Diffusion tensor imaging of benign intracranial hypertension: absence of cerebral oedema

Cerebral oedema, it has been suggested, may have a role in the pathophysiology of benign intracranial hypertension (BIH). We applied diffusion tensor MR imaging (DTI), a technique able to detect cerebral oedema, to the study of patients with BIH. A quantitative regional analysis of diffusion parameters (trace and relative anisotropy) was conducted by comparing five BIH patients and six healthy controls. A small but significant increase in anisotropy accompanied by a small but significant decrease in trace was found in the putamen and head of the caudate nucleus. No significant changes were demonstrated in the thalamus, cerebral white matter or cortical regions. Our findings support other recent work that suggests cerebral oedema is not a factor in the pathogenesis of BIH.

Retinal nerve fiber layer analysis in idiopathic intracranial hypertension

BACKGROUND

The chronic nature of idiopathic intracranial hypertension (IIH) represents a risk factor for progressive optic nerve damage and structural abnormalities of the retina.

AIM

We measured the retinal nerve fiber layer (RNFL) thickness in patients followed with the diagnosis of IIH who had no or mild visual impairment to search for possible structural alterations in the retina for diagnostic and prognostic purposes.

SETTINGS AND DESIGN

Case-control prospective study.

MATERIALS AND METHODS

The study group consisted of 12 women followed and treated with the diagnosis of IIH in our clinic. The selection criteria were the, normal optic nerve, normal visual fields or mild visual field defects (Grade 1-3) by Humphrey perimeter. Randomly assigned, age-matched 12 healthy women were taken as the control group. Retinal nerve fiber layer thickness was evaluated with scanning laser polarimetry and both eyes were studied for each case in both groups.

STATISTICAL ANALYSIS USED

Mann-Whitney U test.

RESULTS

The mean ages of the patient and the control groups were 34.58+/-4.2 and 34.42+/-5.7 years respectively (P=0.87). The mean duration of disease was 5.5+/-3 years. Some parameters related to RNFL thickness were found to differ significantly between patients with IIH and control subjects. Namely superior ratio (P=0.007), inferior ratio (P=0.039), superior-nasal ratio (P=0.025), maximum modulation (P=0.01) and symmetry (P=0.006) were lower in the patient group than controls.

CONCLUSION

Scanning laser polarimetry might be a good adjunct for determining possible structural affects of IIH on the retina in patients with no or mild visual impairment.

Basilar megadolicho trunk causing obstructive hydrocephalus at the foramina of Monro

We report on a 54-year-old man with megadolicho basilar artery presenting with acute signs of raised intracranial pressure due to a compromise of cerebrospinal fluid (CSF) flow at the level of the foramina of Monro by the basilar apex extending more than 3 cm cranially to the dorsum sellae. The diagnosis was confirmed on computed tomographic angiography and emergent CSF drainage relieved symptoms immediately.

Photodynamic therapy increases brain edema and intracranial pressure in a rabbit brain tumor model

The objective of this study was to evaluate the effect of a single photodynamic therapy (PDT) on brain edema and intracranial pressure (ICP) in a rabbit model of brain tumor. A total of 57 adult New Zealand rabbits were assigned to 3 groups: the PDT group, the tumor group, and the tumor plus PDT group. Rabbits in the PDT group (n = 9) received PDT but no tumor implantation; rabbits in the tumor group (n = 18) received VX2 carcinoma implantation but no PDT; rabbits in the tumor plus PDT group (n = 30) received tumor implantation with subsequent PDT 16 days later. Brain edema and ICP levels were then evaluated. We found that ICP in the PDT group was 7.43 +/- 0.50 mmHg. After tumor implantation, ICP increased rapidly (18.43 +/- 1.10 mmHg, 21 days later). PDT alone did not increase ICP, but compared with that in the tumor group, ICP increased significantly in the tumor plus PDT group (9.55 +/- 1.32 vs. 13.31 +/- 1.13 mmHg, p < 0.01) 24 hours after treatment. Brain water content in the tumor group increased rapidly after tumor implantation. PDT again increased perineoplastic brain edema 24 hours after treatment (81.09 +/- 0.97% vs. 78.32 +/- 0.49%, p < 0.01). It should be noted that PDT alone did not induce brain edema. In conclusion, PDT causes transient brain edema and increases ICP in a rabbit brain tumor model.

Primary empty sella syndrome in a series of 142 patients

OBJECT

The primary empty sella syndrome (ESS) represents a heterogeneous clinical picture characterized by endocrine disturbances and signs of intracranial hypertension. An increase in intracranial pressure (ICP) is proposed to be one of the involved pathogenetic factors.

METHODS

The series included 142 patients who were observed during a period of 20 years. All patients underwent an ICP and cerebrospinal fluid (CSF) dynamics evaluation through the use of a lumbar constant-rate infusion test. Impairment of ICP and CSF dynamics was observed in 109 patients (76.8%). In 35 of the 36 patients affected by severe intracranial hypertension without rhinorrhea, improvement in adverse neurological symptoms was achieved after implanting a CSF shunt. Visual function, already seriously compromised before surgery, remained severely altered in one patient. In the group of 34 patients affected by rhinorrhea, CSF leakage was controlled using different surgical treatments: CSF shunt placement in 16 cases, surgical repair of the sellar floor in three, and both procedures in the remaining 13. Two patients refused any surgical treatment.

CONCLUSIONS

The role of increased ICP in the pathogenesis and perpetuation of primary ESS has been confirmed. Adverse neurological signs and a CSF leak are correlated with an actual increase in ICP and are relieved after CSF shunt insertion. Cerebrospinal fluid rhinorrhea is more common than generally thought. Its resolution can be achieved using a careful diagnostic protocol and sometimes may require different surgical procedures.

Comparison of simultaneous continuous intracranial pressure (ICP) signals from a Codman and a Camino ICP sensor

Simultaneous continuous intracranial pressure (ICP) signals from two different sensors were compared. Continuous ICP monitoring from two ICP sensors (i.e. Codman ICP MicroSensor; Johnson & Johnson, Raynham, MA and Camino OLM ICP; Camino Laboratories, San Diego, CA) placed within the brain parenchyma was performed in three patients within the intensive care unit (ICU) as part of routine management of severe subarachnoid hemorrhage. For each 6s time window mean ICP was computed, showing large differences in mean ICP values between the signals. Differences above 5 mmHg were observed in 13% of the 128,425 time windows derived from 214 h ICP recordings in these three patients. In one patient, mean ICP differed more than 10 mmHg in 23% of the time windows. Comparisons of 675,503 individual single pressure wave pairs of these 128,425 time windows revealed marginal differences in single wave amplitude (dP, i.e. pulse pressure) and latency (dT, i.e. rise time) values, suggesting that differences in mean ICP were caused by differences in baseline pressure. For the individual time windows were computed the mean wave amplitude and mean wave latency values according to a new algorithm. There were as well marginal differences between signals of mean wave amplitude and latency values. Thus, changes in baseline pressure affect mean ICP but not single pressure wave characteristics such as amplitude (dP) and (dT) latency values.

