Hydrocephalic infants: developmental assessment and computed tomography

29 hydrocephalic infants (less than 30 months) who had shunts were studied with the 'Bayley Mental Scale' and with computed tomography. It was found that patients with a medical history indicating brain injury in addition to hydrocephalus had lower scores on the 'Bayley Mental Scale' than a comparable group whose hydrocephalus had been uncomplicated. Dilatation of the lateral ventricles was assessed by computing the ventricle-brain ratio (VBR) from the CT scan. The VBR was inversely correlated with the 'Bayley Mental Scale' score. Two thirds of the sample were reevaluated after 1 year; there was a significant decrease in VBR, but mental quotient was unchanged. These findings are in agreement with studies on older children in that the prognosis for cognitive functioning in hydrocephalic children is affected by brain injury. A correlation between brain mass and intelligence has been reported in older children with uncomplicated hydrocephalus, but not in groups with mixed etiology.

Ventricular enlargement after closed head injury

To study the relationship between enlargement of the cerebral ventricles and neuropsychological deficit after closed head injury (CHI), we measured the area of the lateral ventricles on computed tomographic scans obtained at least 30 days after severe CHI in 32 young adults and a control group of similar age. Enlargement of the lateral ventricles was demonstrated in 72% of the head-injured subjects, as defined by the ventricle-brain percent ratio (VBR). Ventricular dilation was related to the duration of coma after high-speed motor vehicle accidents and to intellectual and memory defects. The VBR may be a useful index of the severity of brain damage in certain categories of head-injured patients.

Endosalpingiosis

The origin of psammoma bodies in cul-de-sac fluid must always be explained. Multiple, histologically benign, predominantly peritoneal foci of tubal-like epithelium are described in a woman with endometriosis and psammoma bodies in the cul-de-sac fluid. Because no primary ovarian neoplasm was present, the diagnosis of endosalpingiosis was made. The pathogenesis and significance of endosalpingiosis are discussed.

An immunoperoxidase technique to aid in the differential diagnosis of prostatic carcinoma

The unlabeled immunoperoxidase technique and antibody to human prostatic acid phosphatase was used to study a variety of normal and neoplastic tissues. The technique was found to be a useful adjunct in the differential diagnosis of prostatic carcinoma versus transitional cell carcinoma of the bladder and rectal adenocarcinoma, but was not entirely specific, as cross-reactivity with rectal carcinoid tumors was documented. This study emphasizes the importance of controlled testing of these antibodies by pathology laboratories using immunoperoxidase techniques to assure accurate surgical pathologic diagnosis.

The effect of sterile ureteral reflux on intact and diverted upper urinary tracts

We studied the effect of sterile ureteral reflux on intact and diverted upper urinary tracts. Five dogs underwent transvesical left ureteral meatotomy and anastomosis of the right ureter to a refluxing ileal conduit. Several normal nonrefluxing renal units were also studied. At 6 months, renal function studies were not significantly different among control, ilealureteral, and vesicoureteral refluxing renal units. No radiographic or histopathologic abnormalities were observed in experimental renal units. Sterile intestinalureteral and vesicoureteral reflux do not seem to cause functional or morphologic renal damage.

Quantitative indexes of computed tomography in dementia and normal aging

Quantitative indexes of compute tomography were compared in 28 patients with Alzheimer dementia and in 30 elderly persons with no history of neurologic disease. Age-corrected ventricle-brain ratios were abnormal for half of the dementia patients, whereas only a single subject in the control group had ventricles outside the limits of normal variation. Measurement of the distance between the third ventricle and Sylvian fissure indicated that the dementia patients had significantly more atrophy in this area. Employment of quantitative indexes standardized for age may aid in differentiating cerebral atrophy associated with dementia from that associated with normal aging.

Cerebellar ataxia, opsoclonus, and occult neural crest tumor. Abdominal computerized tomography in diagnosis

A 9-month-old female with opsoclonus and ataxia was examined. Computerized axial tomography (CT) of her abdomen identified a retroperitoneal mass of neural crest origin that was not recognized by more conventional roentgenographic methods. The syndrome of cerebellar ataxia, myoclonus, and opsoclonus, and its relationship to neural crest tumors is reviewed along with the usefulness of abdominal CT.

