A case of delayed cerebral infarction occurring in puerperium preceded by herpes zoster ophthalmicus in late pregnancy]

Delayed central neurological symptoms following herpes zoster ophthalmicus (HZO) such as "herpes zoster ophthalmicus and delayed contralateral hemiparesis" are considered to be due to ipsilateral intracranial vasculopathy. We experienced a rare case with cerebral infarction occurred in puerperium following HZO in late pregnancy. A healthy 30-year-old woman had left HZO at weeks 35 of gestation. She was given acyclovir (ACV) for external use and improved with small pigmentation on the left eye-lid. Seven weeks after the onset of HZO, she suddenly developed aphasia and right hemiparesis. Cerebral angiogram showed narrowing on M 1 segment of the ipsilateral middle cerebral artery. The occlusion was seen on peripheral portion of the angular artery on the same side. In cerebrospinal fluid (CSF), cell count was slightly elevated, but concentration of protein and sugar were normal. Varicella-zoster titer was increased in both serum and CSF. She was treated with intravenous ACV (1500 mg/day) for 10 days. On the next day after the treatment, the cell count was normalized and on 18th day, varicella-zoster titer was decreased in CSF. Higher brain function improved and no relapses occurred. This is a first case of delayed cerebral infarction occurring in puerperium preceded by herpes zoster ophthalmicus in late pregnancy, as far as we searched. We should treat carefully pregnant or lactating patients with HZO, considering delayed cerebral infarction.     

Influence of nimodipine on cerebral blood flow in human cerebral ischaemia

Summary Cerebral blood flow (CBF) was measured by xenon-133 inhalation and single photon emission computerized tomography (SPECT) in 7 patients with acute cerebral ischaemia prior to and 30 min after intravenous infusion of nimodipine (1 mg). Neurological examination, CT and CBF study were performed no later than 6 h after the onset of symptoms. Regional perfusion abnormalities were seen in all patients when the CT scan was still normal. Follow-up CT revealed low-density areas roughly corresponding to the core of the perfusion defect. Nimodipine infusion significantly decreased the mean arterial blood pressure (P<0.01), while PaCO₂ and clinical symptoms remained unchanged. A significant CBF improvement (P<0.05) after nimodipine was seen in the border zone of the ischaemic infarct but not in the core of the lesion or in the unaffected contralateral hemisphere.     

Regional cerebral blood flow in the acute stage with ischemic cerebrovascular disease studied by xenon-133 inhalation and single photon emission computerized tomography

The papers about cerebral blood flow (CBF) in patients with cerebrovascular diseases have been already reported by positron emission computerized tomography (PET), single photon emission computerized tomography (SPECT), Xray CT (CT) using cold Xe, and so on. However the literature about the CBF changes in acute stage is few. We studied CBF in 68 patients with ischemic cerebrovascular disease within 48 hours after the onsets from February 1984 through February 1985. CBF was measured by a rapidly rotating single photon emission computerized tomography (SPECT) using non-invasive Xenon-133 inhalation method. Our subjects included 51 cases with cerebral infarction (male 37, female 14, average 62.9 years) and 17 cases with TIA (male 13, female 4, average 60.5 years), the patients who had a past history of stroke were excluded from the subjects. The SPECT was performed with use of Tomomatic 64 developed by Dr. Lassen, et al, SPECT and carotid arteriography were simultaneously performed within 48 hours in all cases. CT we used were GE CT 9800 scanner and Hitachi HF CT. The following results have been obtained: 1) SPECT clearly showed an ischemic focus correlated with clinical symptom after the attack rather than CT, the positive finding by SPECT was 92.2% and that by CT was 62.7% within 48 hours after the onset. 2) The remote effect phenomenon so-called crossed cerebellar diaschisis was demonstrated in 7 of 14 cases (50%) with cerebral infarction due to internal carotid artery occlusion and in 9 of 26 cases (34.6%) with that due to middle cerebral artery occlusion. 3) SPECT and CT were performed within 8 hours after the onset in 20 cases with cerebral infarction. SPECT showed decreased CBF in all cases whereas the positive finding by CT was 40.0%. The area of decreased CBF was always larger than the low density area that CT demonstrated. Mean CBF value of the cerebral hemisphere in the cases with ICA occlusion within 8 hours after the onsets was 31.0 (ml/100 g/min), and that of MCA occlusion was 36.0 (ml/100 g/min), and that of MCA occlusion was 36.0 (ml/100 g/min). 4) The positive finding by SPECT on TIA cases was 47% and that by CT was 41.1%, SPECT usually did not demonstrate a small ischemic focus especially at the deep region (ie, basal ganglia region). 5) SPECT using Xe-123 inhalation was useful and non-invasive method for the diagnosis in acute stage with ischemic cerebrovascular disease.(ABSTRACT TRUNCATED AT 400 WORDS)     

