Cauda Equina Syndrome Occurred by Adhesive Arachnoiditis of the Lumbar Spine with an Unknown Cause / 대한정형외과학회잡지

Spinal adhesive arachnoiditis is an inflammation and fibrosis of the subarachnoid space and pia mater caused by infection, trauma, spinal vascular anomalies, and iatrogenic (surgery and/or puncture). Adhesive arachnoiditis develops various symptoms and signs (gait disturbances, radiating pain, paralysis, and incontinence). On the other hand, adhesive arachnoiditis associated with cauda equina syndrome has not been reported in Korea until now. The authors experienced cauda equina syndrome caused by adhesive arachnoiditis of the lumbar spine with satisfactory results following decompression. We report this case with a review of the relevant literature.

Aracnoidits y quistes aracnoideos espinales múltiples. Revisión bibliográfica a propósito de un caso / ARACNOIDITIS AND MULTIPLE ARACNOID CYSTS : CASE REPORT AND REVISION OF THE LITERATURE

Los quistes aracnoideos son lesiones malformativas que contienen en su interior un líquido de características similares al líquido cefalorraquídeo. Constituyen alrededor del 1% de todos los procesos ocupantes de espacio a nivel intracraneal y, en menor número de casos pueden localizarse a nivel espinal. Presentamos una asociación de aracnoiditis espinal y posterior cavitación.

Arachnoid cysts are malformative lesions that contain a liquid with characteristics similar to cerebrospinal fluid. They constitute about 1% of all space-occupying processes at the intracranial level and, in a smaller number of cases, they can be located at the spinal level. We present an association of spinal arachnoiditis and posterior cavitation

Surgical Management of Syringomyelia Associated with Spinal Adhesive Arachnoiditis, a Late Complication of Tuberculous Meningitis: A Case Report / 대한신경손상학회지

Syringomyelia associated with tuberculous meningitis is an extremely rare condition. Only a few studies have reported clinical experience with syringomyelia as a late complication of tuberculous meningitis. Twenty-six years after a tuberculous meningitis episode, a 44-year-old man presented with progressively worsening spastic paresis of the lower limbs and impaired urinary function for 2 years. Radiological examination revealed syringomyelia extending from the level of C2 to T9 and arachnoiditis with atrophy of the spinal cord between C2 and T3. We performed laminectomy from C7 to T1, dissected the arachnoid adhesion and placed a syringo-pleural shunt via keyhole myelotomy. One year after the operation, his neurological condition improved. The postoperative control magnetic resonance imaging revealed the correctly located shunt and significantly diminished syringomyelia cavities. We aim to discuss the mechanism of syrinx formation following tuberculous meningitis and to share our surgical therapeutic experience with this rare disease entity.

Intradural Extramedullary Capillary Hemangioma In the Upper Thoracic Spine with Simultaneous Extensive Arachnoiditis

Capillary hemangiomas are common benign vascular tumors on skin and soft tissues, but developing as an intradural and extramedullary (IDEM) tumor in spine is extremely rare. In this report, we present IDEM tumor compressing thoracic cord in T2–3 level with extensive arachnoiditis below the tumor level in a 60-year-old man. The lesion was removed and histological diagnosis was capillary hemangioma. Prompt diagnosis and resection are important to avoid neurological deterioration from acute hemorrhagic condition. Simultaneous arachnoiditis may be originated from old subarachnoid hemorrhage associated tumor before diagnosis, and we suggest it as a helpful diagnostic feature to suspect vascular tumors such as capillary hemangioma.