Intracranial hypertension as an initial manifestation of spinal neuroectodermal tumor

A 19-year-old girl had headaches, blurred vision and vomiting for 2 weeks. Neurological examination revealed only bilateral papilloedema and left abducens palsy. Neuroimaging of the brain was normal. Cerebrospinal fluid study showed intracranial hypertension (IH), hypoglycorrhachia, hyperproteinorrhachia, and a negative cytology study. Eight months after the onset, paraparesis occurred. Spinal magnetic resonance imaging showed intramedullary masses at the cervical and thoracic cords with extensive seeding. Biopsy of the mass showed primitive neuroectodermal tumor (PNET). IH rarely occurs in patients with spinal cord neoplasms. Its incidence is low and the condition is always associated with signs of myelopathy. We report a patient whose initial manifestation of spinal PNET was IH only. Spinal tumor should be considered in IH patients whose intracranial examinations are negative.

IPSAPIRONE AND KETANSERIN PROTECTS AGAINST CIRCULATORY SHOCK, INTRACRANIAL HYPERTENSION, AND CEREBRAL ISCHEMIA DURING HEATSTROKE

We assess the effects of ipsapirone (a 5-HT1A receptor agonist), ketanserin (a 5-HT2A receptor antagonist), (-)-pindolol (a 5-HT1A receptor antagonist), and DOI (a 5-HT2A receptor agonist) on heatstroke in a rat model. Animals, under urethane anesthesia, were exposed to high ambient temperature of 42 degrees C until mean arterial pressure and local cerebral blood flow in the striatum began to decrease, which was arbitrarily defined as the onset of heatstroke. Normothermic controls were exposed to room temperature of 24 degrees C. In rats treated with normal saline immediately before the initiation of heat stress, the values for survival time were found to be 21 to 25 min. Systemic administration of ipsapirone (10 mg/kg) or ketanserin (2 mg/kg) immediately before the initiation of heat stress significantly increased the survival time to new values of 92 to 104 min. Combined treatment with ipsapirone and ketanserin had additive effects (survival time of 156-194 min). In contrast, systemic administration of (-)-pindolol (2 mg/kg) or DOI (2 mg/kg) significantly decreased the survival time to new values of 2 to 3 min. In vehicle-treated heatstroke rats, the values for core temperature, intracranial pressure, and the extracellular levels of cellular ischemia (e.g., glutamate and lactate/pyruvate ratio) or damage (e.g., glycerol) markers and neuronal damage scores in striatum were significantly higher than those of normothermic controls. On the other hand, the values for mean arterial pressure, cerebral perfusion pressure, cerebral blood flow, and brain partial pressure of O2 were significantly lower than those of normothermic controls. The heatstroke-induced hyperthermia, arterial hypotension, intracranial hypertension, cerebral hypoperfusion and hypoxia, and increased levels of cellular ischemia and damage markers in striatum were all significantly attenuated by prior administration of ipsapirone or ketanserin. The present results strongly suggest that previous activation of 5-HT1A receptors or antagonism of 5-HT2A receptors protects against heatstroke by reducing circulatory shock and cerebral ischemia, whereas prior antagonism of 5-HT1A receptors or activation of 5-HT2A receptors exacerbates heatstroke.

Bilateral involvement of a single cranial nerve: Analysis of 578 cases

The author reviewed 34 years of personal experience with inpatients in a large municipal hospital to analyze the seats and causes of involvement of single pairs of cranial nerves. Among 578 cases, the sixth (n = 234) and second (211) nerves predominated, followed by the fourth (48), seventh (30), third (27), and eighth (18) cranial nerves. Trauma (99), infection (94), tumor (92), increased intracranial pressure (85), vascular disease (74), and demyelination (66) were common causes.

Resolution of neurogenic arterial hypertension after suboccipital decompression for Chiari malformation. Case report

A Chiari malformation Type I may remain asymptomatic until the patient has reached adulthood and acute presentation of symptoms occurs. In several clinical and experimental studies it has been shown that essential hypertension is associated with vascular compression of the brainstem, particularly of the rostral ventrolateral medulla oblongata. Nevertheless, two cases of Chiari malformation and neurogenic arterial hypertension have been reported. In this article the authors describe a patient with Chiari malformation Type I and neurogenic arterial hypertension. A simple suboccipital decompression not only provided neurological improvement, but also led to resolution of the hypertension. In cases of Chiari malformation and concomitant neurogenic arterial hypertension, careful preoperative clinical and neuroimaging assessments may reveal the cause of the arterial hypertension. Resolution of neurogenic arterial hypertension may be expected even in a case of simple suboccipital decompression.

Trigeminal neuralgia secondary to Chiari's malformation—treatment with ventriculoperitoneal shunt

BACKGROUND

Trigeminal neuralgia (TN) is most commonly related to vascular compression of the trigeminal nerve. Trigeminal neuralgia associated with Chiari's malformation and associated hydrocephalus are rare.

CASE DESCRIPTION

A 31-year-old male presented with classical TN affecting the mandibular division of the right trigeminal nerve. His symptoms were poorly controlled with increasing doses of carbamazepine. Magnetic resonance imaging scan of brain revealed Chiari's type I malformation and associated hydrocephalus. Approximately 1 month after insertion of a programmable ventriculoperitoneal shunt, his TN resolved.

CONCLUSIONS

Chiari's malformation and hydrocephalus are rare associates of TN. The pathophysiology of TN in these cases may be due to neurovascular conflict, related to raised intracranial pressure from the hydrocephalus and/or the small posterior fossa volume in these patients. Drainage of associated hydrocephalus may be an effective surgical treatment.

Postischemic reperfusion: ultrastructural blood-brain barrier and hemodynamic correlative changes in an awake model of transient forebrain ischemia

OBJECTIVE

In nonrecovery models of cerebral ischemia, blood-brain barrier (BBB) and cerebral blood flow (CBF) changes are known to occur during reperfusion. It is unknown, however, whether those CBF and BBB alterations occur after brief, transient ischemia with neurological recovery. The purpose of this study was to characterize the time course of CBF and BBB ultrastructural changes during reperfusion in an awake, recovery model of transient global forebrain ischemia (GFI).