Acetazolamide effects on cerebral blood flow in acute reversible ischemia

Cerebral blood flow (CBF) was studied in 4 patients with acute reversible ischemia (RIND). To test the ischemic areas' vasoreactivity, CBF was measured by the Xenon-133 inhalation method, before and after acetazolamide injected intravenously. At the baseline CBF study, 3 patients presented hypoperfused areas while one patient had increased CBF over the affected hemisphere. The acetazolamide test, showed in this latter case a "steal phenomenon" while in the other 3 an increase of perfusion was evidenced, in areas of normal flow, as well as in areas with reduced flow. These results suggest that in the acute phase of patients with RIND, when brain regions of hypoperfusion and neurological signs are still present, the vasomotor response may be preserved.     

Mechanisms of recovery from aphasia: evidence from serial xenon 133 cerebral blood flow studies

In 21 patients who suffered aphasia resulting from left hemisphere ischemic infarction, the xenon 133 inhalation cerebral blood flow technique was used to measure cerebral blood flow within 3 months and 5 to 12 months after stroke. In addition to baseline measurements, cerebral blood flow measurements were also carried out while the patients were performing purposeful listening. In patients with incomplete recovery of comprehension and left posterior temporal-inferior parietal lesions, greater cerebral blood flow occurred with listening in the right inferior frontal region in the late studies than in the early studies. In patients with nearly complete recovery of comprehension and without left posterior temporal-inferior parietal lesions, early listening studies showed diffuse right hemisphere increases in cerebral blood flow. Later listening studies in this latter patient group showed greater cerebral blood flow in the left posterior temporal-inferior parietal region. The study provides evidence for participation of the right hemisphere in language comprehension in recovering aphasics, and for later return of function in left hemisphere regions that may have been functionally impaired early during recovery.     

Infantile herpes zoster ophthalmicus and acute hemiparesis following intrauterine chickenpox

A 17-month-old boy developed herpes zoster ophthalmicus (HZO) and delayed contralateral hemiparesis following intrauterine varicella exposure. CT demonstrated multiple areas of hypodensity in the left basal ganglia, and angiography showed occlusion of left lenticulostriate arteries. As in most adults with HZO and delayed hemiparesis, this infant had a self-limiting course with excellent recovery.     

Comparative study of regional cerebral blood flow values measured by Xe CT and Xe SPECT

The regional cerebral blood flow (rBCF) values measured by stable xenon-enhanced computed tomography (Xe XT) and by radioactive xenon-133 single photon emission computed tomography (Xe SPECT) were compared in 16 patients with cerebral infarct. On the non-lesion side Xe SPECT recorded 10.7% higher rCBF values than Xe CT in the anterior cerebral artery territory while Xe CT recorded 9.6% higher values than Xe SPECT in the middle cerebral artery territory. These differences were not statistically significant. Although the rCBF values were almost the same no correlation was found between the two methods in the posterior cerebral artery territory and the basal ganglia. Only hemispheric CBF on the non-lesion side showed the same value and a good correlation between the Xe CT and the Xe SPECT. There was a good correlation in the hemispheric CBF values on the lesion side, too. The difference of rCBF between the non-lesion side and the lesion side was expressed smaller in the Xe SPECT than in the Xe CT. This is in agreement with the previous reports that Xe SPECT overestimates the flow in the low flow areas. The higher rCBF values in the anterior cerebral artery territory measured by the Xe SPECT was ascribed to the artifact from the radioactivities in the inhalation mask and the air passages as reported previously. In conclusion, there is no good correlation between the rCBF values measured by the Xe CT and by the Xe SPECT. Only hemispheric CBF shows a good correlation between the two methods.     