Intrascrotal Wilms' tumor developing in a heterotopic renal anlage of probable mesonephric origin

A case of intrascrotal primary Wilms' tumor is reported. The histopathologic appearance of the primary tumor and subsequent pulmonary metastasis are identical with that of a typical intrarenal Wilms' tumor. The origin of this tumor in a heterotopic renal anlage consistent with mesonephric origin suggests that tissue from the intermediate and caudal segments of the nephrogenic cord may produce Wilms' tumor. Wilms' tumor arising in an embryologic rest of renal tissue is a rare occurrence. We are reporting the seventh well-documented case and the first case with confirmed distant metastasis.

Facial recognition in patients with focal brain lesions

The performances of patients with radiologically or surgically verified focal lesions on a test requiring the identification of unfamiliar faces were investigated. Nonaphasic patients with posterior right hemisphere lesions and aphasic patients with substantial impairment in language comprehension showed a notably high frequency of defect. The frequency of defective performance in nonaphasic patients with right anterior lesions was higher than normal but less than that of the previously mentioned groups. Nonaphasic patients with left hemisphere lesions and aphasic patients without substantial impairment in language comprehension performed on a level comparable with that of control subjects. It is concluded that the identification of unfamiliar faces is a bihemispheric process, possibly involving linguistic as well as visuoperceptive components.

The Galveston Orientation and Amnesia Test. A practical scale to assess cognition after head injury

The Galveston Orientation and Amnesia Test (GOAT) was developed to evaluate cognition serially during the subacute stage of recovery from closed head injury. This practical scale measures orientation to person, place, and time, and memory for events preceding and following the injury. The distribution of test scores in 50 patients who had recovered from a mild closed head injury was used to define the range of variation in performance and to analyze the effects of demographic factors. In a validity study of 52 closed head-injured patients, the duration of impaired GOAT scores was strongly related to the acute neurosurgical ratings of eye opening, motor responding, and verbal responding on the Glasgow Coma Scale. Duration of post-traumatic amnesia, as defined by the persistence of defective GOAT scores, was longer in patients with computed tomographic evidence of diffuse or bilateral brain injury as compared to cases with focal unilateral lesions. Serial GOAT scores were also predictive of long term level of recovery. Review of the brief cognitive test literature disclosed that several techniques have adequate validity data substantiating their use in the detection of dementia in geriatric, psychiatric, and medical populations. Recommendations for the clinical application of the various brief cognitive tests are discussed.

Testicular biopsy in the study of male infertility: its current usefulness, histologic techniques, and prospects for the future

Testicular biopsy has been widely used for the diagnosis of male infertility for more than three decades. During that time, with advances in cytogenetics, radioimmunoassay, and endocrinology, the role of testicular biopsy has changed. Testicular biopsy is still useful in the diagnosis of azoospermic and oligospermic males without stigmata of gonadotropic insufficiency or Klinefelter's syndrome. A classification and description is presented of pathologic changes in the testis as seen on testicular biopsy by light microscopy. The present rationale for testicular biopsy in infertility, the processing and staining of histologic material, and the role of testicular biopsy in infertility and infertility related situations, including cryptorchidism, malignant disease, and chemotherapy related changes, are discussed. Further understanding of testicular function and disease will depend upon the correlation of histologic and ultramicroscopic changes, immunohistologic localization of hormones, and epidemiologic and endocrinologic data.

Effects of physostigmine and lecithin on memory in Alzheimer disease

Because there is evidence that central cholinergic mechanisms are depleted in dementia, we studied the effects of central cholinergic augmentation on the memory of 5 patients with Alzheimer disease. Patients received placebo, lecithin, physostigmine, or lecithin plus physostigmine in a double-blind study using titrated doses of the acetylcholinesterase inhibitor physostigmine. Memory was evaluated with alternate forms of the selective reminding procedure. Compared with lecithin alone, the combination of physostigmine and lecithin consistently enhanced memory storage and retrieval; physostigmine without lecithin produced no memory facilitation. The strategy of combining a cholinergic agonist and precursor holds promise, although a larger clinical trial is needed.