METHODS

Forty-five adult Sprague-Dawley rats were subjected, while awake, to 10 minutes of GFI by the nine-vessel occlusion method. Thirty-five age-matched animals composed a sham-operated group. Normal control (n = 5), sham-operated (n = 5), and nine-vessel occlusion/reperfusion (n = 15) rats were selected for ultrastructural analysis. Electroencephalography was performed, and CBF, mean arterial blood pressure, and intracranial pressure were measured during ischemia and reperfusion up to 24 hours. Quantitative morphological analysis of cortical BBB capillaries was performed by transmission electron microscopy at the same time points at which specific CBF changes occurred during reperfusion.

RESULTS

CBF decreased to 6% of preocclusion values during GFI. This correlated with coma and decerebrate rigidity. During reperfusion, short-lived hyperemia (225 +/- 18%, P < 0.001) was characterized by increased intracranial pressure (28.3 +/- 2.6 mm Hg, P < 0.001) and isoelectric electroencephalogram. This was followed by hypoperfusion, which reached a nadir of 59.7% (59.7 +/- 8.8%, P < 0.01) from baseline by 90 minutes. At this time point, the electroencephalogram recovered, and intracranial pressure and mean arterial blood pressure showed no abnormalities. By 8.5 hours, CBF returned to normal, and this coincided with complete recovery of the animal. Ultrastructural BBB analysis revealed astrocyte end-foot process edema and patent capillaries during hyperemia. Severe interstitial BBB edema and capillary lumen collapse was observed during hypoperfusion. Detachment and migration of pericytes was observed during hypoperfusion and beyond.

CONCLUSION

A biphasic CBF response is elicited during reperfusion after brief nonlethal GFI under awake conditions.

[Sonography of the optical nerve -- experience in 483 children]

INTRODUCTION

In case of increased intracranial pressure (IICP), the inflow of cerebrospinal fluid widens the space between the optic nerve (ON) itself and the surrounding dura mater leading to the sonographic appearance of increased diameter of the ON. The purpose of the study was to gain clinical experience in children and to determine (a) the mean values for patients without proven IICP and (b) pathologic values of those with proven IICP.

MATERIALS AND METHODS

Ultrasound of the optic nerve was performed in 483 children with symptoms consistent with IICP, comprising 287 males and 196 females at an age ranging from 4 days to 24 years with a mean age of 7.5 + 5.1 years. The measured diameter of the ON of both eyes and the morphologic criteria concerning nerve sheath and papilla were evaluated retrospectively.

RESULTS

Most of the investigated patients (n = 466) had no IICP as confirmed by neurological examination, EEG, sometimes CCT and/or MRI and clinical follow-up. The typical morphological findings in patients with normal intracranial pressure (ICP) were a clear and longitudinally extended demarcation of the ON with a well-delimited nerve sheath and without prominent papilla. The mean diameter of the ON in patients with normal ICP was 3.4 mm + 0.7 mm. In 17 patients with proven IICP, the mean diameter of the ON increased to 5.6 mm + 0.9 mm. Typically, the nerve sheath was indistinguishable from the hypoechoic ON, often but not invariably associated with a prominent papilla. In patients with IICP, the diameter of the ON alone matches the diameter of the ON plus nerve sheath in patients with normal ICP.

CONCLUSION

IICP was detected with a high sensitivity by ultrasound using the diameter and the morphological criteria of an indistinguishable nerve sheath. A diameter of more than 4.5 mm is definitely pathologic and requires further investigation. Prominence of the papilla is an unreliable criterion for acute IICP.

Correlation of cell apoptosis with brain edema and elevated intracranial pressure in traumatic brain injury

OBJECTIVE

To study the correlation between brain edema, elevated intracranial pressure (ICP) and cell apoptosis in traumatic brain injury (TBI).

METHODS

In this study, totally 42 rabbits in 7 groups were studied. Six of the animals were identified as a control group, and the remaining 36 animals were equally divided into 6 TBI groups. TBI models were produced by the modified method of Feeney. After the impact, ICP of each subject was recorded continuously by an ICP monitor until the animal was sacrificed at scheduled time. The apoptotic brain cells were detected by an terminal deoxynucleotide-transferase-mediated dUTP-digoxigenin nick end labeling (TUNEL) assay. Cerebral water content (CWC) was measured with a drying method and calculated according to the Elliott formula. Then, an analysis was conducted to determine the correlation between the count of apoptotic cells and the clinical pathological changes of the brain.

RESULTS

Apoptotic cell count began to increase 2 h after the impact, and reached its maximum about 3 days after the impact. The peak value of CWC and ICP appeared 1 day and 3 days after the impact, respectively. Apoptotic cell count had a positive correlation with CWC and ICP.

CONCLUSIONS

In TBI, occurrence of brain edema and ICP increase might lead to apoptosis of brain cells. Any therapy which can relieve brain edema and/or decrease ICP would be able to reduce neuron apoptosis, thereby to attenuate the secondary brain damage.

Evolution of Brain Tissue Injury after Evacuation of Acute Traumatic Subdural Hematomas

OBJECTIVE:

Acute traumatic subdural hematoma complicated by brain parenchymal injury is associated with a 60 to 90% mortality rate. Early surgical evacuation of the mass lesion is essential for a favorable outcome, but the severity of the underlying brain injury determines the outcome, even when surgery has been prompt. The purpose of this study was to analyze tissue biochemical patterns in the brain underlying an evacuated acute subdural hematoma to identify a characteristic pattern of changes that might indicate evolving brain injury.

METHODS:

Prospectively collected data from 33 patients after surgical evacuation of acute subdural hematoma were analyzed. Both a brain tissue oxygen tension probe and an intracerebral microdialysis probe were placed in brain tissue exposed at surgery. On the basis of the postoperative clinical course, the patients were divided into three groups: patients with early intractable intracranial hypertension, patients with evolution of delayed traumatic injury (DTI), and patients with an uncomplicated course (the no-DTI group).

