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Evacuation of hypertensive intracerebral hematoma by a stereotactic technique.

30 patients with a hypertensive intracerebral hematoma were treated by stereotactic evacuation between 1986 and 1988. There were 20 males and 10 females; their ages ranged from 37 to 78 years. The time interval from onset to operation was in 16 patients 24 days and in 14 patients 2-7 days. In 19 patients the hematoma was found in the internal capsule, in 5 in the cerebellum, in 4 in the subcortex, and in 2 in the brain stem. The operation was performed with a Leksell computed tomography guided stereotactic apparatus and a Backlund hematoma evacuator. More than 80% of the hematoma could be aspirated in 20 patients and 60-80% in 10. 29 patients are alive, and 1 patient died.

Adult↗

Does epileptic pain really exist?

Painful seizures do exist, but are usually caused by uncontrolled muscle contractions that produce pain. Heretofore, no cases of seizures of the pain system have been reported. We will present a case of chest wall pain with episodic, severe exacerbation of the localized pain associated with focal muscle contractions. The episodes of severe pain could be provoked by stimulation of the internal capsule, producing repeated episodes of pain/muscle activity. The symptoms could be stopped by intravenous diazepam and reduced by periventricular grey stimulation.

Chest Pain↗

Chronic cerebellar stimulation (CCS) and deep brain stimulation (DBS) in involuntary movement disorders.

Motor disorders of disinhibition may be modified by prosthetic mobilization of CNS inhibitory mechanisms by chronic electrical stimulation of the cerebellar cortex (CCS) and by deep brain stimulation of the thalamus and internal capsule (DBS). Reduction in spasticity, abnormal movements, intractable epilepsy and aggressive behavior has been reported after CCS, although negative results in human and animal studies have been published. No adverse neurologic, psychologic or intellectual effects of stimulation have occurred after 7 years of CCS, although subclinical histological changes may occur in the cerebellar cortex under the electrodes. CCS has been shown to produce physiological changes in evoked potentials, motoneurone excitability, epileptic discharges in the EEG and quantitative changes in movement. Surface and deep thalamic recordings have shown reduced amplitudes of somatosensory responses after CCS. Over the last 2 years we have employed chronic deep brain stimulation (DBS) in 49 patients with clinically useful results in half the patients. The technique allows reversible modification of movement disorders, and the technique can be used on the second side after a previous thalamectomy. Physiological testing, direct thalamic recordings and quantitative analysis of movement have allowed assessment of optimal rate and voltage of stimulation. For some intractable movement disorders DBS has effected significant therapeutic results when all other therapeutic techniques have failed.

Adolescent↗

Experimental studies on therapeutic effect of electrical stimulation of the brain on muscular hypertonus.

Possible effective sites in the central nervous system for therapeutic electrical stimulation in muscular hypertonus are presented. The tonic vibration reflex (TVR) was used as a suitable model of a hypertonic muscular mechanism. Using cats, vibration of 225 Hz was applied to the tendon of the gastrocnemius and soleus muscles. During TVR, stimuli of 200 Hz were applied at various sites within the brain. Results showed that stimulation of the contralateral precruciate cortex, the medial part of the internal capsule, the ventralis anterior nucleus of the thalamus, and the ipsilateral anterior lobe of the cerebellum produced an intense inhibitory effect on TVR, but no significant effect by stimulation alone. Therefore, it is suggested that stimulation of these structures should be suitable for clinical application.

Animals↗

Vascular lesions of the thalamus on the dominant and nondominant side.

A clinicopathological study was done on 87 subjects with VPL lesions due to vascular pathology, with special reference to the difference of clinical manifestations between the right and left sides. Thalamic pain was far more common in VPL lesions on the right side. The responsible lesions for thalamic pain were observed in lesions of VPL and VPL extending to the internal capsule, while in the lesions of the VPL extending to the centrum medianum, central pain was rare. 2 cases with aphasia due to thalamic hemorrhage were found in this series, both in the dominant hemisphere. It is suggested that the thalamus in the dominant hemisphere may be related to speech and in the nondominant to a central pain mechanism.

