Visual hallucinations associated with pituitary adenoma.

Visual hallucinations were the presenting symptom in three patients with pituitary adenoma. One patient reported only simple unformed hallucinations, which are a well-documented phenomenon occurring in lesions compressing the optic nerves and chiasm. The other two patients, however, experienced complex formed visual hallucinations believed to be of the release type. No evidence of seizure activity responsible for the hallucinations was found; the mechanism producing them is discussed with correlation to operative findings and electrophysiological studies.

Somatosensory evoked potential to peroneal nerve stimulation in patients with herniated lumbar discs.

The somatosensory evoked potential (SEP) to peroneal nerve stimulation was recorded from 76 patients with myelographically proven herniated lumbar disc and was compared with normative data obtained from 65 healthy subjects. All patients with disc herniation had an abnormal SEP even when examination failed to disclose sensory deficits. In the patients with distortion of a root sleeve, the SEP abnormality was confined to the involved side. When myelography demonstrated large defects in the dural sac, there was electrophysiological evidence of disturbed conduction from the asymptomatic leg also. SEP changes in postoperative examinations correlated well with improvement or worsening of the patient's condition and enabled objective evaluation of the dynamics of sensory conduction along the involved structures.

Entrapped lumbar nerve root in pseudomeningocele after laminectomy: report of three cases.

The authors report three patients with symptomatic postlaminectomy pseudomeningocele. At operation a loop of a nerve root was found to be trapped within the dural defect. All three patients exhibited a delayed onset of radicular symptoms and signs after disc surgery. The pseudomeningocele was demonstrated computed tomography and myelography, but the entrapped root could be identified only at operation.

Spinal intradural ependymal cyst: a case report and review of the literature.

Spinal intradural ependymal cysts are extremely rare. The case presented is the sixth reported in the literature. The symptoms are consistent clinically and radiologically with a spinal intradural space-occupying lesion. The cyst wall is lined with both ciliated and nonciliated cells, resting directly on connective tissue. The exact embryonal origin of these cysts is obscure.

Intracranial hemorrhage in patients with hemophilia.

Intracranial hemorrhage (ICH) is a life-threatening complication of hemophilia. Seven of the 288 hemophiliacs living in Israel suffered eight episodes of ICH during the years 1972 to 1982. All episodes occurred in hemophilia A patients, with a higher incidence among patients with factor VIII inhibitor. Diagnosis was confirmed by computed tomographic scan in seven of the eight episodes. Four of the 7 patients died despite adequate factor replacement and supportive therapy, probably due to a conservative and hesitant neurosurgical approach. The correction of factor VIII to hemostatic level alone is inadequate in the majority of cases, and there is sudden deterioration in the patient's condition and death. Operation is strongly recommended when no improvement is noted within a few hours.

Acute angle closure glaucoma precipitated by orbital pseudotumour.

A 62-year-old woman presented with acute angle closure glaucoma. After a poor response to conventional treatment the presenting signs were re-evaluated and a diagnosis of pseudotumour of the orbit was made. Treatment with oral steroids resolved both the glaucoma and the orbital pseudotumour. The presumed pathogenesis and literature are reviewed.

Neurogenic pulmonary edema associated with a colloid cyst in the third ventricle. Case report.

Neurogenic pulmonary edema (NPE) is usually the result of head trauma. The authors describe the case of a 13-year-old girl, in whom NPE was associated with a colloid cyst of the third ventricle causing acute hydrocephalus. The mechanisms involved in the development of NPE are briefly discussed. The possible role of the colloid cyst in the distortion of the anatomical relationships in the vicinity of the hypothalamic nuclei is considered.

Transient hemiparesis: a rare manifestation of diphenylhydantoin toxicity. Report of two cases.

