A case of cortical deafness following bilateral putaminal hemorrhage]

A 59-year-old man had suffered from consciousness disturbance and right hemiplegia in December, 1996. He was diagnosed as left putaminal hemorrhage and his symptoms improved by conservative treatment. After one week since the onset, when he became alert, he noticed deafness. He was admitted in our hospital because of deafness and dysarthria in March, 2001. T 1-weighted MR image of the brain revealed bilateral putaminal hemorrhage and a low signal area in the white matter of right temporal lobe. Single photon emission computed tomography image revealed hypoperfusion in the bilateral temporal lobes. His electrocochleogram and auditory brainstem response were normal. Audiogram revealed increased air and bone conduction thresholds. Therefore, we diagnosed his condition as cortical deafness. He could only recognize loudness as the sound by the electrical promontory test. These results indicate that his cortical deafness might be caused by his bilateral acoustic radiation damage associated with the right partial temporal lobe damage and that some fibers of the acoustic radiation, which were responsible for the recognition of loudness of sound, were spared. Therefore he has a possibility of regaining hearing capability by a cochlear implant.     

Preeclampsia complicated by cerebral hemorrhage and brain abscess

Summary A 34-year-old, preeclamptic woman developed a right basal ganglia hematoma during a vaginal delivery. Her course was later complicated by an infected episiotomy. As a consequence of bacterial seeding most likely from the infected episiotomy, the intracerebral hematoma became infected, developing into a brain abscess. Because of her existing neurological deficits, the developing brain abscess was not recognized until signs and symptoms of increased intracranial pressure developed. This patient illustrates another potentially life-threatening neurological infection that may occur in the peripartum period.     

A study of aphasia caused by putaminal hemorrhage

Aphasia was evaluated in 21 right-handed patients (39-74 years old) with putaminal hemorrhage, and compared with that caused by thalamic hemorrhage. The patients were divided into three groups by the volume of the hematoma: small hematoma (I, n = 6), middle hematoma (II, n = 8) and large hematoma (III, n = 7) groups in computed tomographic findings. Aphasia examination was performed 8-37 days (mean 21 days) after the onset. In group I, aphasia was not seen or just transient, if any. In group II, aphasia was mainly a mixed type, and the prognosis was excellent in many patients. In group III there were expressive type at anterior lesion, receptive type at posterior lesion and global aphasia at anterior-posterior lesion, and the prognosis was not good. It is suggested that the putamen itself does not participate in language behavior, and that aphasia caused by putaminal hemorrhage is due to destruction of the surrounding tissue of the putamen. The type of aphasia and prognosis are varied by the site of a lesion and a hematoma volume. It is also suggested that the thalamus is related to language behavior in a circle of thalamus-cortical language area-thalamus. Aphasia caused by putaminal or thalamic hemorrhage was observed to be different from classical cortical aphasia. But there was no significant difference between aphasia caused by putaminal lesions and that by thalamic lesions.     

Witzelsucht after right putaminal hemorrhage: a case report

Witzelsucht is a tendency to tell inappropriate and poor jokes. It usually occurs after a focal lesion involving orbitofrontal cortical or paramedian thalamic regions, especially on the right side. Here we report a 56-year-old man developing witzelsucht and hypersexuality after a right putaminal hemorrhage. The hematoma extended to the sublenticular part of posterior internal capsule and mesencephalon. The hemorrhage might have disconnected the fibers in the ascending reticular systems, and the fibers between paramedian thalamus and orbitofrontal cortex, and thus could be responsible for the patient's rare clinical manifestations.     

A case of myotonic dystrophy proved by DNA analysis]

The authors describe a case of a 53 years old man with myotonic dystrophy. Based on characteristic clinical symptoms and EMG results the diagnosis was established and proved on DNA examination. Myotonic dystrophy gene analysis showed on 3' untranslated region one hundred and fifty CTG triplet repeats. The accessory examinations revealed: cataract arrhythmias, gallbladder stones, impotence, cerebral atrophy on neuroimaging (CT and MRI). Apathy, somnolence, concentration troubles were present. Pedigree of the presented patient and possibility of spontaneous mutation are discussed.     

Focal asterixis caused by a small putaminal hemorrhage

Unilateral asterixis and mild pure motor hemiparesis contralateral to a small putaminal hemorrhage were observed in a 74-year-old hypertensive man. The motor deficit proved to be rapidly reversible, but the focal asterixis remained for some time as the only sign of the intracranial hemorrhage. This case suggests that altered striopallidal inhibitory input to the thalamus probably disturbed the circuit subserving the maintenance of postural tone.     

