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A patient presented with a pure left sensory deficit of sudden onset. CT scan showed a small capsular infarct in the anterior choroidal artery territory involving the superior thalamic peduncle in the posterior limb of the internal capsule.
The nervous system of 13 patients who died of an acute oral intoxication with carbophos was subjected to morphological examinations. Vascular changes were expressed as congestive plethora, perivascular edema and microfocal hemorrhages. Cellular abnormalities mainly included acute swelling, severe ischemic and hydropic alterations. Pathomorphology of the fibers was manifested in foci of secondary demyelinization in the internal capsule, lateral columns of the spinal cord and the peripheral nerves of the extremities.
Oculomotor disorders in 22 infarctions in the thalamic region are recorded. Clinical examination and electro-oculography (17 cases) showed that paramedian thalamo-subthalamic lesions were responsible for clear deficits: upgaze paralysis and in some cases downgaze paralysis, partial paresis of the oculomotor nerve, deficits of lateral eye movements, myosis, paralysis of head flexion combined with downgaze paralysis. Postero-median choroid artery infarction was associated with upgaze paresis, slight deficit of lateral eye movements and myosis. Postero-lateral choroid artery infarction resulted in a partial visual field defect and in some cases, a contralateral hypometria; myosis was slight and inconstant. Infarctions of the internal capsule (anterior choroid artery, deep branches of the middle cerebral artery) were associated with a deficit of contralateral saccades. Ocular pursuit, when possible, was often saccadic, whatever the site of the infarction. This prevailed with gaze towards the lesion side.
The nature and degree of motor disorders, the degree and rate of recovery were shown to be more dependent on the localization than on the size of the cerebral infarction specified by computer-aided tomography of the drain. Localization of infarct in the posterior femur of the internal capsule proved the least favourable with regard to the recovery of motor functions.
To determine the possible role of age in motor rehabilitation, the authors compared the degree of restoration of impaired motor functions in patients of different age groups with infarction foci in the large hemispheres of the brain. Localization and size of post-ischemic changes in the cerebral substance were assessed by computer-aided tomography. By the end of the late rehabilitative period. (12 months after the development of infarction), there were no statistically significant differences between the degree of recovery of impaired motor possibilities. Most important for recovery seems to be an intactness of functionally significant structures, especially of the posterior femur of the internal capsule.
In spite of a recent remarkable progress in operative results of ruptured middle cerebral artery aneurysms, a mortality rate of 2-8% appears to be unavoidable. In the present study, 53 ruptured MCA aneurysms were retrospectively analyzed to determine causative factors of unfortunate outcome (fair, poor and dead). Surgical results of 53 ruptured MCA aneurysms are shown in Table 1, where the outcome was unfortunate in 7 cases (17%). Intracerebral hematoma was responsible for 4 cases, two of which were fatal and postoperative vasospasm for 3 cases. There were 13 cases with intracerebral hematomas (25%) ranging from 21 mm to 68 mm in diameter. Although hematomas less than 40 mm in diameter localized in temporal or frontal subcortical areas and yielded no neurological deficits, those more than 60mm extended to the caudate nucleus or thalamus through the internal capsule and led to deep coma (Table 2, Fig. 1). Intracerebral hematoma with the diameter between 50 to 60 mm seems to be critical in regard to postoperative outcome. Repeated rupture caused intracerebral hematoma (50%) more frequently than single rupture (21%) and aneurysm with intracerebral hematoma was liable to bleed (27%), resulting in acute deterioration of neurological conditions by marked enlargement of the hematoma (Fig. 2). Accordingly it is essential for the cases with intracerebral hematoma to prevent rerupture. Subarachnoid hemorrhage and symptomatic vasospasm were observed less frequently in hematoma group than in non-hematoma group. However, prophylactic treatment of vasospasm is important even in the cases with intracerebral hematoma since more than half of them suffer from relatively thicker subarachnoid clot.
