a vascular barrier in these cases. This pattern of predominant lateral thalamic involvement may indicate selective vulnerability of this area in this group. It contrasts sharply with the localization in classical kernicterus (three cases) and in a disparate group where yellow discolouration of future white matter areas was observed (thirteen cases).

CT scan and metrizamide CT cisternography in arachnoid cysts of the middle cranial fossa: classification and pathophysiological aspects

Thirty-one cases of arachnoid cysts of the middle cranial fossa were investigated by CT scan, 7 of them undergoing additional metrizamide CT cisternography. In this paper we analyze and correlate the different findings from these two examinations and propose a classification of arachnoid cysts of the middle cranial fossa into three basic types. Pathophysiological and surgical implications are discussed.

Effects of brain-stem and thalamic lesions on the corneal reflex: an electrophysiological and anatomical study

In 9 patients with Wallenberg's lateral medullary syndrome, one patient with a midbrain lesion involving the right side of the tegmentum, and 2 patients with a thalamic lesion, corneal reflexes were investigated by a new electromyographic technique. The electrophysical results were compared with the results obtained by clinical observation. In the lateral medullary lesions the electrophysiologically obtained reflex responses showed four types of abnormality. Type A consisted of a bilateral delay and type B a bilateral absence of the corneal reflex response to stimulation on the affected side in combination with a normal reflex response on both sides when the cornea on the normal side was stimulated. Type C, which was present in one case, and type D which was seen in 3 cases, consisted of a bilateral absence of the corneal reflex upon stimulation on the affected side; stimulation on the unaffected side produced a normal reflex response on the intact side in combination with, respectively, a delay or absence of the corneal reflex response on the affected side. Comparison of the clinical observations with the electrophysiological findings revealed minor discrepancies in type A and B abnormalities. However, the electrophysiological type C and D abnormalities were not detected by clinical observation. These findings demonstrate that electrophysiological recording of the corneal reflex may reveal clinically undetectable abnormalities. From the electrophysiological findings it is concluded that the corneal reflex is conducted along medullary pathways running both ipsilaterally and contralaterally from the stimulated side before connecting, respectively, with the ipsilateral and contralateral facial nucleus. From the anatomical findings it is suggested that the ascending pathways from the spinal fifth nerve complex to the facial nuclei are located in the lateral reticular formation of the lower brain-stem. The normal corneal reflex responses in the presence of thalamic and midbrain lesions involving nociceptive fibres in the trigeminothalamic tract do not support a previously postulated long-loop reflex arc passing through this tract. The suprabulbar influence upon the corneal reflex is discussed.

The Trail Making Test and Bender Background Interference Procedure as screening devices

The Trail Making Test and Bender Background Interference Procedure were evaluated with 598 Ss against both external neurologic criteria and against psychological opinion derived from a more complete evaluation. For Trails, highly significant differences in mean scores were seen when preselected neurologic patients and patients without neurologic stigmata were compared. Similarly, the distribution of classification of these patients by Bender is significantly different from chance. Application of these measures in a screening paradigm, however, yielded large numbers of false negatives against both neurological and psychological criteria. It was not possible to establish an optimal cutting score to justify application of these measures as screening devices, either alone or in concert.

Evaluation of posterior fossa lesions by computer assisted tomography (CAT)

Valuable neuroradiologic information can be obtained with routine examination of the posterior fossa by computer assisted tomography (CAT). The diagnosis can be difficult in the posterior fossa due to the relatively small size of the compartment and its proximities to large bony masses and air in the mastoid cells. However, many lesions can be accurately diagnosed when close attention is given to anatomic detail and the frequent use of contrast enhancement. We introduced a new CAT classification of posterior fossa neoplasms.

[Globoid cells leukodystrophy apropos of a case of Krabbe's disease]

A case of Krabbe's leucodystrophy is reported after photon and delayed ultrastructural microscopic study. Cerebroside overload within the cerebral globoid cells was shown as well as in the interstitial histiocytic infiltration of the peripheral nerves. Reviewed with the published literature, the characteristics of the inclusions observed seem to be unspecific and, from a morphological standpoint, Krabbe's disease may be related to the gangliosidoses.

[Puttman-Reye syndrome and ekiri. Neuro-anatomical study and attempt at classification]

The authors report two cases of Puttman Reye syndrome: one, classical, involving a young child with a fatal encephalopathy with visceral fatty infiltration, the other, less typical, not showing any signs of visceral fatty degeneration. Both cases were subjected to complete anatomical examination of the brain, revealing marked cerebral oedema, in localised areas or in a laminar distribution, with degenerative changes in the neurones and slight demyelinisation. The authors, on the basis both on the classical appearances of the first case as well as the atypical features of the second, envisage a clinical, anatomical and biological link between the Puttman-Reye syndrome,. Thai encephalopathy and Ekiri, which they consider to represent a single entity.