Idiopathic Cervicosyringomyelia in 2 year-old Boy

Syringomyelia is a disorder in which a cavity has formed within the spinal cord. Idiopathic syringomyelia is not associated with identifiable causes such as Chari type 1 malformation, spinal cord tumor, vascular malformation, tethered cord, arachnoiditis, hydrocephalus, or previous spinal surgery. The main neurologic symptoms of idiopathic syringomyelia are toe-walking, constipation, incontinence, abnormal reflexes, and lower extremity weakness. Patients may present with various symptoms such as scoliosis, cutaneous markers, pain in the lower extremities or back, or may be asymptomatic. Herein, we report a young child with idiopathic syringomyelia presenting with subtle neck pain. A 23-month-old boy visited the neurologic clinic after 3 months of right occipital area neck pain. He had no history of trauma or central nervous system infection, and neurologic examination results were normal except for right posterior neck hyperesthesia. Brain and spinal magnetic resonance imaging showed an ovoid intramedullary cystic lesion (9.7×5.0×4.7 mm) at C6/7 of the spinal cord. There was no evidence of Chiari malformation or other lesions that can be primary pathologies of syringomyelia. Electromyogram/nerve conduction velocity results were normal. The subject was diagnosed as idiopathic syringomyelia. His symptoms and neurologic/radiologic indications showed no change at a 1-year follow-up. Idiopathic syringomyelia symptoms are varied and may be overlooked by physicians. Pediatricians may consider syringomyelia if patients complain about persistent sensory abnormality. All patients who present with syringomyelia should undergo detailed neuroimaging of the entire neuraxis to elucidate the proximate cause of the lesion.

A Long, Solitary, Rosary-Shaped Spinal Neurofibroma

STUDY DESIGN: Case report. OBJECTIVES: We report the case of a long, solitary, rosary-shaped neurofibroma that was misdiagnosed as another disease due to the patient's surgical history involving repetitive procedures and its abnormal appearance. SUMMARY OF LITERATURE REVIEW: Neurofibroma is an intradural-extramedullary spinal tumor. It is generally not difficult to diagnose due to its frequent occurrence and specific magnetic resonance imaging (MRI) findings. However, to date, neurofibromatosis stigmata and long, solitary, rosary-shaped neurofibromas have rarely been reported. MATERIALS AND METHODS: A 60-year-old woman was admitted to our hospital due to persistent pain, despite previous surgery and repetitive procedures. On physical examination, vision loss, hearing loss, skin discoloration, or subcutaneous nodules were not observed. A neurologic examination revealed normal motor and sensory function and voiding sensation. No pathologic reflexes such as the Babinski sign were observed. Previous sequential MRIs revealed intradural lesions that progressed from the thoracic vertebra 11 to the lumbar vertebra 3. She had no signs of neurofibromatosis stigmata, and the neurologic examination was unremarkable. The initial diagnosis was based on serial MRIs, which revealed a parasite infestation, a spinal cord tumor (myxopapillary-type ependymoma with hemorrhage), arachnoiditis, and vascular malformations. Total mass excision was performed, and the final diagnosis was neurofibroma. RESULTS: There were no signs of a tumor remnants or local recurrence in a 1-year follow-up MRI study. CONCLUSIONS: Although intradural spinal tumors are very rare, their clinical features are nonspecific and resemble other degenerative spinal diseases, including spinal stenosis and disc herniation. These diseases may easily be overlooked by physicians.

Surgical Outcome of Tuberculous Myelitis, Arachnoiditis and Spondylitis after Brain Meningitis: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of a surgically treated tuberculous myelitis and arachnoiditis patient with incomplete paraplegia. SUMMARY OF LITERATURE REVIEW: Tuberculous myelitis and arachnoiditis is a rare disease with a high rate of neurologic deficit. This condition is treated using antituberculous medication and high-dose steroid therapy, but surgical treatment has rarely been reported and the outcomes vary. MATERIAL AND METHODS: A 29-year-old female had tuberculous myelitis and arachnoiditis. The patient was treated with antituberculous medication and high-dose steroid therapy, but the treatment failed and the patient could not walk because of incomplete paraplegia. The surgical treatment was performed twice; we decompressed by total laminectomy and debrided the infected arachnoid membrane. Four months after surgery, we performed anterior interbody fusion due to the development of spondylitis with kyphosis. RESULTS: Three years after the first operation, the patient's neurologic state improved and she could walk 90 m without assistance. CONCLUSIONS: Here, we report a very rare case of surgically treated tuberculous myelitis and arachnoiditis and provide a treatment option for this condition to spine surgeons.

