Vertex epidural hematoma - neuroradiological findings and management.

Epidural hematomas occurring at the vertex are uncommon, and they can be difficult to diagnose by axial CT. We report a case of acute traumatic vertex epidural hematoma, which resolved spontaneously with time. We stress the importance of MR investigations in this diagnostic challenge.

[Spinal cord injury following knife stab wound]. / Ryggmargsskade etter knivstikk.

BACKGROUND: Problems about penetrating injuries are well known, but spinal cord damage is rare. Stab wounds to the spinal cord may be a new type of injury in our society. MATERIAL AND METHODS: We describe two patients brought to our hospital with stab wounds to the cervicothoracic region and major neurologic injury. One was treated initially only with cleaning and primary closure of the skin. After two weeks the intraspinal damage was repaired in our neurosurgical unit. The second patient was immediately brought to neurosurgery. The intraspinal damage was explored and the dural tear was closed. RESULTS: The first patient got a superficial infection and spinal fluid leakage after initial treatment. This resolved when the dura was closed. There were no wound complications in the second patient. Both demonstrated Brown-Séquard's syndrome. Neurologic recovery was much better in the first than in the second patient. INTERPRETATION: Minor penetrating wounds in the neck region may represent damage to the spinal cord with major neurologic injury. Further investigation with MR is preferable and we recommend immediate surgical treatment with closure of the dural tear.

[South American blastomycosis--a differential diagnosis to tuberculous meningitis]. / Søramerikansk blastomykose--en differensialdiagnose til tuberkuløs hjernehinnebetennelse.

BACKGROUND: South American blastomycosis is primarily a lung infection often complicated by multiorgan or intracranial disease. MATERIAL AND METHODS: We describe the clinical and pathological findings of fatal cerebral blastomycosis occurring in a woman that immigrated to Norway from Brazil 23 years earlier. RESULTS: The clinical symptoms together with the radiological findings of multiple cerebral lesions and thickening of the basal meninges were interpreted as cerebral tuberculosis. Examination of cerebral spinal fluid was inconclusive. A diagnosis of cerebral fungal infection was subsequently established by brain biopsy. INTERPRETATION: This case history stresses the importance of confirming a clinical diagnosis by brain biopsy and extended investigation of the cerebrospinal fluid when intracranial lesions may have an infectious origin.

[Continuous intrathecal infusion of baclofen. A new therapeutic method for spasticity]. / Kontinuerlig intratekal infusjon med baklofen. Ny behandlingsmetode for spastisitet.

Intrathecal administration of baclofen is now generally accepted as a powerful treatment of spasticity caused by spinal lesions. 35 patients with severe spasticity, 29 of spinal origin and six of supraspinal origin resistant to conservative treatment, had a programmable pump (Synchromed, Medtronic) for continuous intrathecal baclofen infusion implanted. The patients were followed-up for an average of 29 months (0-68). The initial effect of the treatment was positive for all patients; spasms were less frequent, there was remission of pain caused by cramps, and in some cases improved ambulation. In five patients, however, the pump was later removed: in two patients the pump ceased to be effective, two patients became infected, and one experienced multiple catheter problems. Problems with the catheter was the most common complication experienced, and this was seen in nine patients. Three patients died of the underlying disease. The majority of patients became accommodated to intrathecal baclofen and it was necessary to administer increasingly larger doses to maintain the clinical effect. Long-term control of spinal spasticity by intrathecal baclofen can be achieved in most patients, but close follow-up is necessary for assessing efficacy and refilling the pump.

Clozapine versus typical antipsychotics. A retro- and prospective study of extrapyramidal side effects.

Schizophrenic patients in long-term neuroleptic monotherapy with clozapine (n = 100) and perphenazine, flupenthixol or zuclopentixol (controls, n = 100) were evaluated for extrapyramidal side effects (EPS) (blind) as well as other side effects and mental condition (non-blind). In both groups the patients had received neuroleptic treatment for a total of 14 years (median) and the present antipsychotic (clozapine or control drug) for 5 years. Thus the clozapine-treated patients had previously received traditional neuroleptics for 9 years (median). The study was both retrospective (0.3-19 years for clozapine, 0.3-24 years for control drug, by means of chart information) and prospective (1 year, with video-controlled evaluation of EPS). There was a significantly lower prevalence of tardive dyskinesia (TD) in clozapine treated patients than control patients, although prior to this treatment there were more TD patients in the clozapine group (P < 0.05). This lower level of TD in the clozapine group was related to a lower induction of new cases (P < 0.001) and a tendency towards greater disappearance of TD in the clozapine than in the control group (P = 0.07). Clozapine treated patients without TD had started clozapine and ceased traditional neuroleptics at an earlier age than those with TD. Parkinsonian signs were seen in 33% of the clozapine patients versus 61% of the control patients, mainly as hypokinesia; tremor in 3% versus 11% and rigidity in 0 versus 19%. Psychic akathisia was found in 14% versus 40% and motor akathisia in 7% versus 29% of the patients, all differences significantly in favor of clozapine. Clozapine treated patients also had less neuroleptic-induced emotional indifference and depression, but more autonomic side effects than controls.

Zuclopenthixol decanoate in maintenance treatment of schizophrenic outpatients. Minimum effective dose and corresponding serum levels.