Impaired recognition memory after head injury

A continuous recognition memory task employing 120 line drawings of familiar stimuli was administered to patients recovering from closed head injury of varying severity and control patients. Mildly injured patients obtained significantly more correct responses, and higher memory sensitivity (d') values than moderately and severely injured patients who performed similarly. The measure of response criterion, c, was significantly lower in patients with injury of moderate severity when compared to mildly injured cases and control patients. Controls and mildly injured patients did not differ in their performance. In general, the total correct responses most impressively differentiated head injured patients with measurable coma duration as more than two-thirds had scores below the control group. Group differences in hits, false alarms and misses were examined also. Age and education, skull fracture, and hematoma were generally unrelated to any of the measures, whereas coma duration was significantly related to most measures of mnemonic efficiency.

Long-term neuropsychological outcome of closed head injury

Long-term recovery from severe closed head injury was investigated in predominantly young adults whose Glasgow Coma score was 8 or less at the time of admission. Of the 27 patients studied (median follow-up interval of 1 year), 10 attained a good recovery, 12 were moderately disabled, and five were severely disabled. In contrast to previous studies suggesting that intellectual ability after severe closed head injury eventually recovers to a normal level, our findings showed that residual intellectual level, memory storage and retrieval, linguistic deficit, and personal social adjustment corresponded to overall outcome. All severely disabled patients and several moderately disabled patients exhibited unequivocal cognitive and emotional sequelae after long follow-up intervals. Analysis of persistent neuropsychological deficit in relation to neurological indices of acute injury severity demonstrated the prognostic significance of oculovestibular deficit.

Time on target meter

The design and construction of an inexpensive time-on-target meter are presented with a logic diagram. This meter has been found to facilitate the recording of proprioceptive feedback performance by automatically recording the cumulative percent of time that the subject's manual tracking is within a specified range on a given trial.

Alexia without agraphia in a musician after transcallosal removal of a left intraventricular meningioma

After a meningioma situated in the trigone of the left lateral ventricle was excised by the transcallosal approach of Kempe and Blaylock, a right-handed musician with a right hemianopsia developed alexia without agraphia. In contrast to previously reported cases of this syndrome arising from other etiologies, he was unable to read single letters or numbers. Neuropsychological studies at 42 and 126 days after operation also disclosed an inability to associate auditory or tactile stimuli with visually perceived material, whereas speech and verbal comprehension were intact. Although the alexia extended to musical notes, he could interpret other musical symbols (e.g., treble clef). Appreciation of rhythm and expressive musical ability were relatively preserved, although judgment of other musical features (including discrimination of pitch, duration, and loudness) was compromised. The findings suggest that alexia may occur as a consequence of the transcallosal procedure when a right hemianopsia is present. However, other linguistic abilities may be better preserved by the transcallosal approach to the ventricle than by a transcortical operation.

Neuropsychological outcome of closed head injury in children and adolescents

45 children and adolescents recovering from closed head injury underwent neuropsychological testing. Multiple indices were used to classify the severity of injury but most important in this study were the persistence of coma indexed by grades I--III and the Glasgow Coma Scale. Although the presence of early neuropsychological sequelae and long-term intellectual deficit was generally related to the severity of injury, residual impairment was also found in patients with relatively mild injuries. Analysis of memory and learning demonstrated disruption of both storage and retrieval processes.

Behavioral sequelae of closed head injury. A quantitative study

We determined the profile of behavioral disturbance in relation to closed head injury of graded severity. Patients with severe injuries, as defined by duration of coma and the presence of neurological deficit, were differentiated from a group of mildly injured patients by behavioral ratings that reflected cognitive disorganization, emotional withdrawal, and motor retardation. Neurologic measurements of injury related to the severity of behavioral disturbance included hemiparesis, aphasia, and abnormalities on computerized axial tomography. Agitation during the acute phase of injury was also predictive of residual behavioral disturbance. Hemispheric lateralization of the site of greatest injury had no discernible effect on behavioral sequelae.

