A case of intrasellar craniopharyngioma with the symptoms of pituitary apoplexy]

Craniopharyngiomas account approximately for 2.5% of all intracranial neoplasms. They statistically most often arise in Japanese people (8%) and in children (9%). Despite their typical localization in suprasellar region and their close neighbourhood, 10-20% of them occupy intrasellar space, but only very few grow up as intrasellar cysts. Such localization predisposes to hypothalamus-pituitary-axis dysfunction more often, than other localizations. The symptoms of pituitary apoplexy caused by sudden, intrinsic haemorrhage of intrasellar craniopharyngioma are very rare, because the tumour grows very slowly and its vascular supply is usually poor. A very rare localization, extremely atypical course of disease, interesting intraoperative observations and good results of transsphenoidal tumour removal prompted the authors to present this case report.     

A case of Meige's syndrome associated with post head trauma]

The pathogenesis of Meige's syndrome (MS) is controversial and has yet to be determined up to today. We studied a case of MS associated with post head trauma. The patient was a 52-year-old female. At the age of 46, she began to suffer from oro-lingual dystonia after head trauma induced by a traffic accident and the brief administration of neuroleptics to the delusion deteriorated the dystonia. She showed a wry appearance after 1 year and 6 months of the trauma and began to exhibit blepharospasms, oro-mandibular dystonia and cervical dystonia after 2 years and 3 months. For these symptoms her daily life became difficult. These symptoms were resistant to various drug therapies, although trihexyphenidyl relieved the symptoms transiently. Laboratory examinations and cranial MRI findings were normal. By surface electromyogram of ocular orbicular muscles, bilateral continuous discharge was observed. This patient was diagnosed as MS by clinical symptoms and surface electromyogram findings. It was inferred that the head trauma was associated with the development of MS. We discussed the pathogenesis of MS in the present case and it was speculated that MS was presented by a minute lesion of the brain stem which was produced at the time of the head trauma.     

Purkinje cell vulnerability to mild and severe forebrain head trauma

Pathophysiological changes in the cortex, thalamus, and hippocampus have been implicated as contributors to motor and cognitive deficits in a number of animal models of traumatic brain injury (TBI). Indirect cerebellar injury may contribute to TBI pathophysiology because impairment of motor function and coordination are common consequences of TBI, but are also domains associated with cerebellar function. However, there is a lack of direct evidence to support this claim. Hence, in this study, a dose-response relationship of the cerebellum's susceptibility was determined at four grades of fluid percussion injury (1.5, 2.0, 2.5, and 3.0 atm) applied in the right lateral cerebral cortex of adult male Sprague-Dawley rats. Evidence suggests primary and secondary injury mechanisms resulting in selective cerebellar Purkinje neuron (PN) loss, whereas interneurons of the molecular layer were spared. The posterior region of the cerebellar vermis displayed significant PN loss (p = 0.001) at 1 day postinjury, whereas the gyrus of the horizontal fissure and gyrus of lobules III and IV exhibited delayed PN loss at higher levels of injury severity. Interestingly, neither terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling (TUNEL) or cleaved caspase-3 colocalized with PNs at any time point or injury severity. Expression of calbindin-28k increased in regions of greatest PN loss, suggesting that the surviving PNs possess higher calcium-buffering capacities, which may account for their survival.     

So-called mirror injuries in severe head trauma]

Severe head traumas cause high mortality. It was the reason to analyze such a group of patients, treated in the Neurosurgical Department of the CCH MMA in the years 1980-1990. All cases of mirror injuries were divided into three groups. The lesions of frontal and temporal lobes present brain-stem lesion like syndromes. Personality disorders were associated with lesions of both frontal lobes. The third syndrome is caused by focal lesions according to their location. The authors discuss medical and surgical treatment and stress the importance of early brain protection.     

Assessment of endocrine functions in children following severe head trauma

The goal of the present study was to assess endocrine functions in children following severe head trauma. Subjects included 21 children between the ages of 3 years and 18 years 6 months, referred to the Pediatric Rehabilitation Unit at Sheba Medical Center, Israel, between 1984 and 1995. Each was examined 4 months to 11 years following the first admission, undergoing a complete physical examination, including neurologic assessment, biochemical and baseline endocrine profiles, and bone age determination. A GnRH stimulation test was performed in prepubescent children who had advanced bone age. Sixteen children had experienced the head trauma before, or at onset of puberty, according to their chronologic ages. Two children had completed puberty before the head trauma. A 12-year-old male who sustained head trauma at 10 years 6 months of age was found to have Tanner grade 3 pubertal stage and advanced bone age. In addition, 3 prepubescent children also had advanced bone age with no other signs of precocious puberty and a normal GnRH test. For all children studied, the biochemical and hormonal laboratory measurements were in the normal range. Endocrine abnormalities were not found in children examined 4 months or more following severe head trauma. We conclude that clinical monitoring of endocrine status after severe head trauma is sufficient; specific hormonal measurements are not required unless warranted by abnormal physical signs.     

