Un cas de neuropathie mimant un syndrome de Guillain-Barré après une intoxication à l’arsenic

INTRODUCTION

Chronic arsenic toxicity is a global health problem affecting millions of people. Acute arsenic poisoning is less frequent and it is most often lethal. Therefore, its consequences are not well known, more precisely its neurological consequences.

OBSERVATION

We report a case of Guillain-Barré-like syndrome and encephalopathy after acute arsenical poisoning in a 50 year-old man. After 4 month follow-up, the improvement was slow and limited with persistent motor and proprioceptive deficits.

DISCUSSION

The most frequent neurological complication induced by acute arsenical poisoning is a distal, symmetrical, sensory, axonal polyneuropathy. Yet the clinical course and the electrophysiological findings may also suggest a Guillain-Barré like syndrome. Moreover, the chelating is not very effective on the neurological complications.

CONCLUSION

Any discrepancies in the clinical course of a Guillain-Barré syndrome shall lead to reconsider the diagnosis. The association of gastro-intestinal disorders, skin lesions, and encephalopathy and mood disorders leads to discuss intoxication with heavy metal and more precisely with arsenic. Moreover, the chelating is not very effective on the neurological complications.

The place of perceptual analysis of dysarthria in the differential diagnosis of corticobasal degeneration and Parkinson's disease

OBJECTIVE

To characterize the dysarthria in patients with corticobasal degeneration (CBD) and determine if analysis of speech in isolation helps to distinguish CBD patients from patients with Parkinson's disease (PD).

METHODS

60 subjects were assessed by means of perceptual analysis of speech: 15 patients with CBD, 15 patients with PD and 30 control subjects. A detailed profile was furnished with the help of 33 perceptual items. A global perceptual approach was used to classify patients by judges blind to the medical diagnosis. Rating scales were adapted to quantify the degree of spasticity and hypokinesia in the speech of each patient.

RESULTS

Dysarthria was frequent in CBD even though it remained mild for a long period of time. Group analysis revealed the importance of temporal errors of speech control in CBD patients while voice disturbances were most frequent in PD patients. However, attempts to classify patients according to global perceptual analysis remained below a reasonable level of clinical acceptability. Finally, even though the widespread neuropathological changes suggest that deviant speech dimensions of several types of dysarthria might be found in CBD, evidence for a mixed dysarthria with presence of spastic elements could not be established.

CONCLUSION

The findings support the view that even though perceptual analysis is mandatory in the management of dysarthric patients, it does not help in the clinical differential diagnosis of CBD.

Effects of bilateral subthalamic stimulation on sleep in Parkinson's disease

OBJECTIVE

Sleep disturbances are frequently observed in Parkinson's disease (PD). Bilateral chronic subthalamic nucleus (STN) stimulation is an alternative treatment for advanced PD. Improvements in motor disturbances after STN stimulation are well documented and seem to be associated with better sleep quality, even though the objective effect on sleep structure remains unclear. We have therefore studied the sleep/wakefulness cycle before and after surgical treatment in 10 consecutive parkinsonian patients.

METHODS

Subjective sleep quality and sleep recordings were evaluated one month before and three months after initiation of STN stimulation. After surgery, the recordings were performed under two conditions: with stimulation (the "on" condition) and-if patients had given their consent-in the absence of stimulation (the "off" condition).

RESULTS

With STN stimulation, subjective and objective sleep qualities were improved. Total sleep time, sleep efficiency and the durations of deep slow wave sleep and paradoxical sleep increased significantly. When stimulation was absent, sleep disturbances were similar to those observed before surgery.

CONCLUSION

Chronic STN stimulation is associated with a sleep improvement, which can be explained in part by the concomitant decrease in motor disturbances but also by the reduction in dosages of antiparkinsonian medication. However, we can not exclude a direct effect of STN stimulation on sleep regulatory centres.

Heart rate variability and Parkinson's disease severity

Heart rate variability (HRV) decrease in Parkinson's disease (PD) could only be a consequence of reduce motor activity besides of being a marker of cardiovascular dysautonomia. Under continuously recorded and standardised motor activity, we studied thirty patients compared to controls in 3 PD stages: group I: less than 2 year-evolution, slight impaired without L-dopa; group II: mildly impaired with L-dopa; group III: advanced PD with motor complications. No difference was observed between group I and controls. The diurnal low frequency power (LF) and the ratio of LF/high frequency (HF) power decreased in groups II and III. The nocturnal vagal indicators: HF power and pNN50 were decreased in group III. Those parameters were correlated with Off-drug-motor handicap, suggesting an evolutive HRV decrease with disease severity but not with On-drug-motor activity. The low LF despite the higher motor activity in group III, due to dyskinesias, suggested a defective cardiovascular up-regulation.