Correcting for cultural factors in evaluating intellectual deficit on the WAIS

Obtained estimates of the effects of ethnic group, sex, education, and clinical diagnosis on WAIS IQ scores of 776 psychiatric patients by least squares regression methods. Estimates of expected IQ for various demographically defined segments of the general population were obtained by setting the expected IQ for white high school graduates at 101 and then adding or subtracting the specific effects associated with different ethnic group, sex, and education. A formula for norming WAIS Full Scale IQ scores to X = 100 and SD = 15 within various demographically defined segments of the population is proposed.

Normal urinary excretion of catecholamine catabolites in children with retinoblastoma

Urinary catecholamine catabolites, homovanillic acid, vanillylmandelic acid, total metanephrines, and total catecholamines were assayed in 12 patients with newly diagnosed retinoblastoma prior to surgery and treatment. These values were within normal limits for the ages of all 12 patients, including one with metastases to brain, liver, lymph nodes, and bone marrow. The predictive value and efficiency of these tests in the diagnosis of retinoblastoma are insufficient to warrant their continued use on a routine basis.

Hyperbaric oxygenation in the treatment of postencephalitic amnesic syndrome

The efficacy of hyperbaric oxygenation in the treatment of an amnesic disorder was studied in a young woman with a residual memory impairment 2 years after Herpes Simplex Encephalitis. Quantitative testing of memory was performed under controlled conditions before, during, and immediately following treatment. There was no systematic change in storage and retrieval of either verbal or essentially nonverbal information when testing was performed during hyperbaric oxygenation or after termination of four daily treatment sessions. The findings support recent studies which have indicated a lack of therapeutic effects of hyperbaric oxygenation on the mental efficiency of older demented patients.

Impairment of Facial Recognition After Closed Head Injuries of Varying Severity

Perceptual matching of photographs of unfamiliar faces was studied in 46 patients with closed head injury. The severity of head injury as indexed by duration of coma and neurological deficits was inversely related to accuracy of performance. Impairment of facial recognition was specifically associated with signs of concomitant hemispheric and brain stem injury. The presence of neurologic deficits suggesting less pervasive injury essentially confined to the cerebral hemispheres, skull fracture, and EEG abnormality was not related to this visuoperceptive deficit. The findings are discussed in relation to hypotheses concerning neurological dysfunction in head injury.

Memory enhancement after physostigmine treatment in the amnesic syndrome

Central anticholinergic agents (eg, scopolamine) are known to produce transient memory deficits in human and animal subjects. Damage to the limbic system frequently results from herpes simplex encephalitis (HSE) and produces a memory deficit. If this deficit is due to limbic cholinergic pathway destruction, it might improve with central cholinergic agonists (eg, physostigmine). In a doubleblind study over a three-week period, we compared memory performance on three days after 0.8-mg subcutaneous physostigmine therapy (three sessions) to baseline performance and that obtained in three randomly interspersed control sessions. Serial assessment of memory by the Selective Reminding Test showed reproducible enhancement of long-term storage and retrieval with physostigmine treatment. Performance after control injections did not exceed baseline levels. Our findings encourage the hypothesis that cholinergic mechanisms subserve memory and that their pharmacological potentiation might favorable influence some amnesic conditions.

Neurologic and psychologic manifestations of decompression illness in divers

It has been widely accepted that the neurologic sequelae of decompression illness are confined to the spinal cord. Of 10 divers who gave a history of an episode of decompression illness involving the central nervous system, we found that eight had unequivocal neurologic deficits implicating multiple supraspinal lesions. Seven of these neurologically impaired divers completed a battery of neuropsychologic tests that revealed severe deficits in all cases. The findings show that diffuse and multiple central nervous system lesions result from decompression illness and demonstrate the importance and close correlation of thorough neurologic and neuropsychologic tests in assessment following diving accidents.