Calcified giant aneurysm of the middle cerebral artery

A rare case of calcified giant aneurysm of the middle cerebral artery is presented. This is a 28-year-old female with seizures and right-sided hemiparesis in whom plain scull films and computed tomography revealed a large calcified lesion (measuring 7.5 x 5.5 x 4.5 cm) of the left cerebral hemisphere. The lesion was removed by the pterional transsylvian approach and found to be a calcified giant thrombotic aneurysm of the middle cerebral artery. The CT characteristics of these rare lesions and the success of surgery in this case are briefly discussed.     

Herpes zoster ophthalmicus and delayed ipsilateral cerebral infarction

We studied five patients who had acute cerebral infarctions 5 weeks to 6 months after herpes zoster ophthalmicus (HZO). All had infarcts of the cerebral hemisphere ipsilateral to the HZO, and one also had a cerebellar infarct. Cerebral arteriography in one patient disclosed narrowing of the middle cerebral artery, occlusion of the anterior cerebral artery ipsilateral to the HZO and narrowing of the opposite anterior cerebral artery. In another case, arteriography revealed occlusion of the distal internal carotid artery on the side of the HZO.     

Slowly progressive limb-kinetic apraxia with a decrease in unilateral cerebral blood flow

We report two patients with slowly progressive motor disorders, whose principal manifestations were asymmetric limb-kinetic apraxia and muscle rigidity. In both patients MRI revealed no responsible lesion, whereas single photon emission computed tomography (SPECT) showed a decrease in cerebral blood flow (CBF) in the unilateral hemisphere. One patient with mainly right-sided apraxia had a decreased CBF in the left central region between the frontal and parietal cortices, and the other patient with left-sided apraxia in the right parietal cortex. In agreement with asymmetric clinical symptoms, the regional CBF decrease in the unilateral cortical areas including the frontal and parietal cortices may suggest a degenerative disease, presumably diagnosed as having cortico-basal degeneration.     

Regional cerebral blood flow in partial complex epilepsy with and without the presence of lesions

Regional cerebral blood flow (r CBF) was measured by the I.V. 133 Xenon method and use of 27 detectors in 91 patients with complex partial epilepsy in interictal periods (at least 48 h over a complex partial seizure). Some were also examined less than 48 h before or after seizures. All were studied with ictal and interictal electroencephalography (EEG), polysomnography, computed tomography (CT), some had nuclear magnetic resonance scans (MR). The blood flow values were compared with a group of a 20 normal subjects matching for age. A significant decrease of r CBF ranged from 15% to 25% was found in the temporal region in three groups of epileptic patients: with repeated normal CT scans and lateralized EEG abnormalities (N = 46); with cortical atrophy in CT scan (N = 12); with neurosurgical focal lesions on CT and or MR scans glioma, arteriovenous malformation) (N = 10). r CBF was normal or decreased by less than 15% in the other regions of the brain. Patients with repeated normal CT scans and bilateral EEG abnormalities either asynchronous or alternatively observed in the right side or left side on waking EEG or during NREM sleep and REM sleep, did not show reduction in r CBF. In a previous study, r CBF distribution was also found normal during interictal phase in patients with primary generalized epilepsy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Regional cerebral blood flow in chronic alcoholics measured by single photon emission computerized tomography

Regional cerebral blood flow (CBF) was measured by single photon emission computerized tomography of inhaled 133-Xe in 20 chronic alcoholic men. Mean CBF was 51 ml/(100 g x min) compared with 53 ml/(100 g x min) in 20 normals. Reduced cerebellar blood flow correlated both to structural abnormalities seen on CT scan and to cognitive dysfunction. Slight abnormalities of the regional CBF was observed in the alcoholics. They had a higher incidence of regional low flow areas than a control group. Low flow areas were found in frontal and posterior parts of the brain not only in patients with atrophia, but also in patients without CT abnormalities, suggesting neuronal dysfunction. The occurrence of regional low flow areas was associated with the severity of alcoholism, cerebral atrophy and intellectual impairment.     

Right motor neglect associated with dynamic aphasia, loss of drive and amnesia: case report and cerebral blood flow study.