A 24 year-old man experienced a left retrobulbar neuritis which improved completely after 2 months of non-steroid antiinflammatory therapy. One month after the end of the treatment he developed a Korsakoff-like amnestic syndrome. Three months later he complained of horizontal diplopia. A CT Scan showed a diffuse enhancement of the periventricular areas, corpus callosum and fornix. Diplopia and CT scan abnormalities disappeared after the administration of tetracosactide. Subsequently a progressive worsening of the neurological condition developed, including a 1 1/2 syndrome of Fisher. In C.S.F. proteins ranged from 35 to 66 mg/dl, gammaglobulins from 4 to 5 per cent, cells from 2.2 to 6.8 per mm3 without abnormal cells. Rounded areas of enhancement were observed on CT scan in pons and right occipital lobe. Usual biological tests, abdominal echography and lymphography were normal. Death occurred 15 months after the onset of symptoms. Neuropathological examination showed: 1) a cerebral lymphoma of probable B origin with distinct masses in right occipital lobe and pontine tegmentum and a more diffuse perivascular infiltration on the left side in the amygdaloid nucleus, fourth temporal gyrus, sublenticular area, hypothalamus and in the right internal capsule; 2) multiple small clear-cut foci of demyelination with myelin-axonal dissociation bilaterally in the optic pathways, periventricular regions, corona radiata, cerebral and cerebellar white matter, sublenticular areas, temporal lobes, splenium of the corpus callosum and fornices with secondary atrophy of the mamillary bodies. Both recent and old plaques were observed. Inflammatory perivascular cuffing, when present, consisted of small nontumoral lymphocytes.(ABSTRACT TRUNCATED AT 250 WORDS)
Self-stimulation was studied in dogs chronically implanted with electrodes in different points within the basal forebrain. The animals exhibiting pure self-rewarding behavior were defined as "optimal" and "good self-stimulators", whereas those with concomitant aversive phenomena were incorporated into the third category called "self-stimulation-withdrawal". In "optimal self-stimulators" a remarkable resistance of the response to extinction was noted. A strong negative attitude toward food was found in four dogs upon stimulation of the self-rewarding loci. Penile erection accompanied self-stimulation in two animals. Sniffing at first always followed incentive brain stimulation, but later it appeared at the beginning of each experiment and/or preceded the bouts of pressing. A rise of hypothalamic temperature was noted in mast of the animals. In some cases this was equal to or exceeded 1 degree Celsius. The temperature increase was accompanied by intense panting between the bouts. Seizures appeared locally as contractions of masticatory muscles and sometimes developed into a generalized fit. Anatomically the "reward area" in the dog extends from the septum and the preoptic area to the mammillary bodies and reaches laterally to the internal capsule.
Five cases are reported of tuberculous patients who presented with hemiplegia as the initial symptom of their illness. In three patients the paralysis improved rapidly and completely with institution of antituberculous treatment. One case which came to necropsy revealed that the cause of the hemiplegia was a tuberculoma situated in the internal capsule.
In a 6-month period, 40 consecutive patients with a diagnosis of cerebral infarction had computed tomography (CT) scanning. The purpose of this study was to evaluate the association between the location and size of the lesion on CT scan and the functional status of the patient on discharge and follow-up. The results of the CT scan were divided into the following major groups: deep (involving the basal ganglia, internal capsule and thalamus), superficial large and superficial small (involving the cerebral hemisphere up to and including the external capsule) and normal. At discharge, patients were divided into 2 major functional groups: group A, minimal assist to independent in transfers and ambulation; and group B, moderate to maximal assist in transfers and maximal assist in ambulation. Ten of 11 patients with small superficial lesions were in group A, and 10 of 13 patients with deep lesions were in group B. Of 10 patients with large superficial lesions, 5 were in group A and 5 in group B. All 6 patients with normal CT scans results were in group A. Thus, results of CT scanning appear to be associated with degree of functional recovery.
A total of 95 patients operated for hypertensive intracerebral hemorrhages during the first 3 days following the stroke were studied. The average amount of the postoperative lethal outcome was 46% and in the last years--26%. The analysis of the observations demonstrated that in hemorrhages into the cerebral hemispheres (the most frequent hemorrhages) a vital prognosis and evidences for operation are mainly determined by the depth of hematoma position in relation to the internal capsule, a degree of blood hemorrhages into the ventricles, state of brain magistral arteries (carotic, vertebral-basilar) and the brain stem. Cerebral angiography is a very important examination method facilitating the determination of a hemorrhage cause, its localization, expressiveness of dislocation phenomena, as well as the character and degree of changes of the brain magistral arteries (atherosclerotic stenoses, exaggerations, ansae, hypoplasia). The determination of a vital prognosis of a stroke with conservative and surgical treatment with the aid of a computer permits to solve the problem of evidences for an operation more basically.
