Capgras' syndrome following minor head trauma

Capgras' syndrome, the delusion of substitution, has been reported in the setting of many different underlying functional and organic conditions. Only two cases of the syndrome following major head trauma have been reported. The authors present the first reported case of Capgras' syndrome following minor head trauma in an elderly woman.     

Isolated unilateral hypoglossal nerve palsy after minor head trauma

Isolated unilateral hypoglossal nerve palsy after fracture of the occipital condyle is rare. It usually occurs after major trauma, such as high-speed deceleration injuries following road traffic accidents. We describe a case that resulted from minor trauma. An underlying skull base malformation may have been a predisposing factor.     

Transient exacerbation of hemiplegia following minor head trauma in Sturge-Weber syndrome

Sturge-Weber syndrome (SWS) is a sporadic disorder characterized by naevus (port wine stain), a pial angioma, and glaucoma. The angioma comprises abnormal tortuous vessels on the leptomeninges with underlying brain gliosis, calcification, and atrophy. The cerebral angioma is commonly unilateral but may be bilateral. Hemiplegia usually follows recurrent hemiconvulsions and may be related to venous stasis. The hemiplegia can be static, progressive, or fluctuating. Transient worsening of the hemiplegia can be seen with seizures and episodes resembling hemiplegic migraine. We report five patients (four females, one male) with SWS who have had transient worsening of hemiplegia following minor head injuries, occurring between the ages of 10 months and 12 years (median age 4y 6mo). An additional pilot survey suggests that this may affect up to 20% of patients.     

Rapid neurological deterioration associated with minor head trauma in chronic hydrocephalus

CASE REPORT: An 8-year-old developmentally normal boy (status: post third ventriculostomy and resection of posterior fossa low-grade glioma 4 years earlier and with known history of ventriculomegaly/arrested hydrocephalus) presented to the emergency room with vomiting and lethargy after a minor head trauma. Computed tomography scan of the head revealed no acute changes since previous studies. However, the patient's neurological status rapidly declined in the emergency room, where an emergency ventriculostomy demonstrated increased intracranial pressure. The patient's clinical condition improved over 24 h: he underwent placement of a ventriculoperitoneal shunt without complications and was discharged intact. DISCUSSION: The pathogenesis of rapid neurological decline associated with minor head trauma in chronic hydrocephalus is reviewed.     

Postural function in idiopathic normal pressure hydrocephalus before and after shunt surgery: A controlled study using computerized dynamic posturography (EquiTest)

Introduction

Postural dysfunction is one of the major features of idiopathic normal pressure hydrocephalus (iNPH). With computerized dynamic posturography (CDP) balance can be assessed objectively. The primary aim of this study was to describe the postural function in iNPH patients pre- and post-operatively in comparison with healthy individuals (HI) using CDP.

Subjects and methods

Thirty-five patients (16 M, 19 F) with a mean age of 73 (range 49–81) with iNPH, and sixteen HI (7 M, 9 F) aged 73 (62–89) were included. iNPH patients were operated on with a ventriculo-peritoneal shunt. Patients and HI were tested regarding motor function, balance and cognition. CDP, EquiTest (NeuroCom International, Clackamas, OR), was performed before and three months after shunt surgery and twice in HI, with a three-month interval.

Results

Pre-operatively, the 35 patients had poorer balance measured with the Sensory Organizing Test (SOT) score in every condition (p = 0.01 in SOT 1 and p < 0.001 in SOT 2–6) compared to the HI. The greatest difference was in test conditions measuring mainly vestibular function, where loss of balance (LOB) was frequent. Twenty patients were evaluated three months after shunt surgery and 18/20 (90%) of them were considered shunt responders, with a mean improvement of motor score of 26% (range 5–67%). There was an improvement post-operatively in the weighted composite SOT score (p < 0.05) but no significant change in any of the SOT conditions. LOB was not significantly reduced in any of the test conditions.

Conclusion

CDP showed that the patients had a poorer balance than the HI. The greatest difference was in SOT 5–6, indicating that the postural disturbance is of primarily central vestibular origin. There was a slight improvement of balance post-operatively.     

Non-target visual event-related potentials in evaluation of children with minor head trauma

In 50 children, 4 months to 12 years of age, with minor head trauma non-target visual event-related potentials were performed and compared to a second registration of the potentials some months later. On following-up there was a clear tendency for a relative improvement of the latencies of the endogenous potentials. In this way non-target visual event-related potentials proved to be of value in the investigation of mental impairment in early childhood.     