Facial recognition in "pseudoneurological" patients

A test of facial recognition was given to 44 patients whose symptoms raised a question of differential diagnosis between brain disease and functional psychiatric disorder. These "pseudoneurological" patients presented symptoms (e.g., memory impairment, headache, sensory disturbances) that were sufficiently suggestive of CNS disease to warrant thorough neurological evaluation. In each case, such evaluation disclosed no evidence of brain disease and the final diagnosis was some type of functional psychiatric disorder. Facial recognition performances of these patients were indistinguishable from those of medical patients without history or evidence of brain disease. The findings support the clinical application of this type of task in cases presenting problems of differential diagnosis.

Aphasic disorder in patients with closed head injury

Quantitative assessment of 50 patients with closed head injury disclosed that anomic errors and word finding difficulty were prominent sequelae as nearly half of the series had defective scores on tests of naming and/or word association. Aphasic disturbance was associated with severity of brain injury as reflected by prolonged coma and injury of the brain stem.

Short-term recognition memory in relation to severity of head injury

Short-term recognition memory for random shapes was studied in 24 patients with head injury. The severity of head injury as indexed by duration of coma was closely related to impairment in performance. Disruption of short-term recognition memory was associated with neurologic deficit, asphasic disturbance, and signs of brain stem involvement. Performance was not related to association value of the shapes irrespective of linguistic competence. The findings are discussed in relation to recent studies of continuous recognition memory after head injury and hypotheses concerning neurological dysfunction in head injury.

Proprioceptive feedback performance in patients with focal brain lesions

Utilization of proprioceptive feedback in a manual tracking task was studied in patients with circumscribed unilateral brain lesions. Patients with posterior right hemisphere disease showed severe impairment in performance as compared to those with lesions in other areas of the brain. Increasing the intensity of proprioceptive feedback facilitated the tracking performance of left hemisphere damaged patients while patients with right hemisphere lesions failed to improve. The results were interpreted as supporting the view that the posterior right hemisphere plays a particularly important role in the utilization of proprioceptive information to maintain the position of body parts in space.

Anxiety associated with exposure to organophosphate compounds

Acute organophosphate poisoning is known to result in substantial behavioral abnormalities. We assessed psychiatric manifestations of exposure in workers less substantially exposed to organophosphate compounds and showing no obvious signs of toxicity. Commercial pesticide sprayers and farmers recently exposed to organophosphate agents were compared to control subjects on personality tests, a structured interview, and cholinesterase level. The commercial sprayers but not the exposed farmers showed elevated of anxiety and lower plasma cholinesterase than control subjects. Assessment of other behavioral manifestations and red blood cell cholinesterase failed to disclose other group differences. These findings are viewed as tentative until confirmed by additional study, but they point to the possibility that organophosphate compounds may produce subtle defects in workers who are not obviously toxic. The findings do not justify public alarm but do suggest an area warranting more systematic and definitive investigation.

Neuropsychological testing following head injuries: prosopagnosia without visual field defect

Assessment of residual cerebral dysfunction in the post-traumatic patient poses considerable problems particularly when the neurological examination yields minimal or equivocal findings. The clinical picture is frequently complicated by emotional disturbance not easily differentiated from "post-traumatic neurosis." This report describes such a patient whose disorder was elicidated by neuropsychological testing. Numerous studies have established the validity of neuropsychological tests particularly when they are interpreted by psychologists specifically trained in their use. These procedures are also useful in differentiating patients with neurologic complaints of a nonorganic etiology from patients with similar complaints secondary to confirmed brain lesions. Although the findings reported here pertain to a patient exhibiting a rare neurologic consequence of closed head injury, the methods employed are applicable to subtle behavioral manifestations of diverse etiologies. Neurophyshological findings in a patient unable to recognize faces of familiar persons (prosopagnosia) disclosed a severe impairment of visual perception despite intact visual acuity and fields. The prosopagnosia was also associated with a pervasive memory deficit without dementia. Our results challenge current concepts of prosopagnosia and support the need for neuropsychological evaluation of post-traumatic patients.