A case of aneurysm of the peripheral middle cerebral artery presenting putaminal hemorrhage--pitfall in diagnosis]

A case mimicking hypertensive putaminal hemorrhage which was first treated by CT-guided stereotactic aspiration and eventually diagnosed as a sequence of the ruptured aneurysm of the left peripheral middle cerebral artery on postoperative angiography is presented. This 41 old, right-handed, hypertensive female suffered sudden onset of headache and right hemiparesis. Next day hematoma was evacuated by the CT-guided stereotactic aspiration because of progressive deterioration of the consciousness and patient recovered well. Fourteen days after the evacuation when she presented mild right hand weakness and motor aphasia, angiography revealed a saccular aneurysm with broad neck derived from left posterior parietal artery. A neck clipping necessitated an additional anastomosis between superficial temporal artery and distal middle cerebral artery because of parent artery stenosis. Postoperatively she is doing well with slight motor aphasia. Among the typical hypertensive putaminal hemorrhage diagnosed on CT scan, it is stressed that there may be a possibility of ruptured aneurysm situated on the peripheral middle cerebral artery.     

A case of Aspergillus brain abscess presenting angular gyrus syndrome]

A 45-year-old man had been treated for chronic alcoholism and he had fever in September 2000. He was diagnosed as lung aspergillosis from chest X-ray findings, leukocytosis, elevated CRP, and beta-D-glucan. Administration of fluconazole was started and his lung lesion subsided. But, generalized clonic tonic convulsion developed and the brain abscess in the left parietal lobe was found by CT. Therefore we made the diagnosis of brain abscess followed by lung aspergillosis. He also showed angular gyrus syndrome. Its capsule was thick and localized in the left parietal lobe. The patient had the surgical resection in August, 2001. Aspergillus hyphae and infiltration of inflammatory cells were seen in the brain sample, therefore the diagnosis of aspergillosis brain abscess was established. Angular gyrus syndrome was ameliorated after the operation.     

Semiquantitative regional cerebral blood flow evaluation using 123I-IMP SPECT in a case showing transient ischemic attack caused by putaminal hemorrhage

A 69-year-old woman presented a transient cerebral ischemic attack, showing left arm weakness and slurred speech which recovered within 4 h of onset, while computed tomography indicated a putaminal hemorrhage. The regional cerebral blood flow distribution, measured semiquantitatively by use of 123I amphetamine emission tomography, was disturbed, which persisted more than one month up to a maximum of 4.5 months from the onset of symptoms. This case illustrates a variety of putaminal hemorrhage of good functional and vital prognosis, and provides an example in which the regional cerebral blood flow disturbances might persist for more than one month up to 4.5 months after the occurrence of a transient ischemic attack caused by a putaminal hemorrhage.     

A case with cerebral subcortical hemorrhage following the administration of phenylpropanolamine]

A 21-year-old woman experienced severe headache and nausea one hour after taking pills containing 160 mg of phenylpropanolamine for common cold. She had no previous history of drug abuse or hypertension. Physical examination revealed slight left-sided hemiparesis. Her blood pressure was 100/52 mmHg. Subcortical hemorrhage was noted in the right frontal lobe with a cranial computed tomography. On the seventh hospital day, cerebral angiography demonstrated with segmental narrowing of a branch of the right anterior cerebral artery, indicating the presence of focal angitis. This finding disappeared on the 35th hospital day. In the majority of the reported cases of the intracerebal hemorrhage associated with the ingestion of phenylpropanolamine, focal angitis rather than induced hypertension is considered to be a causative factor for hemorrhage. Thus, we would like to emphasize that the administration of phenylpropanolamine should be avoided, even to the patients without hypertention or past history of intracerebral hemorrhage.     