Language disorders developed in a patient following a subcortical infarct involving the left putamen and caudate nucleus. Language was abundant and fluent, with many perseverations, semantic and ideation incoherences, and all activities concerned with verbal or non-verbal expression were affected. Lesions were present in the head and body of the caudate nucleus, the whole of the putamen, the anterior nucleus of the thalamus and the superior part of the internal capsule. The disorder was unique in relation to disturbances of the aphasic type observed in extensive thalamic lesions, or in transcortical sensorial aphasia. Physiopathological interpretation is based on the functional role of the putamen-caudate system in the regulation of many types of behaviour: animal experiments and results of applying stimuli in humans suggests a release of the inhibition exerted by the caudate nucleus on the frontal cortex. Lack of comparable clinicopathological data implies that other similar cases must be reported before the specificity of the disorder can be confirmed.
Intracranial germ cell tumors usually locate either in the pineal region or in the suprasellar region or both. Primary occurrence of germ cell tumor in the basal ganglia is rare. To our knowledge, only 17 cases have been reported in the literatures, and all the patients were Japanese. None of these patients presented elevated serum and CSF AFP levels in the literatures. We are reporting a patient with a germ cell tumor which developed in the left basal ganglia and showed high serum and CSF alpha-fetoprotein (AFP) levels. The patient was a 12-year-old boy who had been completely well until five months prior to the first admission when he developed weakness of right extremities. On admission he showed a right hemiparesis of mild degree and right hypesthesia. CT-scans demonstrated a homogeneous high density area over the caudate head and the putamen on the left side. The anterior limb of the left internal capsule and a part of the posterior limb were also involved. The lesion was moderately enhanced by the contrast medium. Stereotaxic biopsy of the lesion was uncontributory and he was discharged for follow up. Five months later, CT-scans demonstrated the enlargement of the high density area with perifocal edema. Then we performed a craniotomy, and the tumor which was soft and dark red in colour was biopsied at the wall of the anterior horn of the left lateral ventricle. Histopathology of the specimen showed germinoma of two-cell pattern.(ABSTRACT TRUNCATED AT 250 WORDS)
We have investigated the subcortical projections of the rat striate cortex by using the silver-degeneration method and the HRP-technique too. Cortical lesions were made in 60 young animals (1, 4, 5, 6, 7, 10 and 14 days old) and in 6 adult rats. The terminal regions of projection occurred only ipsilateral to the lesions. After passing the internal capsule the degenerating pathway divides into 2 bundles. In the dorsal thalamus one of them runs in caudal direction. The other bundle turns ventrally, reaches the cerebral peduncle and terminates in the pons. The first fibre bundle terminates in the following structures: Nc. reticularis thalami, Nc. lateralis thalami, Nc. lateralis posterior thalami, Corpus geniculatum laterale, pars dorsalis (Cgld), Corpus geniculatum laterale, pars ventralis (Cglv), Nc. praetectalis anterior et posterior and Colliculus superior. The fibers of the second bundle innervate the Nc. lateralis pontis. Fibers from this bundle terminate probably in the Cglv and in the Zona incerta too. By using the HRP-technique it could be demonstrated that the axons terminating in the Cgld originate in layer VI of the area 17. In contrast, the projection to Cglv, Nc. lateralis posterior, Colliculus superior and Nc. lateralis pontis originates from pyramidal cells in layer V. The development of the projection in young animals indicates: Like in adults rats, terminal degeneration is present in all subcortical projection regions at postnatal day (PD) 10. At PD 4-7 we can observe heavily degenerating axons but the terminal degeneration is different. It is remarkable in the "visual" part of the reticular nucleus and iln the Cgld (decreasing from inside to outside). Only a weak terminal degeneration is visible in the pretectal region and in the superior colliculus. At PD 1 the trajectory of degenerating fibres is clearly visible. Signs of terminal degeneration can only be found in the reticular nucleus. It is discussed whether the date of generation of the cortical neurons and the time of the differentiation of the cortical layers is of importance for the time of innervation of the subcortical projection fields. The question when the axons arrive at their terminal region and form there synaptic contacts has not yet been exactly answered. To solve this problem electronmicroscopic investigations are necessary.
