Sleep-related problems in neurologic diseases

There is a strong association between sleep-related problems and neurologic diseases. Neurologic diseases of the CNS can directly cause sleep problems when sleep-wake mechanisms associated with the ascending reticular activating system are involved. The major sleep disorders associated with neurologic problems are outlined in the International Classification of Sleep Disorders, 2nd edition, as hypersomnias of central origin, sleep-related breathing disorders, the insomnias, circadian rhythm sleep disorders, sleep-related movement disorders, parasomnias, and sleep-related epilepsy. In a patient with CNS disease and excessive sleepiness, sleep-related breathing disorders should be a first concern, given the known association between obstructive sleep apnea (OSA) and cerebrovascular disease and the potential confounding effects that OSA might have on an otherwise compromised ischemic CNS penumbra. A basic knowledge of the anatomy and physiology of the sleep-wake mechanisms provides a rationale for pharmacologic intervention. Nonpharmacologic treatments are also important, especially when sleep-related breathing disorders are a concern. In addition, as patients with neurologic diseases are often prone to the adverse effects of many medications, the specific treatment regimen for any given individual should always include good sleep hygiene practices that use cognitive behavioral therapy.

Clinical characteristics of childhood-onset (juvenile) Huntington disease: report of 12 patients and review of the literature

Whereas adult-onset Huntington disease is a well-characterized clinical entity, childhood-onset cases have not received as much attention. In this report, the clinical, demographic, and genetic characteristics in 12 patients with childhood-onset Huntington disease are presented and compared with data in the literature. The patients were divided into two groups based on age at onset of symptoms (< 10 or > or = 10 years old). The majority of patients had onset of symptoms before 10 years of age and most at or below 5 years of age. The delay in diagnosis was longer in those with earlier onset of symptoms. Inheritance was paternal in all patients with onset beyond 10 years of age. We found a preponderance of male patients in the younger age at onset group and of female patients in the older age at onset group. The most frequent heralding symptom was cognitive decline in the group with earlier onset and oropharyngeal dysfunction in the later-onset group. Seizures occurred only in the younger age at onset group. Chorea was not a presenting sign but developed later in the course of the disease and, with dystonia, was more prevalent in the early age at onset group, whereas rigidity and bradykinesia were more prevalent in the older age at onset group. Patients in both groups developed gait, cognitive, and behavioral disorders at some point during the course of the disease. Furthermore, a slow and steady decline in IQ was observed on serial neuropsychologic testing in patients from both groups. Imaging studies were normal early and most commonly revealed neostriatal atrophy later in the course of the disease. In this report, we describe the characteristics of 12 patients with childhood-onset Huntington disease and review those previously reported, expanding our knowledge about the features of childhood-onset Huntington disease, underlining the differences with patients with adult-onset Huntington disease, and suggesting a differential phenotype within patients with childhood-onset Huntington disease depending on the age at onset.

Myasthenia gravis from Thomas Willis to the present

The history of the development of knowledge of myasthenia gravis is reviewed. Clinical profiles of the immune and non-immune mediated forms of myasthenia are discussed. The current theory of pathogenesis is reviewed. Tests used to diagnose myasthenia gravis, and their comparative diagnostic yields are presented. Past and current modalities of treatment are reviewed. Future therapeutic strategies are introduced. The roles of the thymus and thymectomy in the genesis and treatment of myasthenia gravis are discussed.

The basal ganglia: a neural network with more than motor function

The basal ganglia is a group of subcortical nuclei involved in motor control, cognition, and emotion. Basal ganglia disorders are manifested by abnormal movement and a number of neuropsychiatric disorders. Basal ganglia nuclei are organized into sensorimotor, associative, and limbic territories based on their connectivity and function. The caudate nucleus, putamen, and subthalamic nucleus comprise the input nuclei of the basal ganglia. The internal segment of globus pallidus and substantia nigra reticulata are the output nuclei. The input and output nuclei are interconnected by direct and indirect pathways. The cerebral cortex, basal ganglia, and thalamus communicate with each other via closed (segregated) parallel as well as open (split) loops. Recent anatomic, functional, and clinical data have necessitated modifications in the classical models of local connectivity between input and output nuclei of the basal ganglia as well as in the corticobasal ganglia-thalamus-cortical loops.

Childhood-onset chronic inflammatory demyelinating polyradiculoneuropathy with cranial nerve involvement

A 17-year-old male presented with chronic diplopia and generalized motor weakness. He was previously diagnosed with chronic inflammatory demyelinating polyradiculoneuropathy and acute disseminated encephalomyelitis in childhood. Cranial magnetic resonance imaging (MRI) revealed a rarely reported finding of thickening and enhancement of multiple cranial nerves. Nerve conduction studies and electromyography showed peripheral nerve demyelination with axonal involvement. There was improvement in the clinical examination, MRI, and electrophysiologic studies after combined corticosteroid and plasma exchange therapy. We review the clinical presentation, course, and response to therapy among children with chronic inflammatory demyelinating polyradiculoneuropathy, with specific emphasis on the frequency and pattern of cranial nerve involvement.

Chickenpox and the geniculate ganglion: facial nerve palsy, Ramsay Hunt syndrome and acyclovir treatment

Facial nerve palsy has long been considered to have an infectious etiology. Recent diagnostic analyses in children and adults have provided convincing evidence that reactivation of varicella-zoster virus (VZV), sometimes during infectious mononucleosis, can lead to cranial nerve VII palsