Warning symptoms of sinister headache.

Headache is a common complaint. In most patients, it is usually a problem of migrainous or tension-type headache. It is crucial that a physician is able to differentiate sinister causes of headache from the more benign ones. Six cases are presented to illustrate the fact that there are clues in the history to suggest a sinister cause of headache even though there are minimal or no neurological deficits on physical examination. At some point of time, these cases were examined by a senior physician but they were diagnosed as migrainous or tension-type headaches. The first case is a 41-year-old labourer with cryptococcal meningitis. He presented with severe headaches at a relatively late age. A 20-year-old female complained of the worst headache she ever had and this was due to a subarachnoid haemorrhage. The third case was a young woman with a large parietal meningioma. Her headaches had recently assumed a different character. The fourth case involved an investment manager who developed headaches with transient diplopia and projectile vomiting and investigations revealed an ependymoma. A shipyard worker complained of a constant headache which disturbed his sleep. Two weeks after medical consultation, the character of his headache changed and he developed diplopia in all directions of gaze. He succumbed to pituitary apoplexy. The final case is a 28-year-old woman who had a complicated migraine. CT scan of the brain showed a large arterio-venous malformation.

Optic nerve sheath meningioma--report of three cases.

Meningiomas involving the optic nerve and the anterior visual pathways have intrigued neurosurgeons, neurologists and ophthalmologists for more than a century. They may present with the classical triad of progressive painless visual loss, optic atrophy and opto-ciliary bypass vessels. Optic nerve sheath meningiomas are most frequently diagnosed radiologically and lately, magnetic resonance imaging has greatly improved their visualisation. Surgical removal to preserve vision has met with dismal results. We present three patients with optic nerve sheath meningiomas which were diagnosed based on radiological findings. One had improvement in her visual acuity after external beam irradiation. Another had the tumour excised by a neurosurgeon. The last patient absconded follow-up and returned with no deterioration in her visual acuity after three years.

Bilateral proptosis after post-traumatic hydrocephalus: a case report.

Hydrocephalus can cause several neuro-ophthalmological complications but only rarely has it been reported to cause proptosis. A 23-year-old woman developed post-traumatic hydrocephalus after a road traffic accident. She was found to have deteriorating visual acuity bilaterally and bilateral proptosis. Both these complications resolved after a ventriculo-peritoneal shunt was inserted.

Transient oculomotor nerve synkinesis in non-Hodgkin's lymphoma.

A patient with large cell malignant lymphoma presented with transient left oculomotor nerve synkinesis, left trigeminal and abducens nerve palsies. Magnetic resonance imaging showed thickening of the oculomotor and trigeminal nerves characteristic of central nervous system lymphoma. To our knowledge, this is the first reported case of transient oculomoter nerve synkinesis in non-Hodgkin's lymphoma. The rapid onset and quick recovery of the synkinesis following 2 weeks of chemotherapy support the ephatic transmission theory.

The localizing value of downbeat nystagmus.

Downbeat nystagmus (DBN) is a primary position nystagmus with the fast phase in a downward direction. It is a rare but distinctive disorder of ocular motility and usually localizes the lesion at the posterior fossa. Four patients with DBN were seen in the department. One had a medullary glioma, and another congenital basilar invagination. The other two were initially diagnosed as demyelinating disease. One was subsequently found to have Arnold Chiari Malformation on magnetic resonance imaging (MRI). Review of the literature showed that cerebellar ectopia (Arnold Chiari Malformation) is the commonest cause of DBN. However 1/3 of reported cases have no obvious cause. DBN is of such high localizing value that we recommend MRI of cervicomedullary junction for all patients with DBN to exclude cerebellar ectopia or medullary lesion.

Acute intermittent porphyria (AIP)--an unusual cause of acute confusional state. A case report.

Acute intermittent porphyria (AIP) presenting as acute confusional state without the classical features of recurrent abdominal pain, constipation, vomiting is uncommon. Such presentation in a young Malay man after a mild upper respiratory tract infection is reported. This is the first case of AIP with psychiatric symptomatology to be reported locally. The subsequent neuropsychiatric changes and interesting EEG changes are briefly discussed.

Cryptococcal meningitis.

Cryptococcosis is a systemic fungal disease and meningitis is the most serious complication. The purpose of this study is to define problems related to its diagnosis and treatment. This is a retrospective analysis of 25 patients admitted from January 1978 to December 1981. All patients had cryptococcal neoformans meningitis proven by culture of cerebrospinal fluid. One patient had a predisposing illness, being on immunosuppressant therapy after a renal transplant 2 years ago. A progressively severe headache of recent onset was the most striking presentation. Fever was frequently absent as a symptom. Cranial nerve palsies were commonly seen. Impairment of consciousness and areflexia signified a poor prognosis as all four patients who died early in the course of treatment were comatose and two of them were areflexic on admission. In newly suspected cases at least 3 separate lumbar punctures are recommended as initial smears or cultures may be negative. Cerebral CT scans were abnormal in 12 patients and those with cerebral oedema or hydrocephalus had a poorer prognosis. Combined amphotericin B and 5-fluorocytosine therapy was the treatment of choice. If there is no relapse 3 years after completion of treatment, patients are considered as cured. Positive smears may remain for years after completion of treatment and retreatment is only indicated if the cultures are positive. Twenty patients are alive today and none of them have relapsed. One patient had vasculitis of both anterior cerebral arteries as a result of cryptococcal meningitis.

Early and predominant respiratory muscle involvement in motor neurone disease.

We report a 61 year old man with motor neurone disease who presented with dyspnoea and ventilatory failure when the limb and bulbar muscles were relatively spared. This unusual pattern of predominant respiratory muscle involvement persisted throughout the twenty-one month course of his illness.