Behavioral effects of organophosphate in man

Increasingly widespread application of organophosphate pesticies has underscored the importance of studying their effects on human behavior. Clinical reports and laboratory investigations have generally supported the assumption that neurobehavioral manifestations of organophosphate toxicity are attributable to accumulation of acetylcholine at central and peripheral synapses as a result of cholinesterase inhibition. Despite methodologic shortcomings in many of the published studies, investigators generally agree on the presence of several behavioral sequelae of organophosphate poisoning: (a) impaired vigilance and reduced concentration, (b) slowing of information processing and psychomotor speed, (c) memory deficit, (d) linguistic disturbance, (e) depression, and (f) anxiety and irritability. The few studies of asymptomatic workers at risk for repeated exposure to organophosphate pesticides have produced only equivocal findings concerning the presence of less severe or latent forms of these behavioral abnormalities.

The structural study of the saphenous vein

From November, 1971, to September, 1974, 1,179 patients received aortocoronary saphenous vein bypass grafts at the Cleveland Clinic Hospital. Segments of saphenous vein from each patient were sent for microscopical analysis. These vein segments were classified as normal or abnormal (phlebosclerotic). Four hundred ninety-six normal vein grafts in 295 patients were restudied and had a patency of 87.9%. One hundred forty-four abnormal vein grafts in 86 patients were restudied and showed 89.5% patency. This study suggests that histopathological identification of an abnormal (phlebosclerotic) vein segment does not constitute a determining factor as far as late patency is concerned in a vein segment that is not grossly sclerotic.

Testis tumors: review of 125 cases at the Cleveland Clinic

One hundred twenty-five cases of testicular tumor are reviewed. The prognostic significance of clinical features, certain laboratory test results, and histologic type are evaluated, and treatment results are presented. The most important prognostic clinical feature is the presence or absence of clinically evident metastases. The urinary gonadotropin levels are useful prognostically, but the intravenous pyelogram and lymphangiogram are statistically unreliable. The presence of tumor in retroperitoneal lymph nodes influenced survival only in the patients with embryonal carcinoma. Tumor type influenced survival more than any other pathologic factor. Vascular invasion, local extension, and Leydig cell hyperplasia did not correlate with tumor behavior in germinal neoplasms. Patients with clinical Stage IA or IB teratocarcinoma had an 85 per cent survival rate with a wide variety of treatment.

Bilateral testicular tumors of germ cell origin

Four cases of primary testicular tumor of germ cell origin are reported. Three cases were bilateral, while the remaining case involved a unilateral tumor in a non-twin brother of 1 patient with bilateral tumors. Because of the increased likelihood of a second primary tumor developing in a patient who has had a malignant germinal cell tumor and because the changes may be subtle, localized to the testis and occur after a tumor-free interval of many years, careful examination of the contralateral testis and long-term followup are indicated even when systemic chemotherapy for malignancy has been used. This is the seventh time familial occurrence of testis tumors in non-twin brothers has been reported but the first time that one of the brothers had bilateral tumors.

Effects of stereotactic cingulumotomy on a sequential motor task in man

The effect of bilateral cingulumotomy on sequential tapping behavior was investigated in 6 patients, Contrary to previous clinical studies and predictions derived from data on cingulate lesions in the rat, a consistent decrement in postoperative performance was not found. Temporal integration of behavior in man, as measured in terms of accuracy of sequential motor performance, does not appear to be critically dependent upon the integrity of the cingulum bundle at the level of interruption investigated in the present study.

Temporal orientation in patients with brain disease

A brief schedule of questions, based on empirically derived norms, disclosed significant inaccuracy in temporal orientation in 24% of a groups of nonaphasic patients with brain disease. Conventional neurological examination detected temporal disorientation in only 15%. Patients with bilateral lesions showed a higher frequency of temporal disorientation than did those with inilateral lesions. In a group of 15 aphasic patients, 5 (33%) showed evidence of temporal disorientation according to the test while only 3 (20%) were detected on clinical examination. It is suggested that a schedule of questions scored on the basis of empirically derived norms should be incorporated into the neurological examination to assess temporal orientation.