Diffusion tensor imaging in chronic subdural hematoma: correlation between clinical signs and fractional anisotropy in the pyramidal tract.

BACKGROUND AND PURPOSE: Diffusion tensor imaging (DTI) was introduced as a good technique to evaluate structural abnormalities in the white matter. In this study, we used DTI to examine anisotropic changes of the pyramidal tracts displaced by chronic subdural hematoma (CSDH). MATERIALS AND METHODS: Twenty-six patients with unilateral CSDH underwent DTI before and after surgery. We measured fractional anisotropy (FA) values in pyramidal tracts of bilateral cerebral peduncles and calculated the ratio of the FA value on the lesion side to that on the contralateral side (FA ratio) and compared the ratios with motor weakness. Moreover, the relationships between FA ratios and clinical factors such as age, sex, midline shift, interval from trauma, and hematoma attenuation on CT were evaluated. RESULTS: FA values of pyramidal tracts on the lesion side were significantly lower than those on the contralateral side (0.66 +/- 0.07 versus 0.74 +/- 0.05, P < .0001). The FA ratio was correlated to the severity of motor weakness (r(2) = 0.32, P = .002). FA ratios after surgery improved significantly compared with those before surgery (0.96 +/- 0.08 versus 0.89 +/- 0.07, P = .0004). Intervals from trauma and the midline shift were significantly associated with decreased FA ratios (P = .0008 and P = .037). CONCLUSIONS: In patients with CSDH, a reversible decrease of FA in the affected pyramidal tract on DTI was correlated to motor weakness. These anisotropic changes were considered to be caused by a reversible distortion of neuron fibers and vasogenic edema due to the hematoma.

Relationship between the clinical manifestations, computed tomographic findings and the outcome in 80 patients with primary pontine hemorrhage.

The relationship between the clinical manifestations, computed tomographic (CT) findings and the outcome in 80 patients with primary pontine hemorrhage (PPH) was analyzed to clarify factors predicting the outcome. Patients were 58 males and 22 females (60. 5+/-12.9 years old) with PPH. Correlations between the clinical manifestations, CT findings and the outcome was assessed with multivariate regression analysis. The initial level of consciousness and the transaxial size of the hematoma on CT were strongly related to the outcome. In patients with small hematoma (with the transaxial size

[Rare intra-abdominal complications of a ventriculoperitoneal shunt: report of three cases].

Three cases of rare intra-abdominal complications of ventriculoperitoneal shunt (VPS) surgery are reported. Case 1 was a 32-year-old male who had undergone VPS surgery for hydrocephalus following meningitis on July 10, 1980. Two weeks later he developed fever and a cystic mass about 10 cm in diameter in the right hypochondrium. Shuntography and a barium enema study demonstrated a pseudocyst at the distal end of the shunt. The cyst wall was excised, the peritoneal tube removed, and VPS converted to a ventriculoatrial route following which the pseudocyst resolved. Case 2 was a 49-year-old female who developed hydrocephalus following subarachnoid hemorrhage, and VPS surgery was performed on March 10, 1989. Two weeks later, she developed fever and right upper abdominal pain. Abdominal x-ray and CT scan revealed a right subdiaphragmatic abscess. The abscess was drained and the shunt system was removed on April 4. VPS was placed again on April 21 without further complications. She was symptom free for the next 7 years. Case 3 was a 57-year-old female who presented in a semicomatose state after falling from bed on May 5, 1995. CT scan showed left-sided acute subdural hematoma (ASDH) for which surgery was performed. Her neurological status improved postoperatively. She eventually developed hydrocephalus and left-sided subdural effusion for which right VPS and left subduroperitoneal shunt (SPS) surgery was performed on January 25, 1996. The peritoneal end of the tube of the SPS protruded out of the anus one and a half year after shunt placement. The entire SPS system was removed as there was no more collection in the subdural space. We reviewed the literature and discussed the pathophysiology involved in the development of intraabdominal complications following VPS.

[Unilateral dissection of the cervical portion of the internal carotid artery and ipsilateral multiple cerebral infarctions caused by suicidal hanging: a case report].

This paper presents a case of traumatic dissection of the unilateral internal carotid artery of the cervical portion caused by hanging. A 63-year-old man attempted suicide by hanging and was rescued immediately after. No neurological deficits were detected for the first 4 hours. But then, right hemiplegia, aphasia and disturbed consciousness suddenly developed. On the 2nd day, MRI revealed multiple infarctions in the left cerebral hemisphere. MR angiography demonstrated severe stenosis at the cervical portion of the left internal carotid artery due to dissection. The left middle cerebral artery was not demonstrated. The patient was conservatively treated with fibrinolytic agents and regained consciousness gradually. But aphasia and right hemiplegia remained. During the next few weeks, the stenosis at the ICA slightly improved and the MCA was completely recanalized. Extracranial Doppler sonography revealed chronological hemodynamic changes of mean flow velocity and pulsatility index at the proximal and distal portion of the ICA stenosis.

[Putaminal abscess occurring at the site of hemorrhage: a case report].