Among the common side effects of diphenylhydantoin (DPH) overdose, the most frequently encountered neurological signs are those of cerebellar dysfunction. Very rarely, the toxic neurological manifestations of this drug are of cerebral origin. Two patients are presented who suffered progressive hemiparesis due to DPH overdose. Both had brain surgery before DPH treatment. It is assumed that patients with some cerebral damage are liable to manifest DPH toxicity as focal neurological signs.

Reversible facial pain due to hydrocephalus with trigeminal somatosensory evoked response changes. Case report.

A patient with hydrocephalus due to aqueductal stenosis suffered facial pain which was relieved after the insertion of a ventriculoperitoneal shunt. The trigeminal somatosensory evoked response (TSER) of the affected side showed lower amplitudes and longer latencies as compared to the unaffected side. Following surgery, the waves regained higher amplitudes and shorter latencies. An episode of shunt malfunction was accompanied by recurrent facial pain and impairment of the TSER. Both improved after revision of the shunt. The possible etiology of facial pain in patients with hydrocephalus is discussed.

Sensory evoked response to electrical stimulation of the trigeminal nerve in humans.

Electrical stimulation of the upper and lower lips of normal subjects evoked a consistent response recorded from over the face area of the ipsi- and contralateral hemispheres. This response consisted of seven discrete waves. Peak latencies ranged from as early as 8 msec to 115 msec. Stimulation of the lower lip evoked a response of lower amplitude and reversed polarity, as compared to te upper lip stimulation response. The data support the validity of the trigeminal sensory evoked response in the evaluation of the trigeminal pathways. Previously reported methods are reviewed and compared.

Transient global amnesia associated with a single metastasis in the non-dominant hemisphere. Case report.

A patient in whom transient global amnesia (TGA) led to the diagnosis of a metastasis of a transition-cell carcinoma of the bladder to the non-dominant hemisphere is described. In previously reported cases of TGA associated with brain tumors, the tumors involved either the dominant or both hemispheres. The etiology of TGA associated with a brain tumor is most likely vascular, as suggested by the sudden development and the transitory character of the event. In contrast to the "common" form of TGA (where both temporal lobes suffer temporary ischemia), in these patients only one side of the limbic system is affected, because a brain tumor has already compromised the other limbic area. Therefore, the dominance of the hemisphere with the tumor is of no consequence, as both hemispheres have been involved. It is concluded that the TGA in these patients is not due to, but is rather associated with, a unilateral brain tumor.

Delayed postoperative neurological deterioration from prolonged sodium nitroprusside administration. Case report.

Sodium nitroprusside is commonly used for the induction of hypotension during neurosurgical procedures. Its toxicity stems from hemodynamic compromise as well as from its metabolites, especially the formation of cyanide. A patient is described who underwent craniotomy for hypertensive intracerebral hemorrhage. He gradually recovered following the operation, but needed continued administration of sodium nitroprusside for control of hypertension. On the 7th postoperative day, he deteriorated into coma with evidence of severe edema and herniation on the computerized tomography scan. Cessation of sodium nitroprusside and treatment for cyanide poisoning resulted in resolution of his symptoms within hours. The potential toxicity of sodium nitroprusside, measures to prevent toxicity, and therapeutic steps are discussed.

Unusual delayed onset of diabetes insipidus following closed head trauma. Case report.

A case of delayed onset of diabetes insipidus (DI), which developed 27 days after a closed head injury, is reported. The patient sustained only a minor neurological deficit and, except for antidiuretic hormone (ADH) insufficiency, hypothalamic function was intact. This selective damage of posterior pituitary function was total and permanent. Ischemia due to vascular injury may be the most likely etiology. Once the diagnosis of delayed posttraumatic DI is confirmed, the treatment of choice is DDAVP (desmopressin acetate). In contradistinction to DI immediately following minor head injury, most patients with a delayed onset of DI after trauma have permanent ADH deficiency.

Giant nevus of the scalp associated with intracranial pigmentation. Case report.