Effect of tetrabenazine on computerized dynamic posturography in Huntington disease patients

BackgroundImpairment in computerized dynamic posturography scores has been documented in Huntington disease patients. Tetrabenazine is approved to treat chorea in Huntington disease, but its effect on posturography scores, and balance in general, is unknown.Materials and methodsWe designed a study to test computerized dynamic posturography performance while taking tetrabenazine and after stopping tetrabenazine for at least three days.Results10 Huntington disease patients were studied both ON and OFF tetrabenazine. The composite score was statistically different between ON and OFF conditions and both conditions were significantly worse than reference scores. There was no significant difference between ON and OFF trials in the number of falls. A significant improvement on Sensory Orientation Test conditions 3 (sway-referenced vision) and 5 (sway-referenced motion of the support surface and eyes closed) was seen while ON tetrabenazine. Strategy scores 1–3 were also significantly different while ON tetrabenazine.ConclusionThese findings suggest that tetrabenazine aided patients in gating out of abnormal visual cues when other sensory modalities were available, as well as in gating out abnormal kinesthetic cues when visual cues were not available. It could not help with gating out of simultaneous abnormal visual and somatosensory cues. Thus, tetrabenazine can improve postural stability when one sensory modality is irrelevant, but this effect is not sustained when multiple abnormal sensory modalities are present. This is the first study supporting the use of any medicine to treat balance problems in Huntington disease.     

Tonsillar contusion associated with benign tonsillar ectopia following minor head trauma

Purpose

The relationship between tonsil position and symptomatic cerebellar contusion is unclear. To date, there are no reports of symptomatic traumatic brain injury associated with benign tonsillar ectopia. Reported cases are limited to prominent cerebellar tonsillar displacement by ≥5 mm (i.e., Chiari malformations).

Methods

The authors describe a case of symptomatic concussion in a toddler with unusual computerized tomography (CT) presentation and incidental finding of benign tonsillar ectopia, hemorrhagic contusion of the tonsils, blood-brain barrier (BBB) disruption and delayed atrophy shown using magnetic resonance imaging (MRI) studies. The radiological presentation and the clinical challenges are discussed through a review of the literature.

Conclusion

This case suggests that damage to cerebellar structures is not limited only to overt tonsillar herniation. Benign tonsillar ectopia may predispose to cerebellar contusion even after minor concussion and thus has a clinical significance. The current paradigm viewing only noticeable tonsillar herniation as a risk factor for hindbrain injury should be revisited.

     

EEG findings in minor head trauma as a clue for indication to CT scan

In order to investigate the role of EEG in minor head traumata in the pediatric age, EEG and CT scan findings were compared in a series of 103 consecutive cases of children hospitalized within 24 h after head trauma. The EEGs were classified as normal in 50 patients, borderline in 10 patients, and abnormal in 43 patients. CT scan showed contusion in 6 patients and extracerebral hematoma in 4. All cases of abnormal CT scans were reported for patients with frankly abnormal EEG findings. In contrast, no pathological findings were found in CT scans for patients with normal EEG. The data suggest that EEG findings can play a major role in the diagnostic workup of patients with minor head traumata. Specifically, in the case of asymptomatic patients with normal EEG findings, it is likely that the CT scan will also be normal.Presented at the 11th Meeting of the European Society for Paediatric Neurosurgery, Naples 1988     

Delayed rupture of pre-existing cerebral aneurysm in a young patient with minor head trauma.

An intracranial saccular aneurysm is not commonly diagnosed in a patient with head injury. We present a patient with a history of minor head trauma and a CT scan of the brain revealing minimal subarachnoid hemorrhage 17 days prior to admission, complaining of severe headache, dysarthria and focal right limb seizures 3 hours prior to admission. A traumatic aneurysm was suspected based on clinical history and radiological findings including hematoma in the falx region on a CT scan of the brain and an aneurysm of the pericallosal artery on magnetic resonance angiography and four-vessel cerebral angiography. However, at craniotomy, an intracranial non-traumatic saccular aneurysm at the bifurcation of the pericallosal artery was found. The patient recovered fully after successful clipping the aneurysm.     

Delayed symptoms and death after minor head trauma with occult vertebral artery injury.

Head injury without loss of consciousness is seldom accompanied by grave complications. We report the case of an 18 year old cyclist who was struck by a car in a minor road traffic accident, suffered minor head injury without loss of consciousness, and died unexpectedly seven weeks later with vomiting and coma. Necropsy revealed an expanding cerebellar infarct and vertebral artery thrombosis, superimposed on an old dissecting intramural haematoma of the right vertebral artery in the atlantoaxial region. Vertebrobasilar occlusion after minor head trauma, hyperextending or rotating neck injury, or neck manipulation is commonest in young people. Occult ligamentous injury to the cervical spine after trauma may be a contributing factor to the pathogenesis of vertebral artery damage after injury to the neck.     

