[Cerebral imaging in a delirious patient]

An 80-year-old woman attended the emergency department with sub-acute confusion and fever. On examination no focal signs were found. Cerebral CT showed an area of hypodensity suspected to be an infarction, but an MRI scan carried out 10 days later showed cerebral abscesses caused by a dental infection that had occurred four weeks previously. This case report shows that even if a patient with confusion does not show focal signs on examination, an organic brain disease - such as cerebral abscess - may still be present. Hence, when confusion is associated with fever or impaired consciousness, an MRI scan should be carried out.

Subcortical deficit pattern after brain abscess: a neuropsychological study

The consequences of brain abscess (BA) on cognition and behaviour have never been examined in detail. The aim of this study was to determine the long-term cognitive deficits of patients who suffered a BA and to estimate its effect on the quality of life. Twenty patients were included in the study. Follow up with neuropsychological and behavioural tests was performed 6 months to 42 years after BA (mean 10.4 +/- 11.9). Cognitive deficits were defined as a test score of 2 or more standard deviations below controls' mean in those tasks which revealed a significant group deficit. Compared with healthy age, sex and education-matched controls, 13 of 20 patients (65%) exhibited neuropsychological deficits in some cognitive tasks. Ten of those patients (50%) were significantly impaired in < or =2 cognition domains, whilst the remaining three patients (15%) showed three to five impaired domains. No correlation was found between neuropsychological impairments and patients' age, sex, initial neurological symptoms, size and localization of BA, or secondary epileptic seizures. Reduction in quality of life was found in five patients (25%). BA may cause long lasting cognitive deficits. Despite the focal character of the lesion, long-term sequelae follow a more diffuse subcortical deficit pattern.

A case of 'circling seizures' and an intratumoral abscess

We describe a case of a 38-year-old woman who presented with 'circling' seizures and was found to have an intracranial mass with features consistent with a meningioma. Three weeks prior to her presentation she underwent an uncomplicated vaginal hysterectomy. However, after discharge to home she developed a 4-day history of fever, chills and night sweats that eventually resolved. She underwent surgical removal of her intracranial mass without difficulty but intra-operative pathology showed features of acute cerebritis at the margins of the tumor. Further sectioning of the mass revealed evidence of an intratumoral abscess. Culture of the meningioma revealed heavy growth of Bacteroides fragilis. The patient was treated with intravenous antibiotics, discharged home in excellent health and has had no recurrence of seizures. In our case report we will review the historical literature on the incidence and features of intratumoral abscess. Although it is considered a rare event, our case demonstrates both common and unique features about this occurrence and highlights an unusual chain of events in the natural history of the patient's meningioma and the way in which it became clinically apparent.

New-onset psychogenic seizures after intracranial neurosurgery

BACKGROUND

Patients with physical brain abnormalities have an increased risk of developing psychogenic nonepileptic seizures (PNES). Here we describe patients who developed PNES after intracranial neurosurgery for indications other than the control of refractory epileptic seizures and explore whether neurosurgical intervention is at risk factor for PNES.

METHOD

We searched the database of 372 patients diagnosed with PNES at our department over the last 10 years and identified 17 patients (4.6%) in whom PNES first started after intracranial neurosurgery. Surgical procedures included the complete or partial resection of a meningioma, AV malformation, cavernoma, plexus papilloma, neurinoma, astrocytoma, oligodendroglioma, dysontogenetic cyst, the drainage of a brain abscess and removal of a subdural hematoma. PNES were documented by ictal video-EEG, ictal EEG, or ictal observation and examination in all cases. The diagnosis of additional epileptic seizures were confirmed by ictal EEG/video-EEG, or made on the basis of a clinical assessment by an experienced epileptologist.

FINDINGS

Five patients had purely psychogenic postoperative seizure disorders, twelve had epileptic and psychogenic attacks. Median age at neurosurgery was 32 years (range 5-54), median latency between surgery and onset of PNES was 1 year (range 0-17 years).

INTERPRETATION

PNES may develop after intracranial neurosurgery undertaken for other indications than the control of refractory epileptic seizures. Younger patients with a history of pre-operative psychiatric problems or epileptic seizures and surgical complications may be at higher risk. A diagnosis of PNES should be considered in patients who develop refractory seizures after neurosurgery.

'I've got tummy ache in my head'. Communicating with sick children

The traumatic effects of illness and hospitalisation on the child can be minimised with appropriate and effective communication, both with and from the child. When verbal communication is not possible, alternative means of communicating must be set up as soon as feasible, to establish a two-way channel, thus reducing the likelihood of misconceptions, misunderstandings, and unnecessary fears and frustrations.