Hydrocephalus due to Membranous Obstruction of Magendie's Foramen

We report a case of non communicating hydrocephalus due to membranous obstruction of Magendie's foramen. A 37-year-old woman presented with intracranial hypertension symptoms caused by the occlusion of Magendie's foramen by a membrane probably due to arachnoiditis. As far as the patient's past medical history is concerned, an Epstein-Barr virus infectious mononucleosis was described. Fundoscopic examination revealed bilateral papilledema. Brain magnetic resonance imaging demonstrated a significant ventricular dilatation of all ventricles and turbulent flow of cerebelospinal fluid (CSF) in the fourth ventricle as well as back flow of CSF through the Monro's foramen to the lateral ventricles. The patient underwent a suboccipital craniotomy with C1 laminectomy. An occlusion of Magendie's foramen by a thickened membrane was recognized and it was incised and removed. We confirm the existence of hydrocephalus caused by fourth ventricle outflow obstruction by a membrane. The nature of this rare entity is difficult to demonstrate because of the complex morphology of the fourth ventricle. Treatment with surgical exploration and incision of the thickened membrane proved to be a reliable method of treatment without the necessity of endoscopic third ventriculostomy or catheter placement.

Severe transient burning pain after intrathecal steroid injection for treatment of postherpetic neuralgia: two cases report

Until now, we do not have a definitive treatment for intractable postherpetic neuralgia (PHN). But, there is relatively strong evidence for the efficacy of intrathecal methylprednisolone injection in the treatment of intractable PHN. In spite of the effectiveness, many clinicians hesitate to use intrathecal steroids due to adverse effects such as adhesive arachnoiditis. We experienced two cases of temporary severe burning pain after intrathecal steroid injection for treatment of PHN. On the next day, the patients did not have any burning pain, and they were discharged with decreased pain associated with PHN.

Management of paradoxical response in pediatric tubercular meningitis with methylprednisolone

Paradoxical response to anti-tubercular drugs remains a diagnostic dilemma. In India where tuberculosis is quite prevalent, paradoxical response to anti-tubercular treatment [ATT] is either misdiagnosed or under-diagnosed. We report two cases of optochiasmatic arachnoiditis due to paradoxical response in children suffering from tuberculous meningitis. Visual acuity was recorded as no light perception in all eyes of both patients while they were taking 4-drug ATT [isoniazid, rifampicin, pyrazinamide and ethambutol]. However their systemic conditions did not worsen. They were treated with intravenous methylprednisolone for five days followed by systemic corticosteroids on a tapering dose for four weeks along with ATT. This case report highlights the importance of early recognition of this sight-threatening complication and timely, effective treatment to prevent permanent blindness.

Mesenchymal stem cells transplantation for neuroprotection in preterm infants with severe intraventricular hemorrhage / 소아과

Severe intraventricular hemorrhaging (IVH) in premature infants and subsequent posthemorrhagic hydrocephalus (PHH) causes significant mortality and life-long neurological complications, including seizures, cerebral palsy, and developmental retardation. However, there are currently no effective therapies for neonatal IVH. The pathogenesis of PHH has been mainly explained by inflammation within the subarachnoid spaces due to the hemolysis of extravasated blood after IVH. Obliterative arachnoiditis, induced by inflammatory responses, impairs cerebrospinal fluid (CSF) resorption and subsequently leads to the development of PHH with ensuing brain damage. Increasing evidence has demonstrated potent immunomodulating abilities of mesenchymal stem cells (MSCs) in various brain injury models. Recent reports of MSC transplantation in an IVH model of newborn rats demonstrated that intraventricular transplantation of MSCs downregulated the inflammatory cytokines in CSF and attenuated progressive PHH. In addition, MSC transplantation mitigated the brain damages that ensue after IVH and PHH, including reactive gliosis, cell death, delayed myelination, and impaired behavioral functions. These findings suggest that MSCs are promising therapeutic agents for neuroprotection in preterm infants with severe IVH.

Hydrocephalus and Neurocysticercosis: Cases Illustrative of Three Distinct Mechanisms

BACKGROUND: Cysticercosis is the most frequent parasitic infection of the nervous system. Most lesions are intracranial, and spinal involvement is rare. We describe here in two cases of neurocysticercosis (NCC) in the brain and one in the spinal cord that illustrate three distinct mechanisms leading to symptomatic acute hydrocephalus. CASE REPORT: Hydrocephalus was related to intracranial NCC in two of them. In the first case the hydrocephalus was due to an extensive arachnoiditis to the craniocervical junction, while in the second it was caused by obstruction of Magendie's foramen in the fourth ventricle by the scolex of Taenia solium. For the third patient, hydrocephalus revealed cysticercosis of the cauda equina due to the scolex. CONCLUSIONS: NCC should be considered as a possible diagnosis for patients suffering from hydrocephalus when they originate from or have traveled in endemic areas, MRI of the spine is mandatory to search for intraspinal lesions.