Aged↗

Borrelia burgdorferi-seropositive chronic encephalomyelopathy: Lyme neuroborreliosis? An autopsied report.

A 36-year-old Japanese woman presented with progressive cerebellar signs and mental deterioration of subacute course after her return from the USA. Her serum antibody to spirochete Borrelia burgdorferi was significantly elevated. A necropsy 4 years after her initial neurological signs revealed multifocal inflammatory change in the cerebral cortex, thalamus, superior colliculus, dentate nucleus, inferior olivary nucleus and spinal cord. The lesions showed spongiform change, neuronal cell loss, astrocytosis and proliferation of activated microglial cells. The internal capsule was partially vacuolated and the spinal cord, notably at the thoracic level, was demyelinated and cavitated in the lateral funiculus. Microglial cells aggregated within and around the spongiform lesions and microglial nodules were present in the medulla oblongata. Use of Warthin-Starry stain demonstrated silver-impregnated organisms strongly suggesting B. burgdorferi in the central nervous tissues. The dentate nucleus and inferior olivary nucleus showed the most advanced lesions with profound fibrillary gliosis. Occlusive vascular change was relatively mild, and fibrous thickening of the leptomeninges with lymphocyte infiltrates was localized in the basal midbrain. The ataxic symptoms were due to the dentate and olivary nucleus lesions and mental deterioration was attributable to the cortical and thalamic lesions. Spongiform change, neuronal cell loss, and microglial activation are characteristic pathological features in the present case. The cerebellar ataxia and subsequent mental deterioration are unusual clinical features of Lyme neuroborreliosis. Spirochete B. burgdorferi can cause focal inflammatory parenchymal change in the central nervous tissues and the present case may be an encephalitic form of Lyme neuroborreliosis.

Adult↗

Course and collaterals of corticospinal fibers arising from the sensorimotor cortex of the reeler mouse.

The reeler genetic mutation, occurring spontaneously in mice, affects migration of neuroblasts in the central nervous system at its last stage, causing severe cytoarchitectonic abnormalities in laminated structures, such as the cerebral and cerebellar cortex. In the reeler mouse, corticospinal (CS) neurons are malpositioned in association with the deranged laminar cytoarchitecture. To examine whether CS projections in the reeler mouse and their collaterals terminating with subcortical nuclei are normal or not, 5% biocytin was injected into the sensorimotor cortex of 2-month-old normal and reeler mice. Anterogradely labeled CS fibers of normal and reeler mice exited from the cortex and entered the internal capsule and the cerebral peduncle. They penetrated the basal pontine gray matter as longitudinal pontine fibers and entered the medullary pyramid. They continued caudally as a compact bundle along the ventral surface of the medulla, passed through the pyramidal decussation at the spinomedullary junction and entered the contralateral dorsal funiculus of the spinal cord. Both in normal and reeler mice, collaterals arising from these CS fibers projected to the ipsilateral red nucleus, basal pontine gray matter, inferior olivary complex, and the contralateral gracile nucleus. Thus, in the reeler mouse, the course and termination of CS fibers and their collaterals are identical to their normal counterparts, suggesting that radially malpositioned CS neurons in the sensorimotor cortex project to the subcortical nuclei in a manner similar to normal CS neurons.

Animals↗

Diaphragmatic elevation in stroke.

We compared the relative elevations of the two diaphragms in the supine chest films of 62 patients with recent hemiparesis due to a supratentorial stroke with that of 92 acute coronary patients without neurologic disease. Patients with severe hemiparesis or lesions larger than 40 ml exhibited an excessive elevation of the diaphragm on the paretic side compared with controls. This finding was more common with lesions involving the genu of the internal capsule and/or the near anterolateral area. Measurement of the interdiaphragmatic elevation difference may give information on the location and/or size of the stroke.

Cerebral Hemorrhage↗

Progressive multifocal leukoencephalopathy of the posterior fossa in an AIDS patient: clinical, radiographic and evoked potential findings.