[Postural strategies and falls in elderly and in parkinsonism]

OBJECTIVE

To use a posture analysis to show the evolution of postural pattern connected with falls.

MATERIAL AND METHOD

It is a prospective study on two groups of 16 persons of more than 60 years. A group concerns 16 small disability off drug parkinsonian patients, a group concerns 16 healthy witnesses. All the persons benefited from a posture recording by means of a force platform and were followed during 1 year.

RESULTS

Data analysis underlines three groups of persons corresponding to three postural patterns, independently of the presence of Parkinson disease. A group (n = 18) did not contain fallers, the second (n = 10 ) contained 20% of fallers, the third (n = 4) contained 100% of fallers. Differences between the groups were identified on 16 posturographic parameters.

DISCUSSION

A group has a good functional value and one does not record any fall. Its characteristics, which correspond to a category of persons who compensate well for the phenomena of ageing, are found in the literature. A group has an intermediate functional value and regrets 20% of fallers. Kinetic profile reveals a tendency to the stiffness of the posture. This group is going to operate rather ankle strategies. A group has an inferior functional value and regrets 100% of fallers. Kinetic profile seems disrupted and not to be able to adapt itself in a satisfactory way to the situation otherwise than by stereotypical reactions. This group is going to operate systematically much less stabilizing hip strategies.

CONCLUSION

A close determinism between physiological neuromotor ageing and Parkinson disease does exist. We showed with a prospective follow-up, the arisen of fall and showed the evolution of postural patterns related to fall. It appears as well that evolution mainly follows three stages leading from a small risk of fall gait pattern to a major risk of fall gait pattern.

Neural and cognitive bases of upper limb apraxia in corticobasal degeneration

OBJECTIVE

To investigate the neural and cognitive bases of upper limb apraxia in corticobasal degeneration (CBD).

METHODS

Eighteen patients with CBD underwent a cognitive neuropsychological assessment of apraxia and resting [(18)F]-fluorodeoxyglucose PET scanning. Two complementary measures of apraxia were computed for each modality of gesture production. First, a performance score measured error frequency during gesture execution. Second, as a more stringent test of the integrity of the praxis system, the correction score measured the patient's ability to correct his or her errors on a second attempt. For each measure type, a cut-off score for the presence of apraxia was defined with regard to healthy controls. Using each cut-off score, the regional cerebral glucose metabolism of patients with CBD with apraxia (i.e., performing below cut-off score) was compared with that of patients with CBD without apraxia.

RESULTS

Mean performance scores were below normal values in all modalities. Anterior cingulate hypometabolism predominated in patients with CBD who performed below the cut-off performance score. At variance, mean correction scores were below normal values for gesture imitation only. Hypometabolism in superior parietal lobule and supplementary motor area characterized patients with CBD who were unable to correct their errors at the same rate as control subjects did.

CONCLUSIONS

Distinct neural networks underlie distinct aspects of the upper limb apraxic deficits in CBD. Extending previous findings of gesture production deficits in CBD, the use of complementary measures of apraxic behavior discloses a visuoimitative upper limb apraxia in CBD, underlain by a metabolic decrease in a parietofrontal neural network.

[Cytomegalovirus rhombencephalomyelitis in an immunocompetent subject]

We report the clinical and MRI findings of a 31-year-old healthy immuno-competent patient who presented following 48 hours of diffuse headache with progressive and severe rhombencephalomyelitis signs. Cerebral and medullar MRI confirmed the central nervous system improvement. Serology showed relation with cytomegalovirus infection. Spontaneous improvement was observed and favoured by ganciclovir administration.