23 schizophrenic outpatients in maintenance treatment with zuclopenthixol decanoate were included in a study aimed at finding the minimum effective dose and corresponding serum concentration of zuclopenthixol. Every three months the dose was gradually reduced until prodromal symptoms appeared, indicative of an incipient relapse. A slightly higher dose was then promptly reinstituted (the minimum effective dose). At each dose level, two blood samples were drawn to determine the serum concentration. This dose reduction principles proved feasible. Only one patient had a clear-cut relapse. The condition of the remaining patients was acceptably maintained by a dose increase. The minimum effective dose of zuclopenthixol was 200 mg/2 weeks (range 60-400), with a serum concentration of 22 nmol/l (7.1-69.7). There was a significant correlation between the administered dose and the corresponding serum level of the drug (r = 0.66, P < 0.01). A trend towards a positive correlation was found between the serum level at the minimum effective dose and the BPRS score (r = 0.42, P < 0.1). No correlation was found between the serum level and the side-effects or length of neuroleptic treatment. It is concluded that routine serum drug monitoring is hardly indicated in the long-term depot-neuroleptic treatment of schizophrenic patients. A strategy aiming at continually seeking the lowest effective dose on the basis of clinical parameters appears more appropriate, especially in case of depot-neuroleptic treatment.

Cerebral abscess complicating dilatation of a corrosive esophageal stricture.

A case is presented in which a metastatic cerebral abscess developed in a 62-year-old female who required repeated dilatation for an esophageal stricture following accidental ingestion of liquid caustic soda. The literature is reviewed and management suggested for the avoidance of this uncommon complication.

Statistical analysis of clinicopathological features, radiotherapy, and survival in 170 cases of oligodendroglioma.

The postoperative survival time of 170 nonrandomized patients treated for cerebral oligodendrogliomas in Norway from 1953 to 1977 was studied. Survival times were significantly prolonged if postoperative irradiation was performed in addition to surgery (median survival time 26.5 vs. 38 months, p = 0.039). In the group without postoperative radiotherapy, the 5-year rate of survival was 27% compared with 36% in the irradiated patients. The respective survival rates after 8 years were 14% versus 17%; thus, there was little effect on long-term survival. Irradiation appears not to be of benefit after "total" removal. Patients with partly resected lesions appeared to benefit from postoperative radiotherapy; the median survival period after subtotal tumor resection was 37 months with and 26 months without radiotherapy (p = 0.0089). The findings also indicate that irradiation doses between 40 and 50 Gy were as effective as doses between 50 and 60 Gy in increasing the patients' probability of surviving 5 years after subtotal tumor resection. Since the risk of radiation necrosis is proportional to the dose applied, the lower dose is recommended. These conclusions were also valid when adjustments were made for prognostically significant histological and clinical features.

Oligodendroglioma: incidence and biological behavior in a defined population.

The cases of 208 patients with histologically confirmed oligodendrogliomas were studied. The incidence represents 4.2% of all primary brain tumors diagnosed in the Norwegian population over a 25-year period. All of these tumors were cerebral and the majority affected the frontal lobe. The patients' median age at diagnosis was 47 years, with a range from 3 to 76 years; 6% of the oligodendrogliomas occurred in children. The median duration of symptoms before diagnosis was 20.5 months (mean 43 months). Plain skull x-ray films showed calcified deposits in 28% of the tumors. At operation, most of the tumors were poorly defined, without cyst formation, hematoma necrosis, or calcification. The median duration of disease from onset of symptoms until death was 14 months in nine untreated cases. In surgically treated oligodendroglioma patients the median survival time from onset of symptoms was 74 months. The median postoperative survival time was 35 months (mean 52 months). Tumor calcification, as seen on plain skull x-ray films, was associated with a significantly longer survival period. The surgical findings of gross necrosis, gross hypervascularity, and soft tumor consistency were all related to a shorter total duration of disease. Grossly well demarcated lesions were associated with a significantly longer postoperative survival. The length of postoperative survival correlated with the preoperative clinical status. The cumulative proportion of patients surviving 5 years was 0.342. The patient's age and sex did not have a statistically significant influence on survival time. The extent of surgical excision only seemed to play a role when the neurosurgeon considered that he had removed the whole lesion: these patients had a median postoperative survival period 14 months longer than the other oligodendroglioma patients. The ABO blood group of the oligodendroglioma patient was of prognostic value. In particular, patients with blood group A had a distinctly poorer prognosis than patients with O or B blood. The survival data from this unselected series indicate that cerebral oligodendrogliomas have a less favorable prognosis than has generally been believed.

The knee--elbow position in lumbar disc surgery: a review of complications.

Follow-up studies were carried out in 1962, 1977, and 1981 on 35% or 943 or our 2690 patients operated upon from 1950 through 1981 for lumbar disc herniation. Seven hundred and twenty-four were done with and 1848 without spinal fusion. There were 11.2% operative, 8.3% postoperative and 18.9% late complications. Sepsis occurred in 2 patients (0.2%). Thrombosis decreased from 10% in the 1950s to 4% in the 1960s and to zero in the late 1970s. Reoperations were performed in 10.8% of the fused and in 23.6% of the nonfused patients. There were no serious vascular injuries and no postoperative deaths. Serious complications from lumbar disc surgery with the patient in the knee--elbow position occur rarely and ought to be avoided. Posterior spinal fusion seems to give better protection against recurrence of pain than simple removal of the herniated disc material.

Ruptured benign hepatoma associated with an oral contraceptive. A case report.

A ruptured benign hepatoma is described in a woman at full-term pregnancy. The patient had used an oral contraceptive for eight years before she became pregnant. According to several recent reports it seems likely that there is a relationship between the use of oral contraceptive agents and the development of liver cell tumours. Twentythree such cases have been found in the literature. Fourteen of these were not diagnosed before rupture. The present tumour differed from previously described lesions by containing foci of haematopoietic cells. As there were no signs of blood or bone marrow disease, it is suggested that the extramedullary haematopoiesis is a constituent of the tumour tissue.