A 39-year-old intravenous drug user presented with dysarthria and a syndrome of the left cerebellar hemisphere. While in hospital, he developed progressive brainstem findings. Repeated CT scans revealed a lucency in the white matter of the left cerebellar hemisphere. Brainstem auditory and short-latency somatosensory evoked potentials provided evidence of brainstem dysfunction without corresponding lesions on CT. Biopsy of the cerebellum established the diagnosis of progressive multifocal leukoencephalopathy (PML) and the acquired immunodeficiency syndrome (AIDS). Postmortem examination revealed brainstem lesions appropriate to the evoked potential findings and a radiographically inapparent lesion in the right internal capsule. Based on this case and a review of the literature we conclude that: (1) PML occurs with significant prevalence in AIDS patients and may involve the posterior fossa; (2) the diagnosis of posterior fossa PML is suggested by certain clinical and radiographic criteria and may be confirmed by brain biopsy; (3) evoked potentials may be abnormal in PML and can reveal functional abnormalities of white matter without apparent CT abnormalities.

Acquired Immunodeficiency Syndrome↗

Pontine infarction producing dysarthria-clumsy hand syndrome and ataxic hemiparesis.

We describe two patients, one with clumsy hand-dysarthria syndrome and one with ataxic hemiparesis. Both had pontine lesions on CT. Similar clinical syndromes may be seen with lesions of the internal capsule, and it is not possible to predict the lesion's location from clinical information alone. The clinical picture of dysarthria-clumsy hand syndrome or ataxic hemiparesis is also not specific for lacunar infarction.

Ataxia↗

Transient hypodensity on CT scan during hypoglycemia.

A diabetic patient became hypoglycemic with right hemiparesis during a contrast-enhanced CT scan. The scan showed a nonenhancing hypodensity in the left internal capsule, that disappeared the following day after treatment with glucose. This is consistent with experimental models that show selective vulnerability of various brain regions to hypoglycemia.

Aphasia↗

Hyperkinetic motor behaviors contralateral to hemiplegia in acute stroke.

Motor behaviors on the 'good side' of the body, i.e. ipsilateral to the hemispheric lesion, have not been studied systematically. We assessed motor behaviors in 20 consecutive patients during the acute phase (first 1-2 weeks) of a hemispheric stroke with hemiparesis. The behaviors were essentially rotations of the head, neck, eyes and trunk, orofaciopharyngeal or limb stereotypes, compulsive manipulation of the surroundings, or passive mobilization of the paralyzed arm or leg. These behaviors were found only with large infarcts in the territory of the internal carotid artery, middle cerebral artery and/or the anterior cerebral artery (ACA). All but two ACA infarcts involved the internal capsule and basal ganglia. The severity of the motor deficit and the presence of aphasia, neglect, or sensory loss were significantly correlated with the motor behaviors. Although the understanding of these behaviors remains unclear, we suggest that they may represent the clinical expression of early plastic changes of brain maps and circuits after an acute lesion; this is probably an active process induced by disinhibition, in order to establish new compensatory pathways.

Acute Disease↗

Spatial and perceptual impairment related to cortical cerebral blood flow and EEG in deep white matter infarcts of the right hemisphere.

A study was performed in order to investigate how infarcts located in the white matter of the right hemisphere may affect processing of spatial and perceptual abilities. A battery of neuropsychological tests was applied to 7 right-handed patients with CT-verified infarcts of the right internal capsule or periventricular white matter. Examinations were performed 1-3 weeks post stroke and 3-7 months later. The patients were assessed by neurological examinations, EEG, and cortical regional cerebral blood flow (rCBF) measurements. This study suggested that deep white matter infarcts of the right hemisphere may result in persistent spatial impairment in the absence of decreased cortical rCBF. Perception was disturbed in cases of low mean cortical CBF of both hemispheres.

Adult↗

Encephalopathy due to toluene sniffing. Report of a case with magnetic resonance imaging.