[Factors playing a role in the increase of localized perfusion observed by single-photon emission-computed tomography during an epileptic seizure]

Ictal SPECT is a valuable method for the presurgical exploration of partial epilepsy. (99m)Tc Ethyl Cysteinate Dimer stable during 6h has contributed to develop ictal studies to evaluate the location of partial seizure. The aim of this study was to investigate some factors playing a possible role on the regional increase of cerebral blood flow (rCBF) Twenty-three patients with refractory partial epilepsy (temporal epilepsy n=16, extratemporal epilepsy n=7) were included. All the patients underwent a presurgical evaluation (phase I) during a week with detailed clinical history, cranial magnetic resonance imaging, monitoring EEG and video. Ictal and interictal SPECT were performed using a fast rotating brain dedicated camera (TOMOMATIC 564) in a quiet and normally illuminated room with controlled EEG (interictal) or video EEG (ictal); Scanning was started one hour after injection of ECD Tc administered in IV a few seconds after the electrical onset seizure. Slices parallel to the long axis of the temporal lobe were reconstructed. SPECT images were evaluated after normalisation. This study shows that

Neuropsychological abnormalities in first degree relatives of patients with familial Parkinson's disease

OBJECTIVE

To investigate the cognitive profile of first degree relatives of patients with familial Parkinson's disease to determine whether these subjects presented signs of neuropsychological dysfunction compared with healthy controls. Results of recent genetic and neuroimaging studies suggest a genetic contribution to the aetiology of Parkinson's disease and underline the interest in identifying preclinical signs of the disease.

METHODS

A battery of tests evaluating executive function was administered to 41 first degree relatives of patients with well documented familial Parkinson's disease and 39 healthy controls. A factorial discriminant analysis allowed isolation of a subgroup of 15 first degree relatives who could be considered as impaired compared with the healthy controls. Among these 15 "deviant" relatives, nine performed globally worse than the control subjects on all tasks. The six other subjects had mean or even high scores on all task variables, except on those highly correlated with the discriminant score of the factorial discriminant analysis.

RESULTS AND CONCLUSION

Among the first degree relatives of patients with familial Parkinson's disease, some manifested executive dysfunction comparable with that typically associated with the disease. Such impairment could represent a preclinical form of Parkinson's disease.

Impairment of the supervisory attentional system in early untreated patients with Parkinson's disease

The aim of this study was to specify the frontal type dysfunction widely reported in Parkinson's disease (PD) early in the course of the disease and before dopaminergic therapy. Seventeen "de novo" PD patients and 17 healthy control subjects performed modified versions of the Stroop word-color test and the Brown Peterson paradigm. A dissociation between results on the two tasks was observed in PD patients. They had difficulties in inhibiting a strong habitual response and establishing a new, better adapted pattern of response; but they performed as well as controls in a dual-task paradigm requiring correct allocation of the processing resources of working memory. Early in the course of the disease, untreated PD patients suffer from dysfunction of the supervisory attentional system. However, the present findings suggest that this system is not a single unit but rather could be composed of multiple subsystems whose sensitivity depends on the origin of frontal dysfunction. Indeed, only a few of these subsystems seemed to be impaired in de novo PD patients. It can be hypothesized that those involved in the phenomena of adaptation and consolidation of currently appropriate responses depend on the dorsolateral prefrontal loop, which is affected by the dopaminergic innervation of the caudate nucleus.

Phacomatosis pigmentovascularis type II

Phacomatosis pigmentovascularis (PPV) is described as the association of cutaneous vascular malformations and different pigmentary disorders. The different associations are classified into four types, with localized and systemic forms. The constant alteration in each type is a nevus flammeus. Associated pigmented abnormalities are nevus pigmentosus and verrucosus in type I, blue spots in type II, nevus spilus in type III, blue spots and nevus spilus in type IV. Type II is the most frequently reported. In this type, half of the patients have visceral involvement, more often Klippel-Trenaunay or/and Sturge-Weber syndrome. We report two cases of phacomatosis pigmentovascularis type II. The particularity of the first case is the association with a cranio-cervical junction malformation (Arnold-Chiari type I), which to our knowledge, has never been described with PPV. The second case presents with a bilateral scleral melanosis without visceral involvement. Definition of visceral involvement and ophthalmologic manifestations are discussed.