RESULTS:

The overall mortality rate was 46%, with 100% mortality in the intracranial hypertension group (five patients). Mortality in the DTI group was 53% compared with only 9% in the no-DTI group (P = 0.002). There were no significant differences in the initial computed tomographic scan characteristics, such as thickness of the subdural hematoma or amount of midline shift, among the three groups. Physiological variables, as well as the microdialysate measures of brain biochemistry, were markedly different in the intracranial hypertension group compared with the other groups. Differences between the other two groups were more subtle but were significant. Significantly lower values of brain tissue oxygen tension (14 ± 8 mm Hg versus 27 ± 14 mm Hg) and higher dialysate values of lactate and pyruvate were documented in patients who developed a delayed injury compared with patients with uncomplicated courses (4.1 ± 2.3 mmol/L versus 1.7 ± 0.7 mmol/L for lactate, and 104 ± 47 μmol/L versus 73 ± 54 μmol/L for pyruvate at 24 h after injury).

CONCLUSION:

Evolution of DTI in the area of brain underlying an evacuated subdural hematoma is associated with a significant increase in mortality. Postoperatively decreasing brain tissue oxygen tension and increasing dialysate concentrations of lactate and pyruvate in this area may warn of evolving brain injury and evoke further diagnostic and therapeutic activity.

Hypertonic Fluid Resuscitation from Subarachnoid Hemorrhage in Rats

OBJECTIVE

Increased intracranial pressure (ICP) and decreased cerebral blood flow leading to global cerebral ischemia are the primary causes of death after severe subarachnoid hemorrhage (SAH). Hypertonic saline has been demonstrated to exert neuroprotective properties after traumatic brain injury by osmotic mobilization of parenchymal water and improvement of microcirculation. We used a rat model to investigate the effects of hypertonic fluid resuscitation after SAH on ICP, cerebral blood flow, body weight, neurological recovery, and morphological damage.

METHODS

Sixty rats were subjected to SAH induced by an endovascular filament. ICP and local cerebral blood flow were recorded continuously. Animals were assigned to three groups: 1) NaCl 0.9%; 2) NaCl 7.5% (4 ml/kg); and 3) NaCl 7.5% plus 6% dextran 70 (4 ml/kg) given 30 minutes after SAH. Body weight and neurological deficits were assessed daily. Morphological damage was evaluated on Day 7.

RESULTS

SAH resulted in an immediate increase of ICP to approximately 60 mm Hg initially, and then to approximately 30 mm Hg for the next 90 minutes. Although NaCl 7.5% alone and in combination with dextran led to an immediate, significant, and lasting decrease of ICP to 15 to 20 mm Hg, only the combined therapy significantly increased body weight and improved neurological recovery. Furthermore, the group that received combined therapy exhibited significantly more surviving neurons in hippocampus, cortex, caudoputamen, and cerebellum. Mortality was reduced nonsignificantly, from approximately 65% in groups I and II to 35% in Group III.

CONCLUSION

Treatment with NaCl 7.5% plus 6% dextran 70 is significantly effective for reducing the initial harmful sequelae of SAH. The regimen resulted in lowered ICP, improved neurological recovery, and less morphological damage after SAH in the rat.

Chronic Intracranial Hypertension with Unexplained Cerebrospinal Fluid Pleocytosis

In a retrospective review of all cases with a diagnosis of idiopathic intracranial hypertension in two academic departments of neurology over a nine-year period, the authors identified six patients with a clinical course typical of idiopathic intracranial hypertension (IIH) except for the finding of cerebrospinal fluid pleocytosis. There were five women and one man with a mean age at presentation of 25.7 years (range, 25-32 yr). All were obese but had no other associated medical conditions or identifiable risk factors for IIH. In five patients, all or most cerebrospinal fluid cells were lymphocytes. Cerebrospinal fluid pleocytosis persisted for several months in all patients. Patients underwent a thorough laboratory and neuroimaging evaluation that did not reveal a primary cause. Medical treatment directed solely at lowering intracranial pressure was effective in five patients; one patient required lumboperitoneal shunting. Ophthalmic manifestations of increased intracranial pressure stabilized or remitted after treatment was withdrawn with a mean follow-up period of 33 months (range, 14-55 mo). Some patients may present with idiopathic chronic meningitis and elevated intracranial pressure that responds to treatment used for IIH.

Giant Supratentorial Enterogenous Cyst: Report of a Case, Literature Review, and Discussion of Pathogenesis

OBJECTIVE AND IMPORTANCE

To describe a histologically well-documented adult case of a giant supratentorial enterogenous cyst (EC). Fewer than 15 cases of supratentorial ECs are on record: 8 associated with the brain hemispheres or the overlying meninges, 4 with the sellar region, and 2 with the optic nerve.

CLINICAL PRESENTATION

A 31-year-old woman complained of long-standing mild left brachial and crural motor deficit precipitated by headache and signs of intracranial hypertension. Magnetic resonance imaging revealed a huge cyst overlying the frontoparietal brain.

INTERVENTION

Symptoms were relieved by evacuation of the cyst content by means of a Rickam's reservoir, and the lesion was subsequently removed in toto. Histological and immunohistochemical examination of the cyst wall clearly established the enterogenous nature of its epithelium. Follow-up for up to 2 years after intervention showed no sign of recurrence, and symptoms, including treatment-resistant seizures in the postoperative period, have entirely subsided.

CONCLUSION

Supratentorial ECs, distinctly rare in adult patients, may in some cases present as giant lesions. Total removal seems to be curative once careful examination has eliminated the possibility of a metastasis from an unknown primary. A correct histological diagnosis is important because, in contrast to other benign cysts of similar location and size, ECs may be prone to intraoperative dissemination.

Functional genomics as an emerging strategy for the investigation of central mechanisms in experimental hypertension

Centrally mediated increases in sympathetic nerve activity and attenuated arterial baroreflexes contribute to the pathogenesis of hypertension. Despite the characterization of cellular and physiological mechanisms that regulate blood pressure and alterations that contribute to hypertension, the genetic and molecular basis of this pathophysiology remains poorly understood. Strategies to identify genes that contribute to central pathophysiologic mechanisms in hypertension include integrative biochemistry and physiology as well as functional genomics. This article summarizes recent progress in applying functional genomics to elucidate the genetic basis of altered central blood pressure regulatory mechanisms in hypertension. We describe approaches others and we have undertaken to investigate gene expression profiles in hypertensive models in order to identify genes that contribute to the pathogenesis of hypertension. Finally, we provide the readers a roadmap for negotiating the route from experimental findings of gene expression profiling to translating their therapeutic potential. The combination of gene expression profiling and the phenotypic characterization of in vitro and in vivo loss or gain of function experiments for candidate genes have the potential to identify genes involved in the pathogenesis of hypertension and may present novel targets for therapy.