A case is reported of aggressive cellular blue nevus of the scalp. Intracranial pigmentation in association with a melanocytic nevus of the scalp may indicate either benign coexisting melanosis, local extension, or invasive malignancy. The importance of accurate diagnosis is discussed, and the need to be prepared to carry the excision deep enough to include the dura is illustrated.

Intermittent priapism in spinal canal stenosis.

A case of spontaneous intermittent priapism in a patient with spinal canal stenosis is presented. Erection, as well as intermittent neurogenic claudication and urinary incontinence were provoked by physical exertion, mainly walking. The symptoms completely resolved after decompressive lumbar laminectomy.

Postoperative spinal epidural empyema. Clinical and computed tomography features.

Epidural empyema is a rare complication of elective spinal surgery. Four such cases are described. The clinical features of this postoperative complication were surprisingly vague and misleading. Fever was uncommon. Local inflammatory signs or rapid neurologic deterioration were absent. Computerized tomography proved useful in diagnosis and follow-up. Unlike spontaneous spinal epidural abscess, postoperative spinal epidural empyema had a benign course. Causative bacteria were miscellaneous. Surgical evacuation of the purulent collection and appropriate antibiotic therapy resulted in cure in all cases.

Perioperative prophylactic cephazolin in spinal surgery. A double-blind placebo-controlled trial.

We investigated the efficacy of a single dose of 1 g of cephazolin in reducing postoperative infections in patients undergoing 'clean' operations on the lumbar spine. In a double-blind, randomised, trial there were 21 wound or urinary infections in the 71 patients who received placebo and nine in the 70 who received cephazolin (p < 0.05). Nine of the placebo patients (12.7%) developed wound infections (complicated by bacteraemia in two) compared with three (4.3%) in the cephazolin group (p = 0.07). Hospital stay was longer for infected patients than for non-infected patients (p < 0.05). Cephazolin-resistant pathogens were isolated more frequently from patients who received cephazolin than from those who received placebo.

Trigeminal neurinoma with unusual presentation. Report of a case with trigeminal somatosensory-evoked response.

A patient with trigeminal neurinoma, presenting unusual symptoms, is described. There was no trigeminal sensory or motor deficit. The only presenting symptoms were unilateral abducens nerve paresis and alternating hemiplegic episodes. The trigeminal somatosensory-evoked response was normal before surgery. After complete removal of the tumor from both the posterior and middle cranial fossae, severe trigeminal sensory deficit ensued, accompanied by impairment of the evoked response. Improvement of the trigeminal nerve function could be predicted by significant changes in a repeat trigeminal sensory-evoked response obtained 2 months after the operation.

Continuous lumbar drainage of cerebrospinal fluid in neurosurgical patients.

Continuous spinal drainage of cerebrospinal fluid was used in 50 patients with CSF fistulas both traumatic and postoperative. The method seemed to be helpful in the healing of leaks, thereby rendering surgery unnecessary. It also helped the surgical sealing of long standing tears.

Importance of early radiologic diagnosis of congenital anomalies of the spine.

Manifest or occult spinal dysraphism in the absence of neurological symptoms is likely to remain undetected. Therefore, accurate and early diagnosis of such underlying anomalies is of prime importance for early surgical intervention in order to avoid late irreparable damage. During a period of just over 1 year, 17 such cases of spinal congenital anomalies were diagnosed by myelography with metrizamide and computed tomography-myelography. There were 16 cases of tethered cord, six with myelomeningocele, two with diastematomyelia, two with a split spinal cord, three with a lipoma, and the remaining three with vertebral anomalies. Scoliosis was present in 60%, weakness of both legs in 45%, and asymmetry of the feet in 25%. Some of these patients were initially brought to the orthopedic department for corrective surgery before undergoing a complete neurological evaluation; thus the radiologist was acting as the link between patient and neurosurgeon. Clinical experience has shown that surgical treatment can be successful and can thereby obviate further progression of neurological symptoms.