A 27-year-old man with a 10-year history of toluene abuse developed dementia, cerebellar ataxia, dysarthria and pyramidal signs. Magnetic resonance imaging (MRI) revealed atrophy of the cerebrum, corpus callosum, cerebellum and brainstem. The internal capsule showed abnormal intensity. Chronic toluene abuse may affect not only the cerebral and cerebellar cortex or brainstem but also the subcortical cerebral white matter. MRI may be a sensitive tool to use in evaluating the severity and prognosis of the neurological syndrome resulting from toluene abuse.

Adult↗

Childhood form of adrenoleukodystrophy in the sucking infant.

The childhood form of adrenoleukodystrophy (ALD) in a sucking infant was discovered before the appearance of clinical symptoms. C24:0/C22:0 and C26:0/C22:0 ratios in umbilical cord plasma were significantly higher so that very long-chain saturated fatty acid-restricted milk was given. Ultrastructural study on biopsied rectal mucosa revealed rectilinear and/or curved electron-lucent clefts in the histiocytes at 3 months of age, which were also recognized in the elder brother and another boy with symptoms of ALD. However, magnetic resonance imaging and T1 and T2 values were within the normal range in cerebral gray matter, cerebral white matter, caudate nucleus, internal capsule, and thalamus.

Adolescent↗

White matter alterations in cerebral amyloid angiopathy measured by diffusion tensor imaging.

BACKGROUND AND PURPOSE: Cerebral amyloid angiopathy (CAA) represents beta-amyloid deposition in the small- and medium-sized vessels of the brain and meninges. CAA contributes to altered vessel function and is associated with white matter damage, cognitive impairment, and most salient, hemorrhagic stroke. We used diffusion tensor imaging to evaluate the anatomic distribution of white matter degeneration in participants diagnosed with advanced CAA. METHODS: Diffusion tensor imaging was obtained from 11 participants diagnosed with CAA-related intracerebral hemorrhage and 13 matched healthy control participants. Fractional anisotropy (FA) and diffusivity maps were compared using voxel based t test and region-of-interest analyses. RESULTS: FA was reduced in CAA in temporal white matter and in the splenium of the corpus callosum (P<0.001 with approximately 17% reduction in temporal white matter and 15% reduction in the splenium). FA was marginally increased in CAA in the posterior limb of the internal capsule and subthalamic gray matter regions (approximately 7% increase in subthalamic gray). FA changes were bilateral, remained significant in cluster analysis controlling for multiple comparisons, and did not depend on the hemisphere of the cerebral hemorrhage. Diffusivity was not substantially altered. CONCLUSIONS: These findings suggest that a pattern of regional brain tissue degeneration is a characteristic feature of advanced CAA.

Aged↗

Selective lenticulostriate occlusion in the primate. A highly focal cerebral ischemia model.

A highly reliable model for the study of focal cerebral ischemia has been developed using a retro-orbital approach to occlude the lateral lenticulostriate arteries of the baboon. An infarction of the caudate, putamen and the anterior limb of the internal capsule has consistently been produced. Reliability has been attained because the anatomical variations of the lenticulostriate arteries of each animal can be fully appraised, permitting selective vessel occlusion. A well-defined clinical and radiographic lesion has also resulted from this procedure which was clinically well tolerated by all animals. Selective lenticulostriate occlusion provides a new approach to the study of focal cerebral ischemia in the sub-human primate, and serves for the evaluation of proposed therapies for treatment of focal cerebral ischemia.

Animals↗

Computed tomographic findings of good prognosis for hemiplegia in hypertensive putaminal hemorrhage.

Computed tomography (CT) findings were analyzed in 17 patients with hypertensive putaminal hemorrhage accompanied by hemiplegia which had subsided almost completely by conservative therapy within one month after the onset. In such patients a high density area was not seen at the level of the lateral ventricles on CT scan. To study the reason for this, the relationship between the extent of a hematoma and the level at which the pyramidal tract was destroyed was investigated. From consideration of the process of destruction of the pyramidal tract by a hematoma, it seemed that CT findings at the level of the bodies of the lateral ventricles, rather than at the level of the posterior limb of the internal capsule, were of value in evaluating the prognosis of hemiplegia in putaminal hemorrhage.

Adult↗