A 30-year-old right-handed man had right motor neglect, amnesia, aphasia and loss of drive following bilateral thalamic and subthalamic infarctions. Serial resting cerebral blood flow (CBF) measurements with either Xenon 133 inhalation or positron emission tomography at 1, 8 and 10 months post-onset showed a widespread and long-lasting low CBF in the cortex. An additional CBF measurement, during motor tasks, showed a marked interhemispheric asymmetry in the pattern of activation: whereas left hand movement resulted in a CBF increase in contralateral superior rolandic and prerolandic areas, no significant regional CBF changes were seen during right hand movement, despite recovery from motor neglect. This loss of CBF increase in cortical motor and premotor areas during voluntary movement of the previously neglected side points to a disruption of cortico-subcortical pathways subserving motor activation. The pathophysiology of aphasia, loss of drive and amnesia as well as their relationships to motor neglect, may also be discussed on the basis of thalamo-cortical disconnections.     

Effect of flunarizine on cerebral blood flow in baboons with or without focal cerebral ischaemia

In baboons with or without regional cerebral ischaemia (achieved by transorbital clip of the middle cerebral artery), cerebral blood flow (CBF) was measured using the intra-arterial Xenon-133 technique during steady-state, slight hypotension, and hypocapnia before and after administration of various doses of the calcium antagonist flunarizine (0.5 mg kg^–1, 1.0 mg kg^–1, or 10 μg kg^–1 min^–1 over 30 min). In normal baboons flunarizine did not alter CBF significantly, but at reduced blood pressure it increased CBF by 19.9% owing to exaggerated vasodilatory autoregulation. During hypocapnia flunarizine impaired the physiological reduction in CBF owing to reduced vasoconstriction. In baboons with cerebral ischaemia, CBF measurements were stable and comparable with those in a control group using an arterial clip unless flunarizine was added. In a group of five flunarizine-treated animals, mean CBF after positioning of the clip was higher than in the control group. However, the increase in mean CBF varied significantly between animals, indicating that a secondary reduction in CBF due to postischaemic pathophysiological processes was not prevented consistently.     

Serial MR and CT features of primary germinoma originating in the basal ganglia

Serial changes of neuroradiological findings in a 10-year-old boy with primary germinoma originating in the basal ganglia are reported. He presented with a one year history of slowly progressive right hemiparesis. Although initial computed tomography (CT) scans showed no prominent abnormalities, a slight high-density area in the basal ganglia became conspicuous with cortical atrophy on follow-up scans. Sequential magnetic resonance images showed a homogeneous lesion with clear margin and remarkable postcontrast enhancement. Two cell pattern germinoma was histologically verified by CT guided stereotactic biopsy. Following irradiation, the tumour completely disappeared, however, the atrophy of the cerebral hemisphere and the brain stem progressed, and mild hemiparesis remained. We discuss the neuroradiological features and clinical manifestations of this disease.     

A serial study of regional cerebral blood flow before and after hemispherectomy in a child

Hemimegalencephaly (HME) is a severe unilateral brain malformation the prognosis of which may be improved by hemispherectomy. HME also provides a unique opportunity to compare normal and pathological hemispheric function in the same patient. We performed a serial functional cerebral imaging study in a child suffering from a neuropathologically confirmed left HME. He was hemispherectomized at 11 months because of intractable epilepsy; this led to cessation of seizures and dramatic psychomotor improvement. Regional cerebral blood flow (rCBF) was studied at 1, 7, 10, 12 and 25 months with single photon computed tomography (SPECT) using 133-Xenon and with simultaneous EEG recording. At one month of age SPECT was performed ictally. During left EEG discharges, rCBF was 40% higher on the left hemisphere than on the right, even in occipital and frontal regions, usually immature at this age. A crossed cerebellar hyperperfusion was also found. At 7 and 10 months, SPECT was performed interictally; rCBF was 45% lower in the left hemisphere than in the right. During follow-up, global and regional CBF values showed normal levels and normal maturation in the right hemisphere except for a mild and transient decrease observed one month after hemispherectomy. SPECT provides an additional procedure for studying hemispheric function in vivo. Serial SPECT imaging may be useful for the preoperative and postoperative evaluation in unilateral cerebral malformation.     