Influence of chronic administration of L-DOPA on event-related desynchronization of mu rhythm preceding voluntary movement in Parkinson's disease

The spatiotemporal pattern of event-related desynchronization (ERD) during the motor preparation period preceding a self-paced voluntary wrist-flexion was compared in two groups of 10 right and 10 left hemiparkinsonian patients, before and after chronic administration of L-DOPA. ERD was computed in the 9-11 Hz frequency band from 11 source derivations covering the medial frontocentral, central and parietocentral areas, during two successive left and right experimental conditions (100 self-paced wrist flexions). In the two groups ERD appeared with a shorter latency over the contralateral primary sensorimotor area, when the movements were performed with the akinetic hand. After L-DOPA administration, earlier ERD onset before the movement was observed in both groups over the contralateral and ipsilateral central and parietocentral areas. A medial frontocentral ERD distribution was also observed before the onset of movement, especially in the right hemiparkinsonian group. Delayed ERD onset, which shows that programming of movement is affected in Parkinson's disease, may be partially corrected by L-DOPA therapy.

Hereditary chin trembling or hereditary chin myoclonus?

Hereditary chin trembling is a rare autosomal dominant disease often considered as an "essential tremor variant". The clinical and neurophysiological data obtained in a new white family lead to the suggestion that this abnormal involuntary movement is a focal variant of hereditary essential myoclonus.

Late onset familial dystonia: could mitochondrial deficits induce a diffuse lesioning process of the whole basal ganglia system?

BACKGROUND

Striatal necrosis has been related to various clinical syndromes, with acute or chronic progression, and juvenile or late occurrence, but the most common type is Leigh's encephalopathy.

METHODS

Between 1967 and 1995, six out of seven related patients with chronic familial dystonia were examined. MRIs were performed in four, between 1992-1994. The seven members, affected over three generations, were the father, three daughters (one surviving), and three surviving grandsons.

RESULTS

The leading symptoms were gait disorders and dystonia in all, dysarthria in six, verbal and motor stereotypies in two, and parkinsonian and cerebellar signs in three. Optic neuropathy was found in three. A frontal lobe syndrome without amnesia occurred in two. Symptoms occurred between the second and the fifth decade, with progressive deterioration. Magnetic resonance imaging, performed in four, showed in the two patients with severe neurological signs diffuse striatopallidal abnormal hyposignal (comparable with CSF signal) in T1 weighted images, suggesting extensive necrosis of the striatum and pallidum, associated with thalamo-subthalamo-rubro-dentato-nigral and substantia innominata hypersignals in T2 weighted images suggesting gliosis in these respective areas. The same images were described to a lesser extent in a third patient. Concentrations of lactate in CSF and serum were normal in three. Muscle biopsy, performed in four, was shown to be normal. Enzyme histochemistry showed complex I, III, and IV deficiency in surviving patients.

CONCLUSION

This familial dystonia of chronic progression may be related to basal ganglia necrosis or gliosis, associated with alterations in the respiratory chain. These metabolic alterations probably play a part in the pathophysiology of these unusual brain lesions.

Multiple calcified brain metastases revealing a lung carcinoma

The case of a 50-year-old man with multiple calcified brain metastases revealing an undifferentiated lung carcinoma after a delay of two months, is reported. A slow and progressive clinical evolution was noted. Eight months after the brain lesion had been discovered, intramedullary and epidural spinal metastases appeared. However, the calcified brain metastases remained stable 11 months after the diagnosis. One month later the patient died after several episodes of generalized seizures.

Sympathetic skin response and R-R interval variability in multiple system atrophy and idiopathic Parkinson's disease

We compared autonomic function in patients with multiple system atrophy (MSA) or with idiopathic Parkinson's disease (IPD) by measuring sympathetic skin response (SSR) and R-R interval variability (RRIV). SSR was investigated in 26 patients (13 with MSA and 13 patients with IPD). RRIV during deep breathing, Valsalva maneuver, and on standing was investigated in 20 patients (nine with MSA and 11 with IPD). MSA and IPD patients had similar age, illness duration, and therapy. Abnormal SSR was more frequent in MSA (69%) than in IPD (7.7%; x2, 10.4; p < 0.002). RRIV during deep breathing and the Valsalva maneuver was lower in MSA than in IPD (p = 0.02). RRIV during standing up was not significantly different in IPD and MSA. These differences between MSA and IPD may be due to more severe and widespread autonomic disturbance in MSA, related to more severe neuropathologic involvement of the autonomic nervous system. SSR and RRIV may aid in the differential diagnosis of parkinsonism and help to exclude from clinical trials MSA patients clinically misdiagnosed as having IPD.