Aracnoiditis crónica / Chronic arachnoiditis

La aracnoiditis se refiere al compromiso inflamatorio de uno, varios o todos los segmentos de la capa media de las meninges, es decir la aracnoides. Se encuentra asociada con meningitis, neoplasias, hemorragia subaracnoidea, enfermedades infecciosas como tuberculosis, procedimientos invasivos por el uso de medios de contraste tecales, colocación de analgésicos y anestésicos a nivel del raquis, quimioterápicos intratecales, procesos autoinmunes, afecciones ginecológicas e incluso procesos no invasivos. Como en la actualidad esta entidad no se considera entre los primeros diagnósticos en pacientes con clínica de dolor tipo ardor en región lumbar irradiado a miembros inferiores, incontinencia urinaria y disestesias en artejos, queremos resaltar la importancia de tener en cuenta esta patología como diagnóstico diferencial...

Arachnoiditis is a broad term denoting inflammation of one, several or all segments of the middle layer of the meninges known as the arachnoid mater. It is related to meningitis, neoplasia, subarachnoid hemorrhage, infectious diseases such as tuberculosis, invasive procedures using intrathecal injection of contrast media, epidural injection of analgesics and anesthetic agents, intrathecal chemotherapy, autoimmune processes, gynecological disorders and even non invasive procedures. As this disorder is nowadays not considered within the main diagnostic possibilities in patients who manifest burning back pain irradiated to the lower limbs, bladder dysfunction and dysethesia of the toes, we wish to highlight the importance of also considering arachnoiditis as a differential diagnosis...

Arachnoiditis Following Caudal Epidural Injections for the Lumbo-Sacral Radicular Pain

Caudal epidural steroid injection is a very common intervention in treatment of low back pain and sciatica symptoms. Although extensively used, it is not devoid of complications. A few reports of chemical and infective arachnoiditis exist following lumbar epidural anaesthesia, but none following a caudal epidural steroid injection.We report a case of arachnoiditis following caudal epidural steroid injections for lumbar radiculopathy. The patient presented with contralateral sciatica, worsening low back pain and urinary retention few days following the injection, followed by worsening motor functions in L4/L5/S1 myotomes with resultant dense foot drop. Gadolinium-enhanced magnetic resonance imaging suggested infective arachnoiditis with diffuse enhancement and clumping of the nerve roots within the lumbar and sacral thecal sac. As the number of injections in the management of back pain and lumbo-sacral radicular pain is increasing annually, it is imperative to have a thorough understanding of this potentially dangerous complication and educate the patients appropriately.

Solitary Ruptured Aneurysm of the Spinal Artery of Adamkiewicz with Subarachnoid Hemorrhage

Spinal subarachnoid hemorrhage (SAH) due to solitary spinal aneurysm is extremely rare. A 45-year-old female patient visited the emergency department with severe headache and back pain. Imaging studies showed cerebral SAH in parietal lobe and spinal SAH in thoracolumbar level. Spinal angiography revealed a small pearl and string-like aneurysm of the Adamkiewicz artery at the T12 level. One month after onset, her back pain aggravated, and follow-up imaging study showed arachnoiditis. Two months after onset, her symptoms improved, and follow-up imaging study showed resolution of SAH. The present case of spinal SAH due to rupture of dissecting aneurysm of the Adamkiewicz artery underwent subsequent spontaneous resolution, indicating that the wait-and-see strategy may provide adequate treatment option.

A Case of Tuberculous Optochiasmatic Arachnoiditis / 대한내과학회지

Tuberculous optochiasmatic arachnoiditis (OCA) is a rare complication of tuberculous meningitis. We describe a 47-year-old female with tuberculous OCA confused with ethambutol-associated optic neuropathy. She was on anti-tuberculous treatment (i.e., isoniazid, rifampin, ethambutol, and pyrazinamide) for two months due to tuberculous meningitis. Visual impairment occurred during treatment, and ethambutol was changed to levofloxacin because of concern for ethambutol-associated optic neuropathy. Her visual impairment did not improve three months after anti-tuberculous treatment that excluded ethambutol, and she was referred to our hospital. Brain MRI showed enhancement of the optic chiasm and bilateral optic tract, and fundoscopy revealed bilateral optic nerve atrophy, suggesting tuberculous OCA. Her visual acuity was partially improved after anti-tuberculous treatment. Tuberculous OCA should be considered in addition to ethambutol-associated optic neuropathy for a patient with tuberculous meningitis who presents with visual impairment.