A case of primary subarachnoid hemorrhage due to cerebral amyloid angiopathy]

A 77-year-old man who was suffering from an intracerebral hemorrhage of the left subcortex without hypertension was admitted to our hospital. The only neurological symptom was right arm monoparesis. Brain MRI demonstrated a subarachnoid hemorrhage (SAH) in the left frontal lobe. On the day of admission, conventional cerebral angiography revealed no abnormalities in brain arteries. His symptom was disappeared immediately after admission. He was discharged without neurological deficit on day 25. However, he was rehospitalized in our hospital on the same day because he experienced a right subcortical hemorrhage. The neurological symptoms were consciousness disturbance, aphasia and right hemiparesis. Brain CT disclosed a subcortical hemorrhage in the left temporal lobe. CT stereo-guided drainage was performed. Then, we examined tissue removed from the brain's surface. Histologically, beta-amyloid protein was deposited on the walls of the meningeal and cortical vessels, and it replaced all the layers of those walls. Therefore, a diagnosis of cerebral amyloid angiopathy (CAA) was made. His condition gradually improved, but CT showed an asymptomatic ICH in the right parietal lobe on day 36. On day 47, he had a symptomatic ICH in the left caudate nuclei and right frontal lobe. He died on day 66 because of pneumonia. Intracranial hemorrhages due to CAA have been reported and the majority of the lesions have been lober hemorrhage. To the best of our knowledge, few reports have been published regarding primary SAH caused by CAA. The cause of SAH should be considered as CAA when SAH appears without hypertension or in elderly patients.     

Evaluation of brain dysfunction in hypertensive putaminal hemorrhage with multimodality evoked potentials

Changes in multimodality evoked potentials (MEP's), consisting of somatosensory evoked potentials (SEP's), visual evoked potentials (VEP's), and auditory evoked brainstem responses (AEBR's), were studied in 36 patients with hypertensive putaminal hemorrhage to ascertain the relation among areas and distribution of brain dysfunction, the size of hemorrhage on computerized tomographic scan, and the clinical outcome. Among MEP's, SEP's were most significantly involved in all patients. Abnormalities in VEP's and AEBR's remained mild or moderate when the hemorrhage did not extend to the diencephalon. If SEP's were normal or mildly abnormal, they improved early the ictus. These patients did well clinically. If SEP's were absent, the patients had poor outcome even when the hemorrhage was small and located outside the internal capsule. In contrast, deterioration or persistence of MEP's indicated secondary insult to the brain and poor patient outcome. Early and serial MEP studies are useful in evaluating primary and secondary brain dysfunction and in predicting patient outcome in hypertensive putaminal hemorrhage.     

A case of postpartum cerebral angiopathy with intracranial hemorrhage and subarachnoid hemorrhage immediately after delivery]

A 32-year-old woman, gravida 0, para 0, was admitted for delivery at 40 weeks of gestation. She had no history of headache, hypertension, and toxemia. She was delivered of a healthy boy. Although she was given no medication during normal delivery, she suddenly became drowsy and developed left hemiparesis immediately after delivery. Computed tomographic (CT) scan of the brain performed on the admission day revealed a subarachnoid hemorrhage and right putaminal hemorrhage. A 4-vessel cerebral angiogram demonstrated multiple irregular narrowing of the anterior cerebral arteries, middle cerebral arteries, and posterior cerebral arteries. Her conditions seemed to improve without any medication, and the multiple stenoses were no longer observed by angiography in a follow-up examination. On the basis of these observations, she was diagnosed as having postpartum cerebral angiopathy (PCA). Pathogenesis of PCA still remaing unclear to date an ergot alkaloid derivate (ergonovine) and the hydrogenated form of the powerful vasoconstrictor ergot (bromocriptine) have been reported as cause of PCA. We will classify PCA into 3 categories: eclampsia, secondary PCA, and primary PCA. "Primary PCA" is of unknown etiology, "secondary PCA" results from a known etiology such as drugs, and "eclampsia" is a PCA with toxemia of pregnancy. We report here, that PCA may occur even in a normal pregnant woman who was given no medication, and should be considered in the diagnosis of postpartum cerebral vascular diseases in women.     

Nocardial brain abscess: A case report

Summary A case of nocardial abscess is presented in which the investigation was by plane radiography, angiography and computed tomography. Craniotomy was followed by chemotherapy with good results.     

小骨窗开颅治疗高血压基底节区脑出血探讨

目的探讨高血压基底节区脑出血外科治疗的最佳术式.方法根据设定标准选择性收治高血压基底节区脑出血病人,采用CT简易定位小骨窗开颅血肿清除术治疗143例.结果143例近期优良率69%;73例随访3～18个月,远期疗效优良.结论该方法是一种操作简便、创伤小、效果良好的治疗方法,可以推广,尤其适合条件一般的基层医院开展.