Transient focal abnormalities of MRI and angiographic neuroimaging in status epilepticus: case report]

We reported transient changes in computed tomography (CT), angiography and magnetic resonance imaging (MRI) scans in a patient with status epilepticus, referred to us with a tentative diagnosis of neoplasma based on CT, MRI and angiographic findings, MRI showed increased signal intensity, and CT showed decreased left hemisphere attenuation without enhancement. Two months later, resolution of these radiological and clinical abnormalities had been attained. The transient CT and MRI changes probably represented focal cerebral edema, developing during focal status epilepticus.     

Atypical Basal Ganglia germ cell tumor presenting as cerebral and brainstem hemiatrophy

We describe a 20-year-old male patient with a germ cell tumor of the basal ganglia who presented with progressive hemiparesis and hemisensory loss. Initial computed tomography and magnetic resonance imaging showed ipsilateral cerebral and brain stem hemiatrophy predominantly in the left basal ganglia and thalamus, whereas no mass or enhancement was depicted. Single photon emission computed tomography revealed mild hypoactivity of the left cerebral hemisphere. Stereotactic biopsy was performed after a mass lesion became apparent, allowing histologic verification of germ cell tumor to be established.     

Threshold of regional cerebral blood flow for infarction in patients with acute cerebral ischemia

Threshold of regional cerebral blood flow (rCBF) for cerebral tissue survival in relation to time was studied in patients with acute cerebral ischemia with xenon-enhanced computed tomography (XeCT). Case 1: A 58-year-old man with right hemiparesis, total aphasia and a high intensity area of 1 cm 2 in the left insula on diffusion weighted image underwent XeCT CBF study before and after intra-arterial local thrombolytic therapy (IALT) on the occluded middle cerebral artery (MCA) 4 hours and 7 hours after stroke onset, respectively. Case 2: A 65-year-old woman with recurrent transient ischemic attacks (TIAs) caused by severe stenosis of the left MCA underwent XeCT CBF study 5 hours after onset of the last attack. XeCT was conducted by 5-min wash-in method. In Case 1 the rCBF in the pre-IALT MCA territory was 4 to 19 ml/100 g/min. The area where rCBF in the post-IALT increased to above 15 ml/100g/min were saved, but the other area where it remained in the 9 to 14 ml/100 g/min evolved into infarct on subsequent CT scan/MR (magnetic resonance) imaging. The patient was discharged with only mild motor dysphasia. In Case 2 the left corona radiata showed rCBF of 7 ml/100 g/min and this area evolved into infarct on MR imaging. The patient was discharged home with right hemiparesis. Our results showed validity of the rCBF threshold in acute cerebral ischemia reported by Jones et al. Residual rCBF in the acute stage of cerebral ischemic stroke can predict the fate of the lesion.     

Diminished regional cerebral blood flow during the intercritical period in temporal lobe epilepsy

Hemisphere and regional cerebral blood flow (CBF) were determined during interictal periods by intravenous Xenon 133 in 43 patients considered to have "temporal" epilepsy and presenting complex partial attacks with altered consciousness and lateralized EEG anomalies predominant in the temporal region. Brain scans were normal in all cases. Three subgroups were differentiated according to EEG and polygraphic examinations during sleep; temporal epilepsy with left or right EEG anomalies, with asynchronous bilateral EEG anomalies, with alternating labile unilateral EEG anomalies. Measurements of CBF were compared with those of normal subjects (n = 13) of comparable age and with those of epileptic patients with cerebral lesions on CT scan (n = 4). In epileptics with left EEG anomalies CBF was diminished by about 25 p. 100 in the left temporal region and from 15 to 22 p. 100 in other regions of the ipsi- and contralateral hemisphere. In epileptics with right EEG anomalies CBF was diminished by 20 p. 100 in the right temporal region but not on the left. CBF in the third group was comparable to that of normal subjects. In epileptics with abnormal CT scans the reduction in CBF could be correlated with EEG and CT scan findings. Studies were also conducted to determine variations in reactivity to CO2 in the areas with reduced flow, during ictal and interictal periods. Results emphasize the value of CBF measurements for investigation of epileptic foci. The importance of areas of reduced blood flow as a parameter of severity and course is discussed, as well as their pathophysiological significance.