Fatal subarachnoid hemorrhage after carotid stenting

BACKGROUND AND PURPOSE

Cerebral hyperperfusion syndrome with intracerebral hemorrhage (ICH) following carotid angioplasty and stent placement (CAS) of the internal carotid artery (ICA) is well known. We report the occurrence of fatal subarachnoid hemorrhage in a patient undergoing CAS.

CASE REPORT

A 77-year-old woman experiencing a left-hemispheric transient ischemic attack underwent CAS for a 95% stenosis of the left ICA. CAS was performed without acute complications. At 5 hours the patient suddenly deteriorated. Her level of consciousness changed and she developed neck stiffness. CT of the brain revealed diffuse SAH with acute hydrocephalus.

CONCLUSIONS

Like ICH, SAH may develop as a severe complication after CAS. There are no reliable clinical symptoms preceding this fatal complication. However, several factors such as long-standing severe carotid stenosis with contralateral occlusion and increasing blood pressure after CAS accompanied by the extensive use of antithrombotic agents may predispose to this fatal complication.

[Cerebro-cardial disorders in hemorrhagic stroke]

AIM

To elucidate relationships brain-heart in hemorrhagic stroke depending on the size and location of hematoma and initial state of the heart.

MATERIAL AND METHODS

Clinical and paraclinical methods were used in acute and rehabilitation periods in 160 patients with hemorrhagic stroke.

RESULTS

Symptoms of cerebrocardial syndrome in hemorrhagic stroke include arrhythmias (tachycardia, bradycardia, extrasystole, cardiac fibrillation, sick sinus syndrome), blocks (transient bundle-branch block), myocardial dystrophy, in IHD--ischemic myocardial disorders up to subendocardial myocardial infarction. Its severity in massive hemispherical hematomas was due to compression of the brain trunk.

CONCLUSION

Pathogenesis of cerebrocardial syndrome rests on impaired central autonomic regulation occurring in stroke.

Computed tomography and magnetic resonance imaging findings of brain damage by hanging

We reported computed tomography (CT) and magnetic resonance imaging (MRI) findings of brain damage of a 61-year-old man who attempted suicide by hanging. Unenhanced CT demonstrated multiple hyperdense areas indicating subcortical and subarachnoid hemorrhages and brain swelling. MRI demonstrated not only hemorrhagic findings, but also ischemic findings in the middle brain and cerebral cortex. Multifocal cerebral hemorrhages might be caused by venous hypertension due to compression of the jugular veins.

Experimental study of rapid versus slow sagittal sinus occlusion in dogs

BACKGROUND

Clinical, radiological, postmortem and experimental studies are not enough for the definition of pathophysiological differences between rapid and slow-progressing cerebral venous system obstruction.

AIMS

An experimental study was conducted to set some physiopathological differences between rapid and slow occlusion of the superior sagittal sinus.

SETTINGS AND DESIGN

Eighteen dogs categorized into 3 groups were chosen as test subjects. The three groups were the rapid occlusion, slow occlusion and the control study groups and each group had six subjects.

MATERIAL AND METHODS

Intracranial pressure values, histopathological findings, and the degree of cerebral edema formation, estimated by measuring the water content ratio of the brain and the angiographic results in the 2 different groups of subjects that underwent rapid and slow superior sagittal sinus obstruction were compared with that of the control subjects.

STATISTICAL ANALYSIS

Statistical analysis was performed using GraphPad Prisma V.3 statistical software. Variables of the 3 groups were compared using non-parametric Kruskal Wallis ANOVA test and multiple comparisons were made using Dunn's multiple test. The comparison of initial and terminal intracranial pressure values obtained before and after the sinus occlusion, was made using the Wilcoxon test. A probability value of less than 0.05 was regarded as significant.

RESULTS AND CONCLUSIONS

Comparison of the water content ratio of the brain in the 3 groups, the difference between the initial and terminal intracranial pressure values of the rapid occlusion study group, and the difference between the terminal intracranial pressure values of the 3 groups was statistically significant (P<0.05). Dunn's Multiple Comparison Test yielded significant differences in the water content ratio of the brain and in the intracranial pressure values between the rapid occlusion study group and the control group (P<0.05). Moreover, histopathological and radiological examination disclosed more prominent brain edema findings, and less apparent collateral venous flow in the rapid occlusion study group than in the slow occlusion one. To conclude, the clinical severity of sinus occlusion seems directly related to the quickness of the occlusion and the capacity of the collateral venous system.

Clinical picture of patients with cerebral venous thrombosis and patterns of dural sinus involvement

BACKGROUND/OBJECTIVES

Cerebral venous thrombosis may cause focal brain lesions or an isolated intracranial hypertension without focal signs. We investigated whether these different clinical pictures correspond to different patterns of dural sinus thrombosis.

METHODS

Forty-eight patients with cerebral venous thrombosis were classified in 2 groups based on the clinical and neuroradiological picture at admission: one group had clinical signs of intracranial hypertension, without focal neurological signs; the other group had focal neurological signs. The extension of thrombosis in dural sinuses was compared between the groups.

RESULTS

The amount of thrombosed sinuses was significantly different in the two groups, the involvement of the dural sinuses being greater in patients with isolated intracranial hypertension.

CONCLUSIONS

The clinical picture of cerebral venous thrombosis is related to the pattern of dural sinus involvement. The presence of isolated intracranial hypertension is more frequent in patients with a more extended thrombosis of the dural sinuses.

Caspase-8 expression and proteolysis in human brain after severe head injury

Programmed cell death involves a complex and interrelated cascade of cysteine proteases termed caspases that are synthesized as inactive zymogens, which are proteolytically processed to active enzymes. Caspase-8 is an initiator caspase that becomes activated when Fas death receptor-Fas ligand (FasL) coupling on the cell surface leads to coalescence of a "death complex" perpetuating the programmed cell death cascade. In this study, brain tissue samples removed from adult patients during the surgical management of severe intracranial hypertension after traumatic brain injury (TBI; n=17) were compared with postmortem control brain tissue samples (n=6). Caspase-8 mRNA was measured by semiquantitative reverse transcription and polymerase chain reaction, and caspase-8 protein was examined by Western blot and immunocytochemistry. Fas and FasL were also examined using Western blot. Caspase-8 mRNA and protein were increased in TBI patients vs. controls, and caspase-8 protein was predominately expressed in neurons. Proteolysis of caspase-8 to 20-kDa fragments was seen only in TBI patients. Fas was also increased after TBI vs. control and was associated with relative levels of caspase-8, supporting formation of a death complex. These data identify additional steps in the programmed cell death cascade involving Fas death receptors and caspase-8 after TBI in humans.