Cortical hyperexcitability in post-traumatic stress disorder secondary to minor accidental head trauma: a neurophysiologic study

OBJECTIVE: We applied paired transcranial magnetic stimulation (pTMS) to patients with post-traumatic stress disorder (PTSD) secondary to minor accidental head trauma. Our purpose was to determine the potential abnormality of motor cortex excitability in this pathologic condition. METHODS: pTMS stimulation, according to the conditioning-test paradigm employing interstimulus intervals (ISIs) of 1-6 ms, was used to investigate intracortical inhibition in control subjects and patients with PTSD. The study population consisted of 14 patients who had developed PTSD following minor head trauma, 12 healthy volunteers without a clinical history of head trauma and 11 healthy subjects who had reported accidental minor head trauma 1-4 months before the study. This clinical electrophysiologic study was performed at the Department of Neuroscience, University of Rome "Tor Vergata." RESULTS: All patients with PTSD exhibited a significantly lower motor evoked potential (MEP) inhibition than controls at 2 ms, 3 ms and 4 ms ISI. The statistical analysis of the pTMS protocol showed a significant effect (F2,36 = 25.63, p < 0.001) of the factor "group," because patients with PTSD showed a mean conditioned MEP amplitude higher than that observed in both control groups for all 6 ISIs analyzed. The "ISI" factor was also significant (F5,180 = 89.85, Greenhouse-Geisser epsilon = 0.35; p < 0.001), with the mean conditioned MEP amplitude increasing from 22.5% to 127.8% as the ISI increased from 1 ms to 6 ms. Finally, the interaction of group with ISI was also significant (F10,180 = 8.97, p < 0.001), showing that the condition of PTSD secondary to head trauma was able to affect the MEP amplitude at different ISIs. CONCLUSIONS: Our results demonstrate that PTSD can give rise to abnormalities in intracortical inhibition. Our results provide further evidence that alterations in cortical inhibitory circuits may underlie specific forms of neuroticism in humans.     

A practical method for the evaluation of symptom exaggeration in minor head trauma among civil litigants

Forensic psychiatrists and psychologists are often called on to provide opinions and render testimony in which minor head trauma accompanied by persistent somatic, cognitive, and/or emotional symptoms is alleged. The frequency of persistent symptoms following such minor head injury is generally low. The forensic clinician therefore must differentiate between subtle brain dysfunction, symptom amplification, psychogenic-based causes for the presence of cognitive and other deficits, or frank malingering. The purpose of this article is twofold: first, to review critical issues related to the assessment of malingering and symptom exaggeration in mild head injury cases; and second, to offer a practical model for the assessment of amplified neuropsychological and psychiatric deficits in civil litigants in cases of minor head trauma.     

Electroencephalography in minor head injury in children

EEG and CT scans of 280 cases of minor head injury in children under 15 years of age were studied. Abnormality on initial EEG was shown in 42.5%. Those who lost consciousness had a higher incidence of abnormality than those who did not, and it was higher between 4 and 13 years of age. The sleep state has much influence on the finding. The patients should be awake or in a light sleep stage. The most frequent abnormality was slow waves, seen predominantly in the occipital regions, and which tended to disappear more easily than the paroxysmal ones. The EEGs became or remained normal in 95%, excluding incompletely followed-up cases. There was no case of post-traumatic epilepsy in our series, but 4 cases of post-traumatic early convulsions, in which the EEGs were variable. CT scan disclosed abnormality in 6%.     

Postural stability in patients with Huntington's disease.

We characterized postural stability in patients with Huntington's disease (HD) by examining their ability to use different sensory cues to maintain balance and by recording their automatic postural responses to externally applied perturbations. Our HD patients, like normal subjects, depended more on proprioceptive than on visual cues to maintain balance. HD patients, however, developed more sway than normal subjects when proprioceptive cues, or when proprioceptive cues and vision, were altered. Thus, HD patients showed a defect in using vestibular information alone to maintain normal postural stability. The onset of compensatory motor responses in the lower extremities following sudden translations of the support surface was delayed by 30 to 60 msec in HD patients as compared with normal subjects. HD patients also had more sway and falls during unexpected rotations of the support surface, although they could appropriately reduce their motor responses on the next trial.     

Postural stability of Parkinson''s disease patients is improved by decreasing rigidity

Postural instability has a big impact on the quality of life of patients with Parkinson's disease (PD) as it often leads to an insecure stance and fall. We investigated if postural stability in these patients improves by decreasing rigidity with a dopaminergic agonist. In our study, we tested eight PD patients with no concomitant diseases. Their age was 61 +/- 2 years (mean +/- SE) and their Hoehn-Yahr score was 3 +/- 0.1. The patients were evaluated according to the Unified Parkinson's Disease Rating Scale for motor function (mUPDRS) and with stabilometric measurements of forward-backward and side-to-side body oscillations during free stance with eyes open. Both evaluations were performed in an "off "state and in an apomorphine-induced "on" state. As expected, the mUPDRS score was significantly decreased in the "on" state with posture being improved in six patients, gait in eight patients and postural stability in seven of eight patients. In addition, apomorphine caused a significant reduction of the relative amplitude of lower frequencies and an increase of the relative amplitude of higher frequencies of forward-backward body oscillations. The results of stabilometry and mUPDRS evaluations are in agreement with the effect of apomorphine on rigidity, indicating that postural stability of PD patients is improved by decreasing rigidity.