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11/127. Isolated cerebellar edema and obstructive hydrocephalus in a child with cerebral malaria.

    An important complication of cerebral malaria is increased intracranial pressure which, when severe, is associated with high mortality or neurologic sequelae. We describe a 7-month-old child with cerebral malaria for whom cerebellar edema and obstructive hydrocephalus were initial radiologic findings. Despite significant hydrocephalus, the child had normal intracranial pressure during the course of the infection, and he recovered with minimal sequelae. ( info)

12/127. Cystic cavum veli interpositi associated with normal or low pressure hydrocephalus.

    A new clinical syndrome, characterized by progressive increase in head size (without intracranial hypertension), variable delay in milestones, moderate ventricular dilation, and the presence of a cavum veli interpositi is herein described. The arteriographic and venographic signs are suggestive, but not diagnostic, of the presence of a cavum veli interpositi. pneumoencephalography, with adequate filling of the subarachnoid spaces and ventricles, is essential to confirming the diagnosis. Cerebrospinal fluid shunting appears to result in an improvement, but the results cannot as yet be considered definitive since only 10 of our 29 patients were shunted. ( info)

13/127. dementia in the elderly--a search for treatable illnesses.

    Forty patients with senile dementia were evaluated prospectively with laboratory and radiologic investigations, including computerized axial transverse tomography. Five patients were believed to have potentially treatable illnesses causing the dementia. After treatment, the dementia in one patient with hypothyroidism was completely resolved. One patient with pernicious anemia was markedly improved, and a second patient with hypothyroidism was somewhat improved. One patient with a brain tumor was not treated, and a severely demented patient with possible normal pressure hydrocephalus died shortly after shunting without improvement. The discovery of these unsuspected illnesses and the gratifying response to treatment in some suggests the importance of systematic evaluation in all patients with senile dementia. ( info)

14/127. Unusual arachnoid cyst of the quadrigeminal cistern in an adult presenting with apneic spells and normal pressure hydrocephalus--case report.

    A 67-year-old woman was admitted to our clinic with symptoms of normal pressure hydrocephalus, lower cranial nerve pareses, and pyramidal and cerebellar signs associated with respiratory disturbances. Computed tomography (CT) and magnetic resonance imaging revealed a 4.7 x 5.4 cm quadrigeminal arachnoid cyst causing severe compression of the tectum and entire brain stem, aqueduct, and cerebellum, associated with moderate dilation of the third and lateral ventricles. Emergency surgery was undertaken due to sudden loss of consciousness and impaired breathing. The cyst was totally removed by midline suboccipital craniotomy in the prone position. Postoperatively, her symptoms improved except for the ataxia and impaired breathing. She was monitored cautiously for over 15 days. CT at discharge on the 18th postoperative day revealed decreased cyst size to 3.9 x 4.1 cm. Histological examination confirmed the diagnosis of the arachnoid cyst of the quadrigeminal cistern. The patient died of respiratory problems on the 5th day after discharge. Quadrigeminal arachnoid cysts may compress the brain stem and cause severe respiratory disturbances, which can be fatal due to apneic spells. patients should be monitored continuously in the preoperative and postoperative period until the restoration of autonomous ventilation is achieved. ( info)

15/127. Reversal of normal pressure hydrocephalus symptoms by subdural collections.

    BACKGROUND: The pathogenesis of symptoms in normal pressure hydrocephalus (NPH) is unclear. One theory is that in the presence of enlarged lateral ventricles, the ventricular fluid exerts increased force on the ventricular walls, the cerebrospinal fluid pressure remaining normal. This is in accordance with Pascal's principle of F = PxA. It has not been possible to obtain direct evidence for this view. METHOD: The opportunity to gain insight into the matter arose when it was observed that two patients with symptomatic NPH were relieved of their symptoms when they developed bilateral subdural collections, one after head trauma, the other after ventriculo-peritoneal shunting for NPH. RESULT: In each case, concomitant with the subdural collections and the reversal of symptoms, the ventricular system became smaller. In the first patient, symptoms returned when the subdural collections were resorbed. In the second patient, symptoms returned when the subdural collections became excessive. CONCLUSION: Although documentation was less thorough than desired, it was concluded that relief of symptoms was related to the decrease in the ventricular size rather than lowering of the intraventricular pressure, thus providing evidence for operation of the principle F = PxA as the mechanism of symptoms in NPH. ( info)

16/127. Occurrence of subdural hematoma and resolution of gait disturbance in a patient treated with shunting for normal pressure hydrocephalus.

