Extrapyramidal signs and other neurologic findings in clinically diagnosed Alzheimer's disease. A community-based study.

The association between findings on the neurologic examination and the clinical diagnosis of Alzheimer's disease was investigated among 467 individuals from a geographically defined community population. Participants were selected by stratified random sampling based on their memory performance in a population survey of community residents 65 years of age and older. Each participant underwent a structured medical, psychiatric, neurologic, and neuropsychologic examination. Of the 467 persons examined there were 134 cases of probable Alzheimer's disease and 167 control subjects. Multiple logistic regression analysis was used to estimate the degree to which the presence of each of several neurologic examination findings affected the age- and sex-adjusted relative odds of having clinically diagnosed Alzheimer's disease. The most striking associations with the diagnosis of Alzheimer's disease were seen with various measures of extrapyramidal dysfunction. These increased relative odds were not markedly affected by excluding from the analysis cases with severe cognitive impairment. The results suggest that involvement of the extrapyramidal system is a common finding in Alzheimer's disease.

Can money buy happiness? Depressive symptoms in an affluent older population.

OBJECTIVES: To determine if the inverse association between depressive symptoms and income reported in predominantly low- and middle-income older populations is present in a more affluent population of older adults and to determine if this pattern is independent of other known correlates of depressive symptoms such as medical problems, physical disability, and social support. DESIGN: Cross-sectional analysis within a prospective cohort study. SETTING: An ongoing, community-based cohort study conducted by an independent research institution in an affluent Northern California county. PARTICIPANTS: A total of 1948 randomly selected, noninstitutionalized county residents 55 years of age and older who completed the baseline questionnaire and physical performance tests. MEASUREMENTS: The outcome measure was high level of depressive symptoms (score > or = 16) using the Center for Epidemiologic Studies-Depression scale (CES-D). RESULTS: The prevalence of high levels of depressive symptoms (CES-D score > or = 16) was lower than in most other population-based samples using an identical CES-D scale. In age-adjusted, sex-specific analyses, increasing income level was associated significantly with lower levels of depressive symptoms, but the nature of the relationship appeared quadratic rather than linear (Men: odds ratio (OR) income .80, 95% confidence interval (CI) .68-.94; income2 OR 1.006, 95% CI 1.001-1.011. Women: OR income .80, 95% CI .69-.91; income2 OR 1.007, 95% CI 1.002-1.011). In multivariate regression analyses including potential confounding risk factors, the magnitude of the association between depressive symptoms and income decreased and was not statistically significant when measures of health conditions, physical disability, and social support were included in the model (Men: OR income .90, 95% CI .75-1.06; income2 OR 1.003, 95% CI .998-1.009. Women: OR income .90, 95% CI .78-1.05; income2 OR 1.003, 95% CI .998-1.008). CONCLUSION: These findings suggest that poor health, physical disability, and social isolation are the major factors responsible for the observed inverse relationship between income and symptoms of depression in affluent, as well as economically disadvantaged, older populations.

Ventriculovesical shunt. Technical note.

A patient is reported whose hydrocephalus was controlled by diverting the ventricular cerebrospinal fluid directly into the urinary bladder. This drainage route may have a useful place in the management of the adult pressure-sensitive patient whose more conventional shunt requires frequent revision for repeated obstruction.

Spinal subarchnoid metastatic spread from non-neuraxial primary neoplasms. Case report.

A rare case of metastasis to the spinal subarachnoid space from a non-neuraxial primary tumor is presented. Dissemination was shown by computerized tomography to be via the cerebrospinal fluid from secondary deposits in the central nervous system and meninges. This route would seem to be the most common mode of spread to the spinal subarachnoid space.

Gas in a spinal extradural cyst. Case report.

This case report describes a patient with sciatica resulting from lumbar root compression by a gas-containing cyst in the extradural space. Removal of the cyst provided prompt relief. The origin and anatomic distribution of gas collections in the spine are considered based on a review of the literature.

A means of assessing theco-peritoneal shunt patency.

