Neurologic complications associated with influenza vaccination: two adult cases

We describe two adult cases of neurologic complications occurring after influenza vaccination. The first case was a 62-year-old man who experienced convulsions 5 days after vaccination, and the second case was a 70-year-old man who exhibited paraplegia 7 days after vaccination. Diagnoses of acute disseminated encephalomyelitis and transverse myelitis with acute motor axonal neuropathy were made, respectively, and steroid pulse therapy and intravenous gamma globulin therapy alleviated the patients' symptoms. Although the efficacy and cost benefit of influenza vaccination have been widely accepted, such neurologic complications might occur in the elderly or even in adults.     

Surgical indications for infantile subdural effusion

Thirty-four cases of infantile subdural effusion (ISE) were reviewed in relation to surgical treatment and its prognosis during an average of 4 years of extended follow-up. The surgical indications were determined mainly by the size of the ISE on computed tomography (CT) scan and by metrizamide CT cisternography (MCTC). Consequently, 18 cases were categorized as type A according to MCTC, including 11 cases (61.1%) of ISE CT grade 1. All type A cases were closely observed. This nontreatment regimen yielded excellent results in 15 cases (83.3%). For 10 cases categorized as type B according to MCTC, including 5 cases (50%) of ISE CT grade 3, surgical treatment was indicated and excellent results were obtained in 8 cases (80%). For 6 cases categorized as type C according to MCTC and as ISE CT grade 3, surgery yielded excellent results in 4 cases (66.7%). Antiepleptic drugs have been given to three (27.3%) of the 11 patients who had convulsive attacks. In conclusion, the surgical indications for ISE were based mainly on MCTC in addition to the clinical course, and it is emphasized that, in the early stages, surgery on ISE cases categorized as MCTC types B and C is necessary.     

Evaluation of cerebral hemodynamics with perfusion CT]

We report on the evaluation of cerebral ischemic lesions with perfusion CT. Cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) of 52 patients mostly with ischemic cerebrovascular disease were analysed using the box-modulation transfer function method with 30 ml of contrast medium intravenously injected at 5 ml/sec. CBF, CBV and MTT of the middle cerebral artery (MCA) territory were 43.5 +/- 4.6 ml/100 g/min, 1.9 +/- 0.2 ml/100 g and 2.9 +/- 0.6 seconds at the unaffected side, and 37.7 +/- 7.3 ml/100 g/min, 2.1 +/- 0.3 ml/100 g, 3.7 +/- 0.9 seconds at the lesion side with stenosis or occlusion in the main MCA trunks or internal carotid artery, respectively. A statistically significant difference was shown in CBF and MTT values. Furthermore, there was a close correlation in CBF values of MCA territories between Xe-CT and perfusion CT (r = 0.645, n = 76, p < 0.0001). MTT showed a positive correlation with CBV in those subjects when MTT was below 4.1 seconds (r = 0.526, p < 0.0001, n = 83). MTT also showed a negative correlation with CBF in those patients when MTT indicated more than 4.1 seconds (r = 0.818, p < 0.001, n = 21). These results suggest that the progression of cerebral ischemia may be classified in 4 stages using perfusion CT. The stages are as follows: stage 0; normal CBF without prolonged MTT and increased CBV, stage 1; relatively increased CBV, stage 2; significantly prolonged MTT, and stage 3; significantly decreased CBF with prolonged MTT.     

A case of an aged patient suspected of craniopharyngioma with a chief symptom of eunuchoidism accompanied with panhypopituitarism]

A 78-year-old man with developmental disturbance of the genital organs and eunuchoidism was reported. He also had a high pitched voice, thickness of the lower lip and kyphosis of the thorax. He seemed to be fretful, but his intelligence was normal. Neurological tests revealed bilateral hemianopsia and decreased tendon reflexes. A plain skull radiograph clearly showed an egg shaped calcified mass extending upward from the sella turcica which resembled a ballooning shape. Brain CTs showed a high density round mass which expanded the sella turcica and raised the floor of the third ventricle. The inner part of the tumor showed irregular high density. T1-weighted MR imaging revealed an iso signal intensity, and T2 showed low signal intensity in the mass. These findings strongly supported the diagnosis of calcificated craniopharyngioma. Endocrinological study showed panhypopituitarism caused by the tumor compressing the pituitary gland and the hypothalamus. The main reasons why there were no apparent symptoms of hypopituitarism were because the receptors were up-regulated and secondarily because the thyroid and the adrenal cortical functions decreased while struggling to maintain balance with each other. There was also a possibility that these symptoms might have been masked by normal aging. Benign monoclonal hypergammopathy was also indicated, although we could not find a clear correlation between this finding and others.     