Brain abscesses following stroke have been reported only rarely. We presented a case of putaminal abscess following putaminal hemorrhage. The patient was admitted to our hospital because of acute onset of left hemiplegia. The size of the hematoma was medium and the patient was conservatively treated. In about two months after the ictus, he became intermittently febrile and laboratory examinations suggested the presence of general infections including meningitis. Meanwhile, CT and MRI revealed clearly abscess formation at the site of the hematoma with remarkable brain edema. Cerebrospinal fluid analysis showed the findings of meningitis. On diagnosis of brain abscess, stereotactic exploration was performed and pus mixed with old blood was aspirated. Bacteriological study of the specimen demonstrated Morganella morganii. Postoperative course was uneventful and the abscess cavity gradually subsided following drainage and irrigation of the abscess cavity.

[Acute epidural hematoma of posterior fossa: comparative analysis between 20 cases in adults and 10 cases in children].

A comparative study of the clinical features was made among 30 patients, 10 children (less than 14) and 20 adults (older than 15) with traumatic acute epidural hematoma of the posterior fossa (PFEDH). The characteristic findings in both groups were as follows: 1) PFEDH accounted for 15% of 200 epidural hematoma cases. Incidence of PFEDH was 23.3% (10/43) in children and 12.7% (20/157) in adults. Thus, PFEDH is more common in children than in adults. 2) In seven out of 10 children, PFEDH was confined to the posterior fossa but in the other three children, PFEDH extended to the supratentorial area. On the other hand, in all the adult cases PFEDH extended over the supratentorial space. 3) Hematoma density was high in 5 out of 10 children and 18 in out of 20 adults. Mixed (including low) density occurred at a higher rate in children (50%) than in adults (10%). 4) Brain contusion associated with PFEDH was found by CT scan in 12 adult cases and one child case. Subarachnoid hemorrhage was found by CT scan in 4 adult cases. Subdural effusion was found by CT scan in 1 adult case. Thus, intracranial complications associated with PFEDH occurred in a significantly higher number in adults than in children. 5) 20 cases (4 children, 16 adults) of 30 underwent surgery, and 10 cases (6 adults, 4 children) were given conservative treatment. Results (GOS); GR was observed in 22 cases (in all 10 children and in 12 adults), and MD in 8 cases. There were no SD, VS or cases ending in death.

[A case report of chronic encapsulated intracerebral hematoma].

Chronic encapsulated intracerebral hematoma is a rare clinicopathological entity. The authors reported a case of a 52-year-old male who presented with progressive sensory disturbance of the left extremities three weeks prior to admission. Plain CT and MRI scans revealed a subcortical mass in the right temporal lobe associated with extensive peritumoral edema and intratumoral hemorrhage (mixed intensity on T1WI, low intensity on T2WI). There was a ring-like enhancement with GdDTPA. These findings strongly suggested metastatic melanoma associated with intratumoral hemorrhage. During the operation, the mass appeared partly at the surface of the brain and was easily extirpated totally. Histologically, the specimen showed chronic encapsulated hematoma with a thick, fibrous capsule and there was no evidence of neoplasm. The postoperative course was uneventful and follow up CT scan showed disappearance of the mass and the surrounding edema. The relevant literature was reviewed, and the pathogenesis of this entity was discussed.

[Familial occurrence of intracerebral cavernous angioma: report of cases in brothers].

Familial occurrence of intracerebral cavernous angioma has been rarely reported. We report two histologically verified cases of cavernous angioma among brothers and review relevant cases in the literature. Case 1 is that of a 3-year-old boy who suffered front acute onset of headache, vomiting, and tonic-clonic type seizure. CT revealed a well-demarcated tumor with partial hemorrhage in the left frontal lobe which was strongly enhanced with contrast Medium. Complete excision was carried out and the patient had a satisfactory clinical course and was able to be followed up for 13 years after the Surgery. Case 2 is that of a 17-year-old boy who was the elder brother of case 1 and presented with gradually increasing episodes of a psychomotor seizure which started at the age of 16. CT and MRI revealed a well-demarcated tumor in the left subcortical temporal lobe and an asymptomatic small calcified lesion in the left subcortical parietal lobe. The temporal tumor was totally excised and histologically diagnosed as cavernous angioma. The seizures gradually decreased and eventually disappeared one year after the surgery. This report reviews 13 previously reported cases, and surgical indication for asymptomatic cases.

[Spontaneous rotation of programmable pressure valve in the chest wall: report of 3 cases].

Using a Sophy-valve system, complications after V-P shunt have been encountered in 3 cases. Turning over of the valve in a subcutaneous pocket would lead to a false judgement of setting pressure, and to serious iatrogenic complications. The valve seems to turn over only in the condition of subcutaneous placement in the chest. Probable causes are loose chest tissue, difficulty of tight fixation, and round and smooth shape of the valve. It should be kept in mind that the Sophy-valve can spontaneously turn over when it is placed in the chest. Careful examination of the chest X-ray can help to judge whether the valve is in appropriate position or not.