Post neurosurgery Gram-negative bacillary meningitis.

The findings of a retrospective analysis of 20 patients who developed Gram-negative bacillary meningitis (GNBM) following neurosurgery are reported. The predisposing causes included surgery for skull fracture or cerebral contusion (9 patients), neoplasm (6) and vascular disease (2). Nine of the patients (45 per cent) had a cerebrospinal fluid (CSF) leak from a fistula. The organisms isolated, which included Pseudomonas aeruginosa (6), Klebsiella spp. (5) and Escherichia coli (4), had, in 75 per cent of cases, been isolated from other sites prior to the onset of GNBM. Initial diagnosis was achieved by Gram-stain of CSF in 15 of 19 cases (78 per cent). Culture of lumbar CSF was positive in 19 of the patients (95 per cent) and concommittant ventriculitis was confirmed by positive culture of ventricular CSF in 10 of 11 cases (91 per cent) from whom it was obtained. The overall mortality was 80 per cent, 11 patients dying of causes directly related to GNBM. Eradication of the infecting organism from CSF was achieved in 79 per cent of patients receiving intraventricular aminoglycoside therapy, but in only 40 per cent of those receiving intralumbar therapy. Deaths in the latter group were associated with ventriculitis whereas those in patients receiving intraventricular therapy resulted from intracranial abscess formation. These findings, plus the observation of chloramphenicol resistance in 80 per cent of the isolates, suggest that systemic and intraventricular aminoglycoside administration is indicated in patients with post-neurosurgical GNBM.

Antimicrobial prophylaxis in patients with rhinorrhea or otorrhea: a double-blind study.

A controlled double-blind study was performed on patients with injury to the head and face which had caused rhinorrhea or otorrhea. The patients were treated, at the time of the admission to the hospital, with penicillin (20 mega-units daily) or a placebo. A total of 52 patients was studied, 26 in each treatment group. Meningitis developed in one patient in the placebo group. Staphylococcus epidermidis (sensitive to penicillin) was the causative pathogen in this patient who also had a retained intraventricular foreign body. The frequency of extra-neurological infections and of asymptomatic pulmonary bacterial colonization was similar in both groups, but frequency of asymptomatic bacteriuria was higher in the placebo-treated patients.

[Aneurysm at the bifurcation of the internal carotid artery (author's transl)]. / L'anévrysme de la bifurcation carotidienne intra-crânienne

The authors analyse 14 cases of aneurysm occurring at the point of bifurcation of the internal carotid artery into the middle and anterior cerebral arteries. Distinguishing features of this aneurysm are often its fairly large size and extensive implantation on the artery. Clinical symptoms are not specific but various neurological signs are frequent. The bifurcation of the carotid artery is not always readily visible; oblique views and angiotomography are often necessary. Owing to the usual severity of the natural evolution of this type of aneurysm (death in six out of eight cases), surgical treatment is advisable. Ligation of the carotid artery is disadvised because of the unpredictable nature of its results (further fatal haemorrhage in one out of three cases).

[Hydrocephalic and/or degenerative dementia]. / Démence hydrocéphalique et/ou dégénérative.

The authors report ten cases of progressive dementia. Nine are associated with gait disturbances and seven with urinary incontinence. Despite the severity of dementia and Ct Scan signs of cortical atrophy, magnitude of neuroradiological ventricular dilatation and ventricular reflux at isotopic cisternography lead to shunt therapy. After ventricular shunting of CSF, a follow-up at short and long terms shows different clinical evolutions: two transitory improvements, three cases without change and five worsening. Retrospective clinical study of these cases in which diagnosis leads to a degenerative process of the Alzheimer type shows atypical premorbid neuropsychological characteristics by a normal-pressure hydrocephalus. In fact, in the ten cases preoperative neuropsychological investigation shows, at various levels, aphasic, alexic and agraphic signs. Their occurrence in the clinical picture represents an essential contribution to differential diagnosis.

[Pseudo-Hakim-Adams syndrome. Neuropsychological study of 23 cases of misdiagnosed Hakim-Adams syndrome]. / Pseudo-syndrome de Hakim et Adams. Etude neuropsychologique de 23 cas de faux diagnostic de syndrome de Hakim et Adams.

The authors study the characteristics of a group of 23 patients for whom an initial tentative diagnosis of Hakim-Adams syndrome (H-A syndrome) was eventually rejected. On account of several factors distinguishing these patients from the true H-A group, the authors propose using the term "pseudo Hakim-Adams syndrome". The distinguishing factors include: the grounds for admission, i.e. mental or mnesic deterioration, associated with radiological images of ventricular dilatation; a clinical picture dominated by mental disorders with only rare disorders of gait and sphincter control (several neurological defects were direct consequences of previous cerebral disease); no antecedents of spontaneous meningeal hemorrhage or meningitis in the case history; neuropsychological examination showing fewer disorders of concentration and less dyscalculia and constructive dyspraxia than in true HA, and far more atypical signs of the aphasic and anxio-depressive type. The authors think that various pathological processes may be responsible for this pseudo H-A syndrome in which a predominant mental picture is associated with ventricular dilatation.

[Pathological findings in a case of normal pressure hydrocephalus (author's transl)]. / Constatations anatomo-pathologiques dans un cas d'hydrocéphalie normotensive

Pathological findings in a case of normal pressure hydrocephalus are reported with a review of the literature.