A probable case of Creutzfeldt-Jakob disease with electroretinogram alterations]

Although visual disturbance is recognized as a clinical feature of Creutzfeldt-Jakob disease (CJD), lesions within the retina have to date, recorded little attention. In this single case study, we report a case of retinopathy observed in a 72-year-old female patient with CJD. The patient admitted to the hospital complaining of a 2-month history of visual disturbance, dysarthria, and gait disorder. Electroencephalogram showed periodic synchronous discharges synchronizing with myoclonic jerks. Electroretinogram (ERG) using single bright flash in a dark-adapted state demonstrated the absence of b-wave in both eyes. One month later, ERG could no longer record a-wave of the right eye. The absence of b-wave on ERG indicated a disorder within the inner layer of the retina, furthermore lesions detected in the occipital lobe were considered too mild to have elicited such visual disorder. We further conclude that retinopathy may be found in CJD and can progress in retrograde from ganglion cells to photoreceptors. Although the frequency of retinopathy among the CJD population is unclear, detailed clinical observation and analysis of ERG in patients with visual disorders of unknown cause is extremely important for both the screening and exclusion of CJD.     

Bedridden elderly and dementia]

The purpose of this study is to clarify possible correlations between dementia and long term bedridden elderly patients in our special nursing home and geriatric hospital. At the time of our study, 42.6% of all our patients were bedridden, and the ratio increased in those groups of advanced age. The percentage of bedridden female patients was higher than that of males. Most bedridden patients, suffered disorders of the nervous system particularly disorders caused by cerebrovascular disease. Among the bedridden patients, the incidence of dementia was 82.8%. In most these cases, the degree of dementia was severe. The types and respective percentages of dementia were as follows: Vascular type 45.1%, Alzheimer's type 23.2%, mixed type 19.5% and others 12.2%. We think that Alzheimer's type dementia may cause a patient to become bedridden. On the other hand, vascular type dementia may be promoted by a patient's being bedridden for a long time. Tube-fed patients comprised 20% of all bedridden patients and all of these patients showed dementia. We believe that a patient's getting out of bed and receiving rehabilitation as soon as possible is vital to the prevention of becoming permanently bedridden. In respect to the present study of bedridden dementia patients, we would like to further study tube feeding and terminal care.     

A case of basilar artery occlusion successfully treated with tissue plasminogen activator]

This case concerns a stroke in the basilar artery territory that was successfully treated with a tissue plasminogen activator (t-PA). A 44-year-old man suddenly lost consciousness. It took fifty minutes to arrive to our hospital after the onset. On admission, his consciousness was in a coma state. A head CT revealed normal findings but a cerebral angiography showed complete occlusion in the basilar artery. We gave 240,000 units t-PA intravenously for 60 minutes. The intravenous t-PA dramatically improved his state of consciousness. After treatment, the brain CT scan showed low-density areas in the left occipital area and right pons. The cerebral angiography showed arterial sclerosis in the basilar artery. There was no parenchymal hemorrhage or hemorrhagic infarction in the patient. The hitherto reports showed the intravenous infusion of t-PA may be particular value in patients with thromboembolic occlusion in the middle cerebral artery. In contrast, our results support its efficacy in strokes in the basilar artery territory.     

Occlusion of a perforating artery, by descending tentorial herniation after head injury, supplying deep cerebral structure--report of 4 cases and their CT evaluation

Four cases with descending tentorial herniation (DTH) after head injury which showed thalamic, mesencephalic and basal ganglionic low density areas (LDAs) manifesting a infarction in postoperative CT films are reported, and a possible mechanism are discussed in this paper. Case 1: Bilateral acute subdural hematoma with left DTH showed LDAs in the anterior part of the bilateral thalami, left occipital lobe and midbrain. The estimated occluded arteries included the anterior thalamoperforating artery(AThA), posterior cerebral artery and midbrain perforator. Case 2: Right acute epidural hematoma with DTH showed LDAs in the anterior part of the right thalamus and in the left globus pallidus. The estimated occluded arteries included the AThA and anterior choroidal artery. Case 3: Right acute epidural hematoma with DTH showed LDAs in the anterior part of the left thalamus, and in the left midbrain tegmentum. The estimated occluded artery was the interpeduncular thalamoperforating artery (IThA). Case 4: Right chronic subdural hematoma with DTH showed LDA mainly in the left thalamus except for the superior thalamic region. The estimated occluded arteries included the AThA and/or IThA and thalamogeniculate artery. Cases 1 and 4 were adult males and cases 2 and 3 were infant males, and the prognosis was good in the infant males, and poor in the adult males. Each of the 4 cases showed no loss of consciousness just after the head injury while 3 out of them deteriorated within several hours, and one was a case of chronic subdural hematoma.(ABSTRACT TRUNCATED AT 250 WORDS)