Genetic polymorphism of cytochrome P450 2D6 in idiopathic Parkinson disease and diffuse Lewy body disease

We investigated genetic polymorphism of the cytochrome P450 CYP 2D6 gene in 105 caucasian patients with idiopathic Parkinson's disease (IPD) and 15 patients with diffuse Lewy body disease (DLBD). The mutations of the CYP 2D6 gene associated with the poor metabolizer (PM) phenotype of the debrisoquine/sparteine polymorphism were analyzed in DNA by a polymerase chain reaction (PCR)-based DNA amplification combined with Xba I restriction fragment length polymorphism (RFLP) analysis. The rate of genotypically defined PM and the frequencies of the mutation D6-B were not significantly different in IPD and DLBD patients. This study fails to find a relationship between CYP 2D6 impairment and neuropathological lesions diffusion in IPD and DLBD. This study cannot exclude involvement of neuronal expression of CYP 2D6.

[Acute catatonia and neuroleptic malignant syndrome. A case of infantile psychosis]

Similar clinical and biological features in lethal catatonia (LC) and neuroleptic malignant syndrome (NMS) suggest a relationship between both affections and common physiopathologic mechanisms. Pharmacological effects of several drugs--dopaminergic agonists, benzodiazepines, carbamazepine--suggest an impairment of several systems of neurotransmitters. We report the case of a young woman with infantile psychosis who developed catatonic syndrome worsened by neuroleptic treatment, arising the problem of the chronology of both affections. The evolution with treatment may partially explain the physiopathology. A 18-year old woman with an history of infantile psychosis, experienced insomnia, anorexia, paradoxical agitation developed after affective traumatism (mother's hospitalization). Chlorazepate (150 mg) remained inefficient and hospitalization was necessary. The patient was dumb, prostate in bed. She presented negativism, rigidity of the four limbs, catalepsia and hyperpyrexia (38.5 degrees C). Hepatic transaminases were increased (SGOT: 71 UI/l; N < 30). After cumulated dose of levomepromazine (100 mg) profuse sudation, thermic and cardiovascular instability, alteration of consciousness, major rigidity of limbs appeared. (Blood) hepatic transaminases and muscular enzymes increased. Bacteriological samples, cerebrospinal fluid analysis, CT-scan and EEG were normal. Within 48 hours after rehydratation and bromocriptine (30 mg per day) alteration of consciousness and autonomic disorders decreased but hyperpyrexia (38 degrees C) persisted. Biological parameters were normalized 10 days later. Negativism and psychomotor inertia remained. Lorazepam (3 mg per day) failed to be clinically beneficial. On carbamazepine (600 mg per day) she started speaking and moving spontaneously. Catalepsia disappeared but rigidity and anorexia persisted. Electroconvulsivotherapy (ECT) was necessary. After 2 shocks she started standing up, walking, taking food and speaking fluently.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of aging on the spatio-temporal pattern of event-related desynchronization during a voluntary movement

Event-related desynchronization (ERD) of alpha components was studied in young and elderly subjects during planning of voluntary movement. ERD was quantified from 11 source derivations covering regions of the scalp corresponding to the supplementary motor area, the left and right primary sensorimotor areas, the vertex, and the medial posterior parietal cortex. Spatio-temporal display of ERD showed a very different pattern in elderly subjects, with mainly a spatial diffusion of ERD over the parietal and frontal regions. On the contrary, ERD in young subjects was limited to the central regions. ERD was also more lasting in elderly subjects. Changes of the ERD pattern in elderly subjects could indicate a change of cortical activation during voluntary movement. The data also confirm that ERD study is a useful electrophysiological exploration to observe the changes of cortical activation during cerebral aging.

Bilateral metastases in the cerebellopontine angle

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Intradural herniated cervical disc associated with chiropractic spinal manipulation

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[Borrelian meningoencephalomyelitis. A case]