Lumbar myelography using water-soluble contrast media provides a simple means of assessing the patency of theco-peritoneal shunts. Our experience with two consecutive patients is described.

Bilateral brachial paresis following anterior decompression for cervical spondylosis.

This brief report describes the delayed emergence of a profound proximal weakness of both arms following osteophytectomy for cervical spondylosis by the anterior approach. At no time was there any clinical evidence of cord compression. Coincident reversal of the normal lordosis was corrected by traction, and, achieving bony ankylosis in a good position, the patient eventually made a complete recovery.

Solitary exostosis of the thoracic spine. Early diagnosis and treatment.

STUDY DESIGN: A case report. OBJECTIVE: To highlight the importance of early diagnosis and treatment of vertebral exostosis. SUMMARY OF BACKGROUND DATA: Few cases of spinal cord compression caused by solitary thoracic exostoses have been reported. METHOD: A solitary exostosis in the midline of the neural arch of the fifth thoracic vertebra, causing compression of the spinal cord documented on both magnetic resonance and computed tomographic examinations, is reported in a 51-year-old woman who had normal findings in a neurologic examination. RESULTS: The exostosis was successfully excised. CONCLUSION: Accurate preoperative diagnosis of vertebral exostoses is possible using magnetic resonance and computed tomography. Early excision avoids the development of a permanent neurologic deficit.

Herniated intervertebral disc-associated periradicular fibrosis and vascular abnormalities occur without inflammatory cell infiltration.

STUDY DESIGN: Prospective histologic comparison of perineural tissues from patients requiring decompression surgery for herniated intervertebral disc with those from cadaveric controls. OBJECTIVES: To examine the significance of herniated intervertebral-disc-associated perineural vascular and fibrotic abnormalities with respect to back pain symptom generation. SUMMARY OF BACKGROUND DATA: Previous cadaveric studies have demonstrated perineural vascular congestion, dilatation, and thrombosis and perineural and intraneural fibrosis occurring in association with herniated intervertebral disc. It was suggested that these neural abnormalities were the result of ischemia, due to venous outflow obstruction, and also represented a possible cause of ongoing back pain symptoms. Criticisms of such a conclusion arose, however, because the possibility could not be excluded that these abnormalities were the result of postmortem artifact. METHODS: Histologic and immunohistochemical comparison of discal and peridiscal tissues removed from 11 patients with radiographically proven herniated intervertebral disc requiring decompressive surgery and from 6 fresh cadavers without history of back pain in life. RESULTS: Histology and immunohistochemistry of perineural and extraneural tissues from patients revealed vascular congestion, neovascularization, and endothelial abnormalities including luminal platelet adhesion, in association with reductions in von Willebrand factor levels, together with perivascular and perineural fibrosis. Elevated fibrogenic cytokine concentrations were also detected in patients' tissues. These changes occurred without evidence of inflammation and were absent in cadaveric control tissues. CONCLUSIONS: The vascular abnormalities detected in patients may represent an important etiopathologic factor predisposing to intraneural and perineural fibrosis, and hence to chronic pain symptoms, after disc herniation. It seems important to preserve the perineural microcirculation following disc herniation.

Bilateral carotid-cavernous fistulae: a review.

The clinical course of a patient with bilateral carotid-cavernous fistulae is described. The aetiology and pathophysiology of bilateral fistulae are considered. A review of the literature on this rare lesion is followed by an appraisal of the problems confronting successful surgical management.

A case of intractable nausea and vomiting following posterior fossa craniotomy.

We describe a unique case of prolonged nausea and vomiting following posterior fossa craniotomy for removal of a meningioma. No apparent neurological or gastrointestinal causes were discovered except for a delayed gastric emptying time. The symptoms gradually resolved along with normalization of the gastric emptying time. Possible pathogenic mechanisms are discussed.

Optic nerve gliomas in children: a reappraisal.