In order to evaluate physiological significance of F-wave in the diagnosis of spasticity, 10 patients with intracranial mass lesion who did not show clinically lateralizing evidence especially in DTRs were examined and the data were compared with the results obtained from 10 other normal subjects. F-wave was recorded from thenar muscle with supramaximal stimulation to the median nerve at wrist. Latency and amplitude of F-wave failed to show any significant difference in patients compared with normal subjects both on affected sides, however, frequency of F-wave was found to be significantly higher on affected side except for 2 cases who had a mass lesion in occipital lobe in one case and the other was in the state of diaschisis due to recent hemorrhage in the parietal tumor. The site of lesion was carefully determined with CT scan and it was concluded that the F-wave could be detected quite in early stage of intracerebral mass lesion if the process had affected to internal capsule or cerebral peduncle under indirect mass effect such as cerebral edema. On the contrary, it was interesting to note that the mass with no affection to the premotor cortex likely showed higher frequency of F-wave on the ipsi-lateral side of lesion. As the conclusion, F-wave was found to have advantage in the diagnosis of spasticity in the early stage of illness and more accurate information on spasticity could be obtained compared with T or H-wave.
Chronic implantation of a stimulating electrode in the thalamic relay nucleus (11 cases), in the periaqueductal gray (1 case) and in the internal capsule (2 cases) was performed in fourteen cases which suffered from intractable pain. All these cases could get pain relief at least initial two months. Ventricular fluids were collected before and after stimulation with optimal combination of parameters, and measurements of beta-endorphin were performed by radio-immunoassay. Intrathecal morphine (1mg) injection was performed in eight cases. Cerebrospinal fluids were collected by lumbar tap before and 24 hours after morphine injection. beta-endorphin immunoreactivity was measured by the same method. Pain relief was judged to be excellent if the patient so claimed, and if he discontinued analgesics. Pain relief was thought to be good when it was not completely controllable by stimulation but was sufficiently improved that the patient could do without analgesics. It was thought to be fair when patient could not discontinue analgesics, and poor when patient could not get pain relief. We usually attempt to prevent the stimulation-tolerance by administration of the monoamine precursors , i.e., 1-dopa and 1-tryptophan, on the basis of the experimental observation reported previously. In somatogenic pain patients, the thalamic relay nucleus stimulation was performed in 7 cases (excellent; 3, good; 1, fair; 3) and the periaqueductal gray stimulation in one case (good).(ABSTRACT TRUNCATED AT 250 WORDS)
Using immunohistochemical techniques, we demonstrated oxytocin (OT) and vasopressin (AVP) neurons in the cat hypothalamus. The OT immunoreactive neurons were found mainly in the paraventricular nucleus, supraoptic nucleus and dorsal accessory group located lateral to the fornix. In addition to these hypothalamic structures, the AVP immunoreactive neurons were observed in the suprachiasmatic nucleus, ventral accessory group located in the retrochiasmatic area and lateral accessory group, dorsal to the supraoptic nucleus caudally, and ventral to the medial part of the internal capsule rostrally. We further demonstrated a different localization of the OT and AVP immunoreactive neurons in the paraventricular and supraoptic nuclei.
It has been generally accepted that topectomy is a choice of treatment for patients who have an intractable cortical epileptic focus. However, the surgery is not indicated in the cases whose focus is functionally involved in the vital cortical regions. We have experienced a case of intractable traumatic cortical epilepsy, in which the patient underwent cortical surface coagulation on his motor cortex during the dissection of his wide-spread durocortical adhesion. Subsequently, his epileptic attacks have been abolished completely for over 7 years without motor deficit. It is the purpose of this work to confirm experimentally that destruction of apical dendrites on the epileptic focus may prevent occurrence of abnormal spike epileptic discharges without vital neuronal deficit. Fifty dogs were used in this study. In normal dogs, the antidromic cortical response, after stimulation of the internal capsule, showed three predominant negative waves axonal (the first), cortical neuronal (the second) and apical dendritic potentials (the third) by surface recordings. Upon creation of the penicillin-induced cortical epileptic focus, spike discharges appeared on the corticogram, and the third wave of the antidromic cortical response shifted from negative to positive. Selected destruction of the dendrites, in the first and the second cortical layers, in the area of the epileptic focus brought about disappearance of the third wave, to isopotentially, and a marked inhibition or complete disappearance of spikes on the corticograms. The possibility exists, as been suggested by our experiment, to clinically apply this method as a treatment for intractable cortical epilepsy with foci in the functionally vital regions, although there are yet many problems to be solved.