A 22-year old man had spastic paraparesis and cerebellar syndrome of 5 months duration. CSF showed lymphocytosis, elevated protein content, hypoglycorachia, hypochlorurachia and oligoclonal banding. CT scan and MRI were normal. Extensive laboratory procedures disclosed no bacterial, viral, fungic, parasitic or inflammatory disease. Anti-Borrelia burgdorferi antibodies were present in blood (1/4000) and in CSF (1/1024). With antibiotics (penicillin G 20 millions units per day for 10 days, followed by latamoxef 1.5 g per day for 3 months) and prednisone (50 mg per day for 2 months), the cerebellar signs disappeared, the paraparesis improved and the CSF abnormalities disappeared; blood and CSF anti-Borrelia antibody levels decreased. This case is an example of a severe form of CNS impairment by Borrelia burgdorferi. In Europe, most reports show progressive para- or tetraparesis with, sometimes, intellectual, cerebellar or cranial nerve impairment. In some cases, the signs are less diffuse or more acute. Lymphocytic meningitis is present with hyperalbuminorachia and oligoclonal banding; hypoglycorachia is mentioned in only one other report. Diagnosis is made by high blood and CSF antibody titers and demonstration of local synthesis. As in syphilis, borrelian meningoencephalomyelitis could be the third stage of the disease. Its treatment, often disappointing, consists of antibiotics (penicillin G or latamoxef) and in some cases corticosteroids.

Pigmentary type of orthochromatic leukodystrophy (OLD): a new case with ultrastructural and biochemical study

A 34-year-old woman with no family history of orthochromatic leukodystrophy (OLD) developed progressive intellectual deterioration, a frontal syndrome and spastic tetraparesis. She died four years after the onset of the clinical illness. Neuropathological studies included light and electron microscopy of cerebral and nerve biopsies, and a complete postmortem examination. Light microscopy demonstrated OLD with pigmented macrophages and glial cells. Electron microscopy showed electron-dense, membrane-bound intracytoplasmic lamellar inclusions with curved or straight parallel arrangement, or fingerprint pattern, in white matter macrophages, astrocytes and oligodendrocytes. Cortical cells contained lipofuscin which was normal in type and amount. This suggests that the material in white matter glial cells and macrophages is ceroid pigment, however, the distribution is not that seen in ceroid-lipofuscinosis. Similar inclusions have been found in oligodendrocytes in other forms of OLD. Biochemical study did not show evidence of demyelination. Galactolipids were normal. Polyunsaturated fatty acids were decreased. The most striking feature was an increase in plasmalogens.

[Computerized tomography of the distribution of N-isopropyl-p-123 iodoamphetamine in cerebrovascular pathology. Comparison with studies using the 133-xenon inhalation method]

123Iodo-Amphetamine (IAMP) brain distribution was studied with a specially dedicated multilevel tomographic system in 30 patients with vascular ischemic (18) or hemorrhagic (12) disorders. Results were compared with clinical data, CT scan and rCBF measurement obtained by the 133Xe continuous inhalation method. Abnormalities with IAMP were found in 27 cases, in good agreement with the results obtained by the Xenon inhalation technique in 21 studies from the 22 where that method was possible. For 80% cases there was also a good agreement between the results obtained by the IAMP and CT scan: one case normal, and 23 observations with abnormalities. This is true for the localization of lesions, but IAMP appears able to shown remote abnormalities, i.e. crossed cerebellar diaschisis or functional deactivation, in the absence of CT scan lesions in the corresponding areas. This is of particular interest in the protracted regressive ischemic neurologic disorders (PRIND): CT scan were normal in all five observations but IAMP showed abnormalities in four cases. IAMP is however very expensive, so it has to be used only when 133Xe inhalation is technically impossible.

Lateral gaze disturbance in a case of Wallenberg's syndrome

A 63-year-old Caucasian man was admitted for Wallenberg's syndrome following a left vertebral artery thrombosis. In addition to the classical symptoms, an axial lateropulsion to the left and ocular motor disorders (vertical diplopia, tonic deviation of the gaze to the left, skew deviation and horizonto-rotatory nystagmus) were present. These clinical signs are unusual, but in common Wallenberg's syndrome, neurophysiological tests often reveal slight abnormalities of oculomotor function: impairment of jerks, skew deviation, lateral deviation of the gaze in darkness. Interruption of cerebellar pathways is thought to be the cause of these symptoms. Their existence does not seem to change the outcome of these cases.

Management of subdural intracranial empyemas should not always require surgery

Seven patients with subdural empyema were initially treated by antibiotics without surgery. Six have recovered without sequelae. One required delayed surgery and has recovered with epilepsy. The authors emphasise the use of CT for the diagnosis and follow-up of subdural empyema, the principles and modalities of non-surgical treatment, and the good results, especially for late morbidity.