Slit ventricle syndrome after cyst-peritoneal shunting for temporal arachnoid cyst in children--a clinical entity difficult to detect on neuroimaging study

Slit ventricle syndrome, known to occur from malfunction of the shunt procedure for hydrocephalus, is reported after cyst-peritoneal shunt for temporal arachnoid cyst. Two children aged 12 and 10 years, who underwent cyst-peritoneal shunting for a large temporal arachnoid cyst at the age of 10 and 5 years, respectively, recently experienced several episodes of severe headache. Prior to admission, repeated CT scans did not reveal any morphological change in either of these two patients. Evidence of high intracranial pressure by lumbar tap revealed shunt malfunction. Both patients became free of neurological complaints and deficits after shunt revision. Despite elevated intracranial pressure due to shunt malfunction, neuroimaging studies showed no morphological changes in slit ventricle syndrome. Delay in both the diagnosis and prompt treatment may result in complete loss of visual acuity and even death. It is important to suspect this complication in patients with persistent elevated intracranial pressure symptoms and signs after any shunting procedure, regardless of unchanged neuroimaging studies. Once this is suspected, lumbar tap may be necessary and the choice of treatment is shunt revision.

Diagnostic criteria for idiopathic intracranial hypertension

The syndrome of increased intracranial pressure without hydrocephalus or mass lesion and with normal CSF composition, previously referred to as pseudotumor cerebri, is a diagnosis of exclusion now termed idiopathic intracranial hypertension (IIH). Diagnostic criteria of this disorder have not been updated since the Modified Dandy Criteria were articulated in 1985. Since then, new developments, including advances in neuroimaging technology and recognition of additional secondary causes of intracranial hypertension, have further enhanced the ability to diagnose conditions that may mimic IIH. These factors are not addressed in the Modified Dandy Criteria. This report describes updated diagnostic criteria for IIH that may be used for routine patient management and for research purposes.

Unrecognized internal jugular vein obstruction: cause of fatal intracranial hypertension after tracheostomy?

We report an unusual case of fatal intracranial hypertension following tracheostomy due to the obstruction of the internal jugular veins (left side: thrombosis after central venous cannulation, right side: hypoplastic vein) and their collaterals. Principal cerebral outflow through the internal jugular veins can be substituted by the internal and external vertebral vein plexus because blood drains from the brain by two major routes: the internal jugular veins and the vertebral venous plexus. We suggest transcranial color-coded duplex sonography as a simple bedside method to detect patients with significant reduction of venous drainage who are at risk of developing massive cerebral venous congestion as a result of reduced intracranial elastance.

Serum leptin level in women with idiopathic intracranial hypertension

Leptin is a protein secreted by adipose cells which influences regulation of energy balance and body weight. Idiopathic intracranial hypertension (IIH) is recognised as a neurological disorder mainly affecting obese females. The aim of this study was to evaluate the association between IIH and serum leptin level in 15 obese patients and compare the results with those for 16 obese and 15 non-obese women. A significantly higher serum leptin level was found in patients with IIH than in controls (p<0.0001), and this did not correlate with body mass index (BMI). Serum leptin levels were significantly associated with BMI in both control groups (p<0.0006). Additional factors must therefore be involved in the phenomenon of serum leptin increase beyond weight gain. The cause can only be hypothesised, but it seems that the origin is central, probably hypothalamic.

Seizures and raised intracranial pressure in Vietnamese patients with Japanese encephalitis

Japanese encephalitis (JE) causes at least 10 000 deaths each year. Death is presumed to result from infection, dysfunction and destruction of neurons. There is no antiviral treatment. Seizures and raised intracranial pressure (ICP) are potentially treatable complications, but their importance in the pathophysiology of JE is unknown. Between 1994 and 1997 we prospectively studied patients with suspected CNS infections referred to an infectious disease referral hospital in Ho Chi Minh City, Vietnam. We diagnosed Japanese encephalitis virus (JEV), using antibody detection, culture of serum and CSF, and immunohistochemistry of autopsy material. We observed patients for seizures and clinical signs of brainstem herniation, measured CSF opening pressures (OP) and, on a subset of patients, performed EEGs. Of 555 patients with suspected CNS infections, 144 (26%) were infected with JEV (134 children and 10 adults). Seventeen (12%) patients died and 33 (23%) had severe sequelae. Of the 40 patients with witnessed seizures, 24 (62%) died or had severe sequelae, compared with 26 (14%) of 104 with no witnessed seizures [odds ratio (OR) 4.50, 95% confidence interval (CI) 1.94-10.52, P < 0.0001]. Patients in status epilepticus (n = 25), including 15 with subtle motor seizures, were more likely to die than those with other seizures (P = 0.003). Patients with seizures were more likely to have an elevated CSF OP (P = 0.033) and to develop brainstem signs compatible with herniation syndromes (P < 0.0001). Of 11 patients with CSF OP > or =25 cm, five (46%) died, compared with seven (9%) of 80 patients with lower pressures [OR 8.69, 95% CI 1.73-45.39, P = 0.005). Of the 50 patients with a poor outcome, 35 (70%) had signs compatible with herniation syndromes (including 19 with signs of rostro-caudal progression), compared with nine (10%) of those with better outcomes (P < 0.0001). Of 11 patients with CSF OP > or =25 cm, five (46%) died, compared with seven (9%) of 80 patients with lower pressures (OR 8.69, 95% CI 1.73-45.39, P = 0.005). The combination of coma, multiple seizures, brainstem signs and illness for 7 or more days was an accurate predictor of outcome, correctly identifying 42 (84%) of 50 patients with a poor outcome and 82 (87%) of 94 with a better outcome. These findings suggest that in JE, seizures and raised ICP may be important causes of death. The outcome may be improved by measures aimed at controlling these secondary complications.