[Cylindroma of the base of the skull with longstanding neurological disturbances. Anatomo-clinical correlation]. / Cylindrome de la base du crâne à manifestations neurologiques de longue durée. Corrélation anatomo-clinique.

The authors present the clinico-pathological correlation in a women who developed at the age of 43 years progressive pain in the left hemiface with motor and sensitive disorders of the left trigeminal nerve. Progressive involvement of the left IIIrd, IVth and Vth cranial nerves appeared with persistence of intractable facial pain which was not responsive to treatment by Tegretol, nor by thermocoagulation of the left Gasserian ganglion. Partial resection of a tumor was performed. The biopsy revealed its cylindromatous nature. The patient died after eight years of evolution. Autopsy confirmed an extensive tumoral invasion of the left temporal bone with invasion of the dura, the left cavernous sinus, and tumoral infiltration of the IIIrd, IVth, Vth and VIIIth cranial nerves on the left side. Metastases of the cylindromatous epithelioma were found in the liver and adrenals. The precise origin of the tumor could not be ascertained.

[Angiomas of the epidural space (author's transl)]. / Angiomes de l'espace épidural

The authors describe two cases of angiomas strictly limited to the spinal epidural space. They review the literature and stress the rarity of these tumours.

[Epidural metastases at the spinal level. Clinical study of 82 cases]. / Les métastases épidurales au niveau du rachis. Etude clinique de 82 cas.

This is a retrospective review of 82 cases of spinal epidural metastasis. A warning vertebral or radicular pain was present in 85% of the cases. In 33% of the patients, who complained only of pain without any neurological deficit, a complete myelographic block was already present. It is thus of prime importance not to neglect a vertebro-radicular pain in cancer patients, and even in patients without known cancer since the epidural metastasis was the first manifestation of the neoplasm in 30% of our cases. The indications for myelography are defined. The functional result (i.e. ability to walk) after treatment depends on the neurological state before treatment. In our series, total paraplegia was always irreversible. Early diagnosis and treatment are thus very important. The surgical treatment alone is judged insufficient. We were not able to prove the superiority of one of the following therapeutic modalities: laminectomy followed by radiotherapy or radiotherapy alone. Radiotherapy is indicated in all cases, often as the sole treatment. The indications for surgery are defined; they are based on our own experience and the literature. High dose steroids are indicated as adjuvant therapy.

[Causalgia: Report of a case (author's transl)]. / La douleur causalgique: A propos d'un cas.

The authors present the clinical course of a 48 year old workman who developed a progressively extending pain, after having wounded his left second finger with a metallic rod at work. This pain increased despite multiple surgical and medical treatment, including repeated amputations of the segments of the finger and the resection of the corresponding neurovegetative chain. When, two years later, the patient is seen by the authors, psychological analysis clearly shows an imbalanced evolution since chilhood: the pain is a focussing of various physical disconforts. A neuropsychological treatment is started in accordance with the noted background and the pain subsides within a few weaks. The result is stabilized in many months of treatment. From this clinical case, the authors stress the often dominant influence of the mental state in pain in general, and more specifically is the so called causalgic pain.

[Post traumatic schizophrenic bouts: with regard to 6 cases of traumatic schizophrenia (author's transl)]. / Les décompensations schizophréniques post-traumatiques. A propos de 6 cas de schizophrénie traumatique.

The authors describe 6 cases of post-traumatic schizophrenia and make a critical review of the literature concerning this unusual post-traumatic personality disturbance. Various schizophrenic manifestations are observed: they principally consist of delusion, hallucination, paranoid and mystical ideas, autism, psychomotor instability, fugues. Post-traumatic schizophrenia occurs mostly in young men, before thirty years. The severity of traumatic brain injury appears irrelevant in its genesis. Temporal lobes are more often involved (one third of the cases). Pre-traumatic personality disturbances are the main factor as demonstrated by the anamnesis and by the results of Rorschach test.

[Normotensive hydrocephalus. Retrospective clinical study of 47 cases]. / Hydrocéphalie dite "normotensive". Etude clinique rétrospective de 47 cas.

The clinical observation of 47 patients, undergoing surgery for "normotensive hydrocephalus" during the period January 1975 to January 1981 have been analysed retrospectively. The condition of half the patients improved following insertion of a cerebrospinal fluid bypass. Complications of varying degrees of severity were noted in 21 percent of cases. The correlation between the post-operative results and the clinical data was subjected to statistical analysis. Some factors appeared to have an important predictive value. These were the age, the absence of cortical atrophy on C.T. scan and the prolonged ventricular filling on cisternography. Other factors, although without statistical significance, seem to predict a better result: the existence of prior etiological data, presence of a frontal syndrome and evidence of periventricular hypodensity on C.T. scan. Finally, some other factors in our series appeared to have no influence on the prognosis. These were: duration of the preoperative evolution of the disorder, the degree of mental disturbance and difficulties of gait, the presence of urinary incontinence, the value of the ventricular cranial ratio. None of the recognized significant criteria was sufficiently reliable to predict the quality of surgical result, when studied in isolation. The association between the different significant criteria, such as have been described above notably, improves the chances of a favorable post-operative outcome but it is insufficient to predict it with great certitude. The continuous monitoring of the intracranial pressure during periods of 24 to 48 hours appears to be the most reliable factor on which to make a decision to operate in the light of the findings described in recent literature.