The Children's Tumour Registry in Manchester records details of children in the North West Region of England with gliomas of the anterior optic pathways. In the 30 years to 1983, the diagnosis of optic nerve glioma was confirmed in only 22 children out of a population of 1 million under the age of 15 years. This paper examines the presentation, investigation and management of these children in relation to the site of their tumour. The place of radiotherapy is considered, and with the widespread availability of new imaging techniques, fresh protocols are offered for the investigation and treatment of this rare tumour.

Access to anteriorly placed tumours in the posterior fossa by medullotomy.

Access to tumours lying in front of the brain stem may be restricted by the neuraxis and cranial nerves, the tentorium, and the bony configuration of the skull base. When there is distortion and attenuation of the brain stem, direct access through the medulla should be considered. A case is described.

Intraventricular blood without parenchymal clot following spontaneous subarachnoid haemorrhage.

The position of an intracerebral haematoma shown on computerised tomography (CT) of patients who have suffered a recent spontaneous subarachnoid haemorrhage is a powerful indicator of the source of the bleed. In the absence of such a parenchymal clot, does the distribution of intraventricular blood have similar predictive value? The scans of 22 patients showing intraventricular blood without parenchymal clot were compared with subsequent angiographic appearances. The distribution of intraventricular blood does not appear to correlate with either the clinical status of the patient, or the nature, site or size of the bleeding lesion.

Radiotherapy in the treatment of low-grade astrocytomas. I. A survival analysis.

Between 1954 and 1986 inclusive, 160 children in the North West Region of England were registered with histologically proven lowgrade astrocytomas (grade 1 or 2). Ten died before receiving any treatment, and a further seven died within 28 days of surgery, leaving 143 children whose survival in relation to treatment modality is the subject of this paper. Low-grade astrocytomas are responsive to radiation therapy. This treatment has no clear benefit to offer children with superficial tumours that can be resected completely or nearly so, but significantly improves survival rates when tumours are deep-seated and not amenable to excision.

Low grade pilocytic astrocytoma presenting as a spontaneous intracerebral haemorrhage in a child.

A girl aged 13 years presented with spontaneous intracerebral haemorrhage. Initially, no cause could be found but she was later found to have a low grade pilocytic astrocytoma. This very uncommon presentation was not considered before surgery.

Psychiatric disorders of abused women at a shelter.

Thirty physically abused women were randomly selected from the population of a local women's shelter and evaluated by psychiatric interview and psychiatric rating scales. High prevalences of major depression disorder (37%) and PTSD (47%) were determined. Furthermore, these disorders were found to be positively associated. These results suggest the need for immediate availability of psychiatric services at such shelters along with further study of their populations and possible intervention strategies.

Do children with severe head injury benefit from intensive care?

Intensive management of severe closed head injury is pursued in most neurosurgical units, as it no doubt reduces mortality. However, the fate of those salvaged from death is less clearly defined. The impact of aggressive management on the psychological recovery is even less clear. This retrospective study of children admitted to a regional paediatric neurosurgical service attempts to address these issues. Eighty-four children between the ages of 3 to 16 years with severe head injuries were studied and categorized according to conservative or intensive treatment groups. The availability of intensive management led to a greater number of such children referred. The mortality in those children sustaining more severe injury, i.e. Glasgow Coma Score (GCS) 3 or 4, was halved (44%) with intensive management from 80% in the conservative group. For those with less severe injury (GCS 5-8), it was unchanged at about 23%. The reduced mortality is at the expense of increased morbidity. Psychological testing showed that the cognitive recovery was comparable.

Isolated intracranial Rosai-Dorfman disease mimicking meningioma in a child.

A 9-year-old boy presented with a 12-month history of headaches and recent grand mal seizures. Computed tomography and magnetic resonance imaging of the brain revealed an enhancing right frontal convexity lesion. The preoperative diagnosis was meningioma. However, histological examination was diagnostic of Rosai-Dorfman disease. Rosai-Dorfman disease confined to the intracranial compartment is very rare, of 34 reported cases only one presented in the first decade. Optimal treatment has not been established, but complete surgical resection alone seems effective and allows histological distinction from meningioma.