Intrathecal lidocaine prevents cardiovascular collapse and neurogenic pulmonary edema in a rat model of acute intracranial hypertension

Sympathetic hyperactivity during sudden intracranial hypertension leads to cardiovascular instability, myocardial dysfunction, and neurogenic pulmonary edema. Because spinal anesthesia is associated with sympatholysis, we investigated the protective effects of intrathecal lidocaine in a rodent model. Halothane-anesthetized rats were given a 10-microL intrathecal injection of saline (n = 10) or lidocaine 1% (n = 6). A subdural balloon catheter was inflated for 60 s to produce intracranial hypertension. Hemodynamics were monitored, and hearts and lungs were harvested for histological examination. In Saline versus Lidocaine-Treated rats, peak mean arterial blood pressure during balloon inflation was 115 +/- 4 mm Hg versus 78 +/- 8 mm Hg (P < 0.05), mean arterial blood pressure 30 min after balloon deflation was 47 +/- 2 mm Hg versus 67 +/- 3 mm Hg (P < 0.05), and lung weight was 1.54 +/- 0.03 g versus 1.41 +/- 0.04 g (P < 0.05), respectively. Cardiac dysrhythmias and electrocardiographic changes were more frequent in the Saline-Treated group (P < 0.05). Saline-Treated rats had extensive, hemorrhagic pulmonary edema, whereas the Lidocaine-Treated rats had only patchy areas of lung abnormality. Histological changes in the myocardium were rare, and no difference was found between the two groups. We conclude that intrathecal lidocaine prevents cardiovascular collapse and neurogenic pulmonary edema in a rat model of acute intracranial hypertension.

IMPLICATIONS

In a rat model of intracranial balloon inflation, intrathecal lidocaine prevented cardiovascular collapse and neurogenic pulmonary edema. Descending neural pathways are involved in the development of cardiopulmonary complications associated with acute intracranial hypertension.

Impairment of autoregulation following cortical venous occlusion in the rat

Recent experiments showed an upward shift of the lower limit of autoregulation (AR) following photochemical occlusion of cortical veins in the rat. The goal of the present study was to prove the hypothesis that occlusion of cortical veins will be associated with impairment of the upper limit of autoregulation as well. In n = 28 Wistar rats unilateral frontoparietal cranial windows were drilled for transdural assessment of regional cerebral blood flow (rCBF) by laser Doppler scanning. The animals were allotted to two groups: (1) Group A (n = 5), control group for determination of the upper limit of autoregulation with stepwise induced arterial hypertension by intravenous administration of the alpha adrenergic drug methoxamine under continuous monitoring of mean arterial blood pressure (MABP); (2) Group B (n = 23), in which two cortical veins were photochemically occluded with rose bengal dye and fiberoptic illumination upon baseline CBF measurement. This was followed by repeated rCBF measurements under AR testing. Loss of AR in control Group A with passive increase of rCBF occurred at MABP of 147.5 +/- 2.9 mmHg. In Group B venous occlusion was followed by an initial phase of reduced rCBF, and then by pressure passive increases, thereby indicating loss of AR. Statistically significant changes of rCBF when compared to baseline MABP occurred at MABPbaseline + 10% (112.7 +/- 6.6 mmHg). We conclude that AR is impaired upon cortical venous occlusion with the propensity for hyperperfusion injury at a lower level of MABP when compared with a control group. In the context with earlier findings this may lead to narrowing of the corridor for MABP management following intra-operative occlusion of large cortical veins.

Reversible coma with raised intracranial pressure: an unusual clinical manifestation of CADASIL

A 50-year-old woman presented with recurrent episodes of headache, nausea and disturbed consciousness that were fully reversible within a few days. Clinical and radiological findings suggested raised intracranial pressure, which on one occasion was confirmed by intracranial pressure monitoring. Magnetic resonance imaging performed in the asymptomatic interval disclosed a diffuse leukoencephalopathy. Brain biopsy surprisingly revealed the typical vascular changes of CADASIL and subtle endothelial alterations. The white matter showed edematous changes and reactive gliosis. Mutational analysis of the Notch3 gene revealed a previously unreported mutation. We suggest that a transient disturbance of the blood-brain barrier related to the underlying vascular pathology may have caused this unusual presentation of CADASIL.

Regional intraparenchymal pressure differences in experimental intracerebral hemorrhage: effect of hypertonic saline

OBJECTIVE

To study regional intraparenchymal pressures within the cranial cavity during and after formation of intracerebral hemorrhage. We also assessed the effect of hypertonic saline on intraparenchymal pressure in different brain regions and on regional brain distribution of sodium within the brain.

DESIGN

Prospective, controlled, laboratory trial.

SETTINGS

Animal research laboratory.

SUBJECTS

Eight mongrel dogs, weighing 15-25 kg.

INTERVENTION

We introduced an intracerebral hematoma in eight mongrel dogs by infusing 6 mL of autologous arterial blood in the deep white matter adjacent to the basal ganglia. Sodium chloride (23.4%, 1.4 mL/kg) then was administered intravenously 6 hrs after introduction of hematoma.

MEASUREMENTS AND MAIN RESULTS

Parenchymal pressure monitors were placed in the perihematoma region, both frontal lobes, and the cerebellum to record intraparenchymal pressure during and 6 hrs after intracerebral hematoma formation. Intraparenchymal pressure measurements were recorded for 3 more hours after administration of 23.4% sodium chloride. Regional cerebral perfusion pressure was calculated for each intraparenchymal pressure measurement. Regional sodium distribution was measured in extracts from brain regions by using ion selective electrode technique. A higher elevation in intraparenchymal pressure was recorded in the perihematoma region during the introduction of the hematoma compared with other compartments. After 5 mL of autologous blood was introduced, intraparenchymal pressure (mm Hg +/- SE) was significantly higher in the perihematoma region (42.1 +/- 3.5) than in the ipsilateral (30.0 +/- 4.6, p <.05) and contralateral (27.1 +/- 5.5, p <.01) frontal lobes and cerebellum (29.1 +/- 4.5, p <.05). Four hours after introduction of the hematoma, the cerebral perfusion pressure recorded in the perihematoma region (43.6 +/- 9.7) remained significantly lower than in the ipsilateral (58.6 +/- 9.3, p <.05) but not the contralateral frontal lobes (54.7 +/- 10.1) and cerebellum (51.0 +/- 11.1). Administration of 23.4% sodium chloride immediately reduced intraparenchymal pressure in each compartment. This effect was still observed at 3 hrs in each compartment. Sodium concentration was higher in the perihematoma region than in the frontal lobes, cerebellum, or brain stem.

CONCLUSIONS

Prominent differences were observed in intraparenchymal pressure and cerebral perfusion pressure in the perihematoma region and frontal lobes during and after intracerebral hematoma. We speculate that the potential importance of regional intraparenchymal pressure differences in the clinical settings may be under appreciated. In this canine model of intracerebral hematoma, a single dose of hypertonic saline effectively reduces the intraparenchymal pressure in all regions of the brain.