A Case of Tuberculous Optochiasmatic Arachnoiditis / 대한내과학회지

Tuberculous optochiasmatic arachnoiditis (OCA) is a rare complication of tuberculous meningitis. We describe a 47-year-old female with tuberculous OCA confused with ethambutol-associated optic neuropathy. She was on anti-tuberculous treatment (i.e., isoniazid, rifampin, ethambutol, and pyrazinamide) for two months due to tuberculous meningitis. Visual impairment occurred during treatment, and ethambutol was changed to levofloxacin because of concern for ethambutol-associated optic neuropathy. Her visual impairment did not improve three months after anti-tuberculous treatment that excluded ethambutol, and she was referred to our hospital. Brain MRI showed enhancement of the optic chiasm and bilateral optic tract, and fundoscopy revealed bilateral optic nerve atrophy, suggesting tuberculous OCA. Her visual acuity was partially improved after anti-tuberculous treatment. Tuberculous OCA should be considered in addition to ethambutol-associated optic neuropathy for a patient with tuberculous meningitis who presents with visual impairment.

Sparganosis in the Lumbar Spine : Report of Two Cases and Review of the Literature

Sparganosis is a rare parasitic infection affecting various organs, including the central nervous system, especially the lumbar epidural space. This report describes the identification of disease and different strategies of treatments with preoperative information. A 42-year-old man presented with a 2-year history of urinary incontinence and impotence. He had a history of ingesting raw frogs 40 years ago. Magnetic resonance (MR) imaging showed an intramedullary nodular mass at conus medullaris and severe inflammation in the cauda equina. A 51-year-old woman was admitted with acute pain in the left inguinal area. We observed a lesion which seemed to be a tumor of the lumbar epidural space on MR imaging. She also had a history of ingesting inadequately cooked snakes 10 years ago. In the first patient, mass removal was attempted through laminectomy and parasite infection was identified during intra-operative frozen biopsy. Total removal could not be performed because of severe arachnoiditis and adhesion. We therefore decided to terminate the operation and final histology confirmed dead sparganum infection. We also concluded further surgical trial for total removal of the dead worm and inflammatory grannulation totally. However, after seeing another physician at different hospital, he was operated again which resulted in worsening of pain and neurological deficit. In the second patient, we totally removed dorsal epidural mass. Final histology and enzyme-linked immunosorbent assay (ELISA) confirmed living sparganum infection and her pain disappeared. Although the treatment of choice is surgical resection of living sparganum with inflammation, the attempt to remove dead worm and adhesive granulation tissue may cause unwanted complications to the patients. Therefore, the result of preoperative ELISA, as well as the information from image and history, must be considered as important factors to decide whether a surgery is necessary or not.

Bayle e a descrição da aracnoidite crônica na paralisia geral: sobre as origens da psiquiatria biológica na França / Bayle y la descripción de la aracnoiditis crónica en la parálisis general: sobre los orígenes de la psiquiatría biológica en Francia / Bayle et la description de l'aracnites chronique dans la paralysie générale: sur les origines de la psychiatrie biologique en France / Bayle and the description of chronic arachnoiditis in general paralysis: on the origins of biological psychiatry in France

A tese de medicina defendida em 1822, em Paris, por Antoine-Laurent Bayle, intitulada “Pesquisas sobre as doenças mentais”, constitui um momento de virada na história das concepções biológicas em psicopatologia. Apoiado sobre um método anátomo-clínico rigoroso. Bayle apresenta seis observações clínicas de pacientes com uma história crônica e progressiva de comportamento exaltado, idéias de grandeza, de poder e de ambição que se transformam no final de algum tempo em delírios maníacos com agitação psicomotora. Simultaneamente, vai-se instalando um quadro de paralisia progressiva de vários grupos musculares, chegando até a incapacidade física extrema. Na fase terminal, os pacientes apresentam uma condição tipicamente demencial e de profundo comprometimento corporal, que os conduz à morte. Ao exame cadavérico, Bayle constatou a presença sistemática de uma inflamação crônica das meninges cerebrais (aracnoidite crônica) à qual ele atribui o fundamento biológico dos sintomas observados. Dessa forma. Bayle realiza uma descrição clínica rigorosa de uma entidade psicopatológica típica, de evolução crônica e progressiva e demonstra sua relação com uma lesão cerebral específica e objetivamente demonstrável. Tal descoberta, inicialmente recebida com muitas reservas, constituiria posteriormente uma espécie de paradigma para a pesquisa e para o projeto teórico e terapêutico para a psiquiatria biológica que começava a se organizar na França ao longo do século XIX.