Musical auditory hallucinosis from Listeria rhombencephalitis

BACKGROUND

Complex auditory hallucinations have rarely been reported in cases of brainstem stroke or tumor.

METHOD

Case study.

RESULTS

A patient with acute Listeria rhombencephalitis complained of formed musical auditory hallucinations on the side of recent sensorineural deafness. MRI revealed an abscess in the middle cerebellar peduncule with extensive surrounding edema.

CONCLUSIONS

Disruption of brainstem auditory pathways may cause complex auditory hallucinations. Potential pathogenetic mechanisms are discussed and a diagnostic approach is proposed.

[Health status and quality of life in patients who recovered after surgery for a brain abscess]

The authors examined a group of 13 patients who recovered after operation of a brain abscess. They evaluated also the records of two patients who were unable to attend examination. For examination the WAIS-R test was used, Wechsler's memory test, Benton's test, the Cornell Medical Index 3 and other methods of evaluation. In the group of the 13 examined subjects in 8 instances a pathological deterioration of mental abilities was found, in five patients a psychopathological symptomatology. In one patient the authors detected ethylism with degradation of personality. The results of the investigation suggest a frequent incidence of serious changes after operation of brain abscesses with consequences for the quality of life of the patients and their families.

Home antibiotic therapy for brain abscesses

Patients with brain abscesses now have the option of receiving intravenous antibiotic therapy at home. However, before discharge from the hospital, these patients require significant education in aseptic technique, general catheter care, medication administration, and troubleshooting. Also provided is a review of the pathology, signs, symptoms, diagnosis, and treatment of adult brain abscesses.

Basic relations among lesion laterality, lesion volume and neuropsychological performance

Although it is widely accepted that lesion size is an important determinant of severity of deficit, difficulties in the quantification of lesion size and the absence of a theoretical model of how lesion volume combines with lesion locus to produce deficits have inhibited the development of methodological and statistical procedures for studying naturally occurring lesions in humans. We propose such a unified model and apply it to the analysis of neuropsychological performance in a sample of patients with naturally occurring unilateral lesions. The analysis suggests that a statistical interaction between lesion size and laterality may be an important determinant of neuropsychological deficit.

Long-term retention of computer learning by patients with memory disorders

Previous research has demonstrated that patients with memory disorders resulting from closed-head injury can acquire the complex knowledge and skills necessary for the use of a microcomputer. The present paper extends the generality of those findings by showing that (1) amnesic patients with other etiologies could similarly learn how to operate a computer and (2) the knowledge and skills acquired were retained over intervals of up to 9 months.

Perceptual discrimination of vowels in aphasia

In the present study 3 hypotheses were investigated: first, the notion that an aphasic impairment of vowel perception is not associated with particular aphasic syndromes or lesion sites, second, that it is a disorder comparable to a general impairment of perception in a normal speaker caused by some form of interference, and third, that perceptual phonemic discrimination is a separate process from the phonemic discriminative function necessary for speech production. The hypotheses were tested by means of a vowel discrimination test administered to 50 German-speaking aphasic patients (roughly equally divided between Broca's, mixed non-fluent, Wernicke's and mixed fluent groups); the same test, masked by white noise at -10 dB was also administered to 20 normal native speakers of German. Results were in support of all 3 hypotheses. First, aphasic patients' error patterns were similar across fluent and nonfluent groups and for all lesion sites. Second, the error distributions of aphasics with slight auditory impairment resembled those of normal subjects in the -10 dB white noise condition, while distributions of aphasics with severe auditory impairment were indicative of an added component of guessing behaviour. And third, the patients' performance on the discrimination task differed from that shown on a comparable repetition test. (It was argued that repetition involves a patient's expressive capacity in addition to his perceptual capacity). The differentiation of perceptual and expressive phonemic discrimination was further supported by an analysis of the speech errors occurring in the spontaneous (purely expressive) speech and in the repetition (expressive plus perceptual) tasks of 16 French Canadian and 5 English Canadian aphasics.

Semantic access dyslexia

An analytical investigation of the residual reading capacities of a single patient with dyslexia without dysgraphia is reported. Both his ability to name and to comprehend letters and words were severely impaired. The major finding of this investigation was AR's striking capacity for categorizing words he could not read. In addition there was evidence of semantic priming effects. Thus AR was frequently able to achieve partial comprehension of words he could not read. The orthodox interpretation of the dyslexia without dysgraphia in terms of a disconnection syndrome is shown to be inappropriate, at least for the present case, where the deficit appears to be within the semantic domain; it is argued that this type of dyslexia is due to an impairment in accessing semantic information.

Cerebral abscess presenting as larceny

Images