Congestive brain oedema associated with a pial arteriovenous malformation with impaired venous drainage

We describe two patients with an unruptured pial AVM accompanied by significant brain oedema at initial presentation. In both cases, the primary drainer was a cortical vein showing varicose dilatation. in which venous congestion was indicated by magnetic resonance imaging (MRI). The restriction of venous drainage presumably caused venous hypertension in the surrounding brain, leading to the brain oedema and neurological symptoms. Brain oedema can develop in patients with an unruptured AVM by venous congestion following spontaneous thrombosis of venous components. Varicosity in a major cortical draining vein and a small nidus are the possible lesions predisposing this fairly rare condition for unruptured AVMs.

Treatment options for large hemispheric stroke

Some stroke patients suffering acute middle cerebral artery (MCA) infarction develop massive brain edema and herniation, a condition known as malignant MCA infarction. Severe swelling increases intracranial pressure (ICP) and leads to progressive brainstem dysfunction. Once ICP reaches critical values (>30 mm Hg) herniation occurs, usually within 2 to 5 days. Patients rarely survive (80% mortality) with standard treatment, and those who do are often severely disabled. Malignant MCA infarction is often missed by neurologists, despite well-defined clinical and neuroimaging (CT scan) diagnostic criteria. After diagnosis, conventional treatments such as osmotherapy, barbiturates, buffers, and hyperventilation center on reducing ICP. The goal of hyperosmolar therapy is to increase the serum osmolarity to approximately 315-320 mOsm/L. Enteric glycerol is used routinely to reduce ICP. In more severe cases and when glycerol fails, mannitol may be administered. Other therapies are also available, including hypertonic saline solution, THAM (Tris-hydroxy-methyl-aminomethane) buffer, and high-dose barbiturates. Hyperventilation also helps reduce ICP. All measures work effectively for a short time only. Other approaches to control elevated ICP, including decompression surgery and hypothermia, have shown promising results. In the Heidelberg decompression surgery trial, mortality in surgically treated patients was significantly lower (32%) than in non-treated patients (76%) despite conventional treatment. Importantly, of the surviving treated patients, 66% were rated independent with only mild to moderate disability. Moderate hypothermia (33-36 degrees C) has recently been shown to be effective in severe MCA infarction. Hypothermia induction within 14 hours of ischemic injury and maintained for 72 hours significantly reduced ICP and mortality (44%).

Cyclosporin A-induced encephalopathy after allogeneic bone marrow transplantation with prevention of graft-versus-host disease by tacrolimus

A 21-year-old woman with severe aplastic anemia received an allogeneic bone marrow transplant (allo-BMT) from an HLA-matched and ABO-matched sibling donor after conditioning with cyclophosphamide, rabbit ATG (Lymphoglobuline; Aventis-Pharma), and total lymphoid irradiation. She had a long history of cyclosporin A (CsA) therapy before conditioning. She complained of severe headache and convulsions on day 0, and findings on magnetic resonance images suggested CsA-induced encephalopathy. CsA was immediately stopped, and tacrolimus for prevention of graft-versus-host disease (GVHD) was started on day 2. Hematological engraftment was observed on day 14 without serious GVHD. Prompt diagnosis, replacement of immunosuppressive agents, and careful monitoring of serum drug concentrations are thought to have contributed to the patient's good clinical course, since CsA-induced encephalopathy tends to be recurrent but to improve completely without any sequelae.

Neuropsychological outcome in relation to the traumatic coma data bank classification of computed tomography imaging

The Traumatic Coma Data Bank (TCDB) classification of CT (computed tomography) scan has been related to the general outcome and intracranial pressure evolution. Our aim was to analyse the relationship of this classification with neuropsychological outcome and late indices of ventricular dilatation. Fifty-seven patients with a moderate or severe head injury (mean admission Glasgow Coma Scale Score, 7.7) were studied from 122 consecutive cases. There were 49 males and 8 females (mean age, 27.7 years). Subjects were classified into TCDB categories on the basis of their most serious acute CT scan finding. From the last control CT scan image, performed at a mean of 6.12 months postinjury, several measures of ventricular dilatation were calculated. Neuropsychological assessment at 6-month included tests of verbal and visual memory, visuoconstructive functions, fine motor speed, and frontal lobe functions. Patients with diffuse injury type I showed better neuropsychological outcome than patients with more severe diffuse injuries and those with mass lesions. Within the diffuse injury groups, the degree of diffuse damage was related to measures of verbal memory and attention and cognitive flexibility. Ventricular enlargement was more evident in patients with mass lesions and it decreased in the remaining groups as the severity of diffuse injury diminished. These results show that there is a relationship between acute intracranial lesion diagnosis according to TCDB classification and neuropsychological results and ventricular dilatation indices at 6 months postinjury.

Neuropathology of inflicted head injury in children. I. Patterns of brain damage

Fifty-three cases of non-accidental head injury in children were subjected to detailed neuropathological study, which included immunocytochemistry for microscopic damage. Clinical details were available for all the cases. There were 37 infants, age at head injury ranging from 20 days to 9 months, and 16 children (range 13 months to 8 years). The most common injuries were skull fractures (36% of cases), acute subdural bleeding (72%) and retinal haemorrhages (71%); the most usual cause of death was raised intracranial pressure secondary to brain swelling (82%). On microscopy, severe hypoxic brain damage was present in 77% of cases. While vascular axonal damage was found in 21 out of 53 cases, diffuse traumatic axonal injury was present in only three. Eleven additional cases, all of them infants, showed evidence of localized axonal injury to the craniocervical junction or the cervical cord. When the data were analysed by median age at head injury, statistically significant patterns of age-related damage emerged. Our study shows that infants of 2-3 months typically present with a history of apnoea or other breathing abnormalities, show axonal damage at the craniocervical junction, and tend also to have a skull fracture, a thin film of subdural haemorrhage, but lack extracranial injury. Children over 1 year are more likely to suffer severe extracranial, particularly abdominal, injuries. They tend to have larger subdural haemorrhages, and where traumatic axonal injury is present, show patterns of hemispheric white matter damage more akin to those reported in adults. Diffuse axonal injury is an uncommon sequel of inflicted head injury in children.

Pineal cavernous angioma presenting with Parkinsonism

Cavernous angioma of the pineal region is rare, as is brain tumour coincident with Parkinsonism. The authors describe the case of a 55 year old woman with a pineal region cavernous angioma, who subsequently developed Parkinsonism after her increased intracranial pressure was relieved. The cause of Parkinsonian syndrome is unclear, but compression of the posterior thalamus and upper mid-brain with congestion of the deep venous system may have caused vascular disturbance of the nigro-striate-pallidal system. Her symptoms gradually improved after total excision of the lesion.