    A 66-year-old man with gait disturbance was diagnosed with normal pressure hydrocephalus (NPH) and treated with ventriculoperitoneal shunting using a programmable valve. The valve ultimately set at a pressure of 40 mm H(2)O after higher settings no longer relieved symptoms. However, this pressure setting was excessively low and was associated with occurrence of bilateral subdural hematomas. Paradoxically, this event was associated with stable improvement of gait. Our patient's gait disturbance was unassociated with muscle weakness, spasticity, cerebellar ataxia, or Romberg's sign, and, therefore, was consistent with a frontal gait disorder. Cerebral cortical blood flow as measured after shunting by single photon emission computed tomography (SPECT) was slightly increased from the value before shunting, possibly because of intracranial hypotension related to the valve setting. Lasting improvement of gait in our case may be a result of increased blood flow in the supplementary motor area (SMA). ( info)

17/127. intracranial pressure in adult non-tumoral hydrocephalus.

    intracranial pressure (ICP) was monitored continuously for 48 hours in four patients with different types of non-tumoral adult hydrocephalus and classificated according to ICP recordings. It is emphasized that ICP monitoring is essential in the diagnosis of normal pressure hydrocephalus (NPH), since its possible to observe abnormal pressure recordings with morphological alterations which can be accompanied or not by periods of raised ICP. It is suggested that this method may help identify cases suitable for surgery. ( info)

18/127. Evidence of subnormal function of association cortex in presenile dementia.

    Regional cerebral blood flow (rCBF) was measured in 23 patients with organic dementia (17 patients with Alzheimer's disease and six with low-pressure hydrocephalus [LPH]). The flow of gray matter was significantly reduced, especially in occipito-parieto-temporal regions, as well as frontally in some patients. During activation with psychologic tests, reading, etc., the flow augmentation in the association areas in the demented patients was not as marked as in nondemented controls. Instead, in some patients, a flow diminution was recorded in the same regions (intellectual steal). Organic dementia appears to be accompanied by a low activity in the association cortex and a reduced ability to activate these regions during mental effort. ( info)

19/127. Acute subdural hematoma after lumboperitoneal shunt placement in patients with normal pressure hydrocephalus.

    Acute subdural hematoma (SDH) is a rare but disastrous complication after lumboperitoneal shunt placement. Four of 206 adult patients with normal pressure hydrocephalus (1.9%) who underwent lumboperitoneal shunt placement suffered acute SDH following head trauma. The interval between shunt placement and acute SDH was one month to 7 years. Two patients had subdural effusion on computed tomography (CT) at 2- and 6-month follow up. All four patients required assistance in their daily activities before acute SDH onset. The traumatic event was a fall. On admission, CT revealed a large SDH that required surgical removal in two patients, of whom one had manifested subdural effusion after shunt placement. The other two patients had a small SDH. None of the four patients had cerebral contusions. patients with lumboperitoneal shunts, especially those not capable of independent daily activities, are at risk for acute SDH after even minor head trauma. ( info)

20/127. Normal-pressure hydrocephalus due to tentorial meningioma.

    Normal-pressure hydrocephalus and the associated triad of dementia, apraxic gait and urinary incontinence may be casued by various, sometimes unsuspected, lesions, usually those that block the flow of cerebrospinal fluid (CSF) around the tentorium. A 58-year-old woman with insidious onset of behaviour and gait problems had occult, normal-pressure hydrocephalus and a tentorial meningioma, resection of which produced complete recovery. This case demonstrates that a distinction must be made between the syndrome of normal-pressure hydrocephalus resulting from disturbance in CSF dynamics and the pathophysiologic features of the underlying lesion. ( info)
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