Antoine Laurent Bayle’s medical thesis, entitled “Studies on mental diseases” and defended in Paris in 1822, represented an important advance in the history of biological conceptions in psychopathology. Based on a rigorous anatomic and clinical method, Bayle presented clinical observations on six patients with chronic and progressive histories of exalted behavior and ideas of grandeur: power and ambition, a condition that eventually evolved to maniac delusion with psychomotor agitation. Simultaneously, a situation of progressive paralysis of several muscle groups set in, leading to extreme physical incapacity. In the final stage the patients showed a typically demential condition with serious physical impairment which led to death. Post-mortem examinations showed the presence, is all cases, of chronic inflammation of the cerebral meninges (chronic arachnoidits), which Bayle held to be the biological basis of the symptoms noted. Bayle thus provided a rigorous clinical description of typical psychopathological entity with chronic and progressive evolution, and showed its relationship to specific and objectively demonstrable cerebral damage. This discovery, first received with considerable reservation, later served as a type of paradigm for research and for the theoretical and therapeutic project for biological psychiatry that began in France during the 19th century.

La tesis de medicina defendida en 1822 en Paris, por Antoine-Laurent Bayle, titulada “Investigación sobre las enfermedades mentales”, constituye un momento de viraje en la historia de las concepciones biológicas en psicopatología. Apoyado sobre un método anatómico-clínico riguroso. Bayle presenta seis observaciones clínicas de pacientes con una historia crónica y progresiva de comportamiento exaltado, ideas de grandeza, de poder y de ambición que se transformaron al final de algún tempo en delirios maníacos con agitación psicomotora. Simultáneamente, se va instalando un cuadro de parálisis progresiva de varios grupos musculares, llegando hasta la incapacidad física extrema. En la fase terminal, los pacientes presentan una condición típicamente demencial e de profundo comprometimiento corporal, que los conduce a muerte. Al examen cadavérico, Bayle constato la presencia sistemática de una inflamación crónica de las meninges cerebrales (aracnoidits crónica) a la cual él atribuyó el fundamento biológico de los síntomas observados. De esta forma, Bayle realiza una descripción clínica rigurosa de una entidad psicopatológica típica, de evolución crónica y progresiva y demuestra su relación con una lesión cerebral específica y objetivamente demostrable. Tal descubierta, inicialmente recibida con muchas reservas, constituiría posteriormente una especie de paradigma para la investigación y para el proyecto teórico e terapéutico para la psiquiatría biológica que comenzaba a organizarse en Francia a lo largo del siglo XIX.

La thèse de médecine soutenue en 1822 à Paris par Antoine-Laurent Bayle, intitulée "Recherches sur les maladies mentales" constitue un tournant dans l'histoire des conceptions biologiques en psychopathologie. Fondé sur une méthode anatomoclinique rigoureuse, Bayle y présente six observations cliniques de patients ayant une histoire chronique et progressive de comportement exalté, idées de grandeur, de puissance et d'ambition qui se transforment au bout d'un certain temps en délires maniaques accompagnés d'agitation psychomotrice. Simultanément, un tableau de paralysie progressive de plusieurs groupes musculaires se met en place, allant jusqu'à l'incapacité physique extrême. Dans la phase terminale, les patients présentent une condition typiquement démentielle et de profond affaiblissement corporel, finissant par en mourir. À l'examen cadavérique, Bayle a constaté la présence systématique d'une inflammation chronique des méninges cérébrales (arachnites chronique) à laquelle il attribue le fondement biologique des symptômes observés. Bayle nous fournit ainsi une description clinique rigoureuse d'une entité psychopathologique typique à l'évolution chronique et progressive et démontre son rapport à une lésion cérébrale spécifique et objectivement démonstrable. Telle découverte, reçue avec beaucoup de réserves au départ, constituera ensuite une sorte de paradigme pour la recherche et pour le projet théorique et thérapeutique de la psychiatrie biologique qui commençait à s'organiser en France au cours du XIX siècle.