A case of hematoma in cisterna magna after mild head injury]

An 18-year-old man suffered severe neck pain, signs of meningeal irritation, and dysesthesia of his left breast and left arm after mild head injury incurred in a traffic accident. On the next day, magnetic resonance imaging(MRI) revealed a hematoma in the cisterna magna, and it extended into the posterior spinal subdural space. Eight days after admission, MRI demonstrated the hematoma on the right posterior aspect of the spinal cord at the level of craniovertebral junction. These MRI findings suggested a ruptured bridging dorsal vein from the spinal cord to the occipital or marginal sinus. The usefulness of MRI for diagnosis of localized hematoma around the craniovertebral junction and the mechanism of this hemorrhage are discussed.     

Multiple sclerosis with consciousness disturbance: a case report

We report here a nine-year-old girl with multiple sclerosis having consciousness disturbance at admission. Neurological examination revealed drowsiness, unstable emotion, decreased visual acuity, disturbance of convergence, and clumsy coordination movements. Her cerebrospinal fluid IgG and myelin basic protein were increased. Electroencephalogram showed intermittent, high voltage slow waves predominant in the frontal lobes. Magnetic resonance imaging (MRI) found multiple demyelinating plaques in the brainstem, thalamus, periventricular white matter. The brainstem reticular formation was involved. Since she had had bilateral acute optic neuritis and papillitis two years before the admission, the diagnosis of multiple sclerosis was made. Methylprednisolone pulse therapy improved her neurological symptoms and MRI findings. Multiple sclerosis in children, unlike that in adults, may present with symptoms mimicking an encephalopathy. Our case suggested that consciousness disturbance in childhood multiple sclerosis results from lesions in the brainstem activating reticular formation including the thalamus.     

Speech disturbance following myelography with iohexol: a case report]

Iohexol (Omnipaque) is a non-ionic contrast media for neuroradiology, which causes the neurological complications on rare occasions. A 63-year-old, righthanded female suffered from dysphemia 12 hours after myelography with iohexol via lumbar puncture. The initial cerebral computed tomography scan revealed the generalized contrast media uptake into the cisterns, which was typical to the finding after intrathecal iohexol injection. Although the cerebral magnetic resonance (MR) imaging 7 days after attack also demonstrated no abnormal finding, the electrical encephalogram revealed the sporadic sharp wave activity. Her nonfluent speech deficit had recovered gradually, however, the neurogenic stuttering was still remained. Some literatures previously reported the cases with speech deficits as complications of metrizamide myelography, whereas, a case manifesting as speech disturbance following myelography with iohexol has been not reported. Metrizamide is also a non-ionic agent and had a lower incidence of speech disturbance, which is supposed to be associated with a focal superficial neurotoxic reaction of the cerebrum. Therefore, our unfortunate case suggests that iohexol could rarely cause speech disturbance such as metrizamide.     

Assessment of regional blood flow in patients after mild head trauma]

Single photon emission computerized tomography (SPECT) using radioisotope markers was applied for analysis of regional blood flow in the brain. The method makes possible demonstration of the presence and extent of damage to the nervous tissue caused by trauma. The degree of blood flow impairment is of prognostic significance in cases of cerebral concussion. In the present study the regional brain blood flow was assessed shortly after trauma and one year in cases of mild cerebral concussion. In the studied group immediately after trauma blood flow impairment was found mostly in the left temporal area and in frontal areas. Changes of rCBI were present also late after trauma. In 7 out of 16 cases SPECT image failed to change one year after trauma. In 8 cases the rCB improved up to normalization. In 1 case the changes progressed, in another case hyperperfusion focus changed to hypoperfusion. In 2 cases the pattern was normal early and lata after trauma. In the studied group in cases with changed rCBF no changes were found in CT and MRI examinations. This evidence a greater sensitivity and usefulness of SPECT in the assessment of early and late consequences of head trauma.     

