Paranoia--an unusual presentation of hydrocephalus.

Hydrocephalus commonly occurs after traumatic brain injury. Normal pressure hydrocephalus after traumatic brain injury is usually associated with a failure to progress in therapy and a plateauing or regression of functional abilities. Behavior disturbances are commonly seen as unfortunate sequelae of traumatic brain injury. However, normal pressure hydrocephalus has not been reported to cause aberrant, antisocial behavior. This case report details the course of a patient who sustained a traumatic brain injury and, subsequently, developed normal pressure hydrocephalus associated with paranoia, delusions, and violent behavior.

Functional assessment following selective posterior rhizotomy in spastic cerebral palsy.

This study used the Pediatric Evaluation of Disability Inventory as a functional assessment tool for children with spastic cerebral palsy undergoing selective posterior rhizotomy. Sixteen patients were followed for 3-12 months following surgery. Improvement in self-care, mobility, and social functional skills were found. Overall, the patients required less caregiver assistance and needed fewer modifications for self-care. The results suggest that selective posterior rhizotomy improves the quality of life in children with spastic cerebral palsy.

The alien hand sign. Localization, lateralization and recovery.

The alien hand sign was first described by Brion and Jedynak as a "feeling of estrangement between the patient and one of his hands." The affected hand frequently shows a grasp reflex and an instinctive grasp reaction as well as elements of what Denny-Brown referred to as a "magnetic apraxia" associated with frontal lobe damage. Most notably, however, the affected hand is observed to perform apparently purposive behaviors that are perceived as being outside the volitional control of the patient. The patients interpret the behavior of their own affected limb as being controlled by an external agent. They do not feel that they are initiating or controlling the behavior of the hand and often express dismay at the hand's "extravolitional" activity. The patients attempt to control behavior of the alien hand with the unimpaired hand by forcibly restraining the affected limb, an act that may be termed "self-restriction." In this paper, we report an additional four cases of alien hand sign in right-handed subjects: two involving the right hand and two involving the left hand. In each case, the clinical findings were associated with extensive unilateral damage of the medial frontal cortex of the hemisphere contralateral to the affected hand. Furthermore, the alien movement gradually disappears over the course of 6-12 months after the stroke. These clinical case studies are presented and discussed in the context of the "dual premotoer systems hypothesis," an anatomicophysiological model that proposes that action is organized by two separate but interactive premotor brain systems corresponding to evolutionarily defined medial and lateral cortical moieties. It is hypothesized that the alien mode behavior results from unconstrained activity of the lateral premotor system in the damaged hemisphere. The residual volitional control in the limb occurs through the activity of the intact medial premotor system of the ipsilateral hemisphere. Recovery may occur through extension of these ipsilateral control mechanisms by compensatory changes in subcortical systems controlling hemispheric activation associated with adaptive behavior. This observation may be important in understanding mechanisms involved in motor recovery after stroke.

Quadriplegia from spinal cord injury in muscular dystrophy.

Recommendations for exercise programs in patients with muscular dystrophy are controversial. These programs are designed to keep a patient ambulatory or functional for as long as possible. There have been no reports of a patient with muscular dystrophy who incurred a spinal cord injury. This report details the course of recovery and rehabilitation of a man with facioscapulohumeral muscular dystrophy with quadriplegia from a traumatic spinal cord injury. The patient was admitted to a spinal cord injury unit. After prolonged bedrest, he participated in physical and occupational therapy that was designed to exercise him just short of fatigue. Except for one incident, when the patient reinjured his spinal cord, he did not lose function that he had already attained. The rehabilitation of this patient demonstrates that it is possible for a patient with facioscapulohumeral muscular dystrophy who sustains a traumatic quadriplegia to enter a rehabilitation program with expectations for a good outcome despite a double disability.

Tibial nerve somatosensory evoked potentials in spinal cord hemisection.

Somatosensory evoked potentials (SEPs) have been studied in many disease states since they were first described by Dawson in 1947. However, there have been very few reports of SEP findings in patients with spinal cord hemisection. On the basis of clinical correlation, Giblin first postulated that the activity giving rise to the initial cortical components of the SEP travels through the dorsal column-lemniscal system. However, the pathway through which these evoked potentials are transmitted has recently been questioned. This paper examines the results of tibial nerve SEPS performed on four patients with spinal cord hemisection (Brown-Séquard syndrome). In all four cases presented, the impairment of cortical SEP components was consistently associated with stimulation of the leg ipsilateral to the side of cord injury. We conclude that the most likely mechanism of transmission is through the ipsilateral dorsal columnlemniscal system.

Liver enzyme abnormalities in spinal cord injury.

A retrospective study of serum glutamic pyruvic transaminase (SGPT) and serum glutamic oxalacetic transaminase (SGOT) was performed on eighteen previously healthy patients with acute spinal cord lesions C1 to L1 and no abdominal trauma. The SGPT rose in 13 of the 17 (76%). The SGOT rose in 8 of the 17 (47%). The SGPT and SGOT values for the entire group were significantly elevated over the upper limits of normal (p less than 0.01). The mean and median days of onset of elevated SGPT after trauma were 22 and 18, respectively. The mean and median days to normalization after trauma were 67 and 64. The mean and median days of onset of elevated SGOT were 26 and 19 respectively. The mean and median days to normalization were 42 and 43. The alkaline phosphatase were elevated in all but eight patients. The bilirubin was elevated in only three patients. Seventy-six percent of the quadriplegics and 60% of the paraplegics had elevated transaminases. The elevations are probably related to liver injury but the mechanism is unclear.