A case of subarachnoid hemorrhage with pituitary apoplexy caused by idiopathic hypertrophic pachymeningitis

Steroid therapy is considered to improve clinical symptoms in hypertrophic pachymeningitis. We present a 70-year-old man with idiopathic hypertrophic pachymeningitis, whose clinical signs progressively worsened despite steroid therapy. He died of subarachnoid hemorrhage (SAH) with pituitary apoplexy 2 months after the admission regardless of improvement of laboratory data and magnetic resonance imaging appearance by one-and-half-month steroid therapy. Autopsy revealed thickened dura mater supporting the diagnosis of hypertrophic pachymeningitis. Brain parenchyma is generally not affected by the disease; however, histological investigation suggested that inflammation of the dura caused damage to superior hypophyseal artery resulting in SAH and apoplexy in the anterior lobe of the pituitary gland. The higher dose and the longer duration of steroid therapy should have achieved in our case although most laboratory data recovered within the normal range. The aggressiveness of hypertrophic pachymeningitis must be evaluated by clinical signs rather than by laboratory data or imaging examinations.     

Multiple cerebral white matter lesions following head trauma with eyeball contusion]

We reported a 36-year-old man with multiple cerebral white matter lesions following head trauma with eyeball contusion. He had suffered from optic neuritis on non-injured side after one and half months from the head trauma. Brain MRI revealed multiple cerebral white matter lesions and lumbar puncture disclosed an elevated level of protein of the cerebrospinal fluid after two and half months from the head trauma. He was treated with steroid pulse therapy and resulted in an improvement of his visual acuity and a remarkable decrease of multiple cerebral white matter lesions. There has been a controversy concerning the causal relationship between trauma and multiple sclerosis (MS). In this case, MS-like multiple cerebral white matter lesions are considered to be relevant to the head trauma.     

重型颅脑损伤合并严重多发伤的临床救治

目的评估重型颅脑损伤合并严重多发伤的临床救治结果。方法对22例重型颅脑损伤合并严重多发伤进行回顾性总结。结果预后按GOS评分,良好者8例（36．4％）,轻残4例（18．2％）,重残2例（9％）,植物生存3例（13．6％）。死亡5例（22．7％）。结论早诊断、早治疗、积极抗休克治疗、合理的救治顺序是提高重型颅脑损伤合并严重多发伤的治疗效果,减少致残率及降低死亡率的有效措施。     

重症颅脑外伤的救治与意识障碍的康复(附960例分析)

目的 探讨重症颅脑外伤的抢救和意识障碍的治疗效果。方法对960例病人的临床治疗结果进行回顾性分析。结果全组960例病人，死亡254例(26、5％)，植物生存31例(3.3％)，重残95例(9.8％)，中残107例(11．1％)，恢复良好473例(49.3％)。结论保持呼吸通畅，及时手术解除脑疝，术后尽快恢复脑水肿，治疗并发症，应用神经细胞营养剂、催醒剂、高压氧、物理康复治疗等手段进行综合救治措施能使重症颅脑外伤的存活率提高，意识障碍苏醒率增高。     

EEG discriminant analyses of mild head trauma

Measures of EEG power spectral analyses were obtained from a total of 608 mild head trauma patients and 108 age-matched normal subjects. A training-set discriminant function was first developed from 264 mild head-injured patients and 83 age-matched controls yielding an overall discriminant classification accuracy of 94.8%. The first independent cross-validation of the discriminant function using 130 mild head trauma patients and 21 age-matched normals yielded a discriminant classification accuracy of 96.2% for the trauma patients and 90.5% for the normals. A second independent cross-validation of the discriminant function using 51 patients and measures of test-retest reliability from 93 patients yielded classification accuracies ranging between 77.8% and 92.3%. A third independent cross-validation of 70 mild head-injured patients tested at a different location with a different EEG computer system yielded a discriminant accuracy of 92.8%. The discriminating EEG power spectral analyses indicated 3 classes of neurophysiological variables which are attributable to mechanical head injury: (1) increased coherence and decreased phase in frontal and frontal-temporal regions; (2) decreased power differences between anterior and posterior cortical regions; and (3) reduced alpha power in posterior cortical regions.     

A case of topographical disturbance following a left medial parieto-occipital lobe infarction]

A 59-year-old man was admitted to our hospital for his sudden-onset right hemianopsia. Thirty days after the onset, neuropsychological examination revealed obvious topographical disorientation and mild optic ataxia. Magnetic resonance imaging showed abnormal intensity area at the left medial parietooccipital region and left splenium of the corpus callosum. Although single photon emission CT showed uptake decrement in the left hemisphere, almost normal uptake was observed in the right hemisphere. He could recognize landmarks, but fail to recognize the relative position of landmarks. Therefore, his topographical disorientation was considered to be due to perceptual disturbance, memory disturbance of relative position of landmarks, or both. He was right-handed with no sinistral relative, and showed dyslexia and dysgraphia early in his clinical course. The laterality index of the dichotic listening test revealed the right ear dominance. These results indicated that his left hemisphere was language dominant. His topographical disorientation could be caused by the medial parieto-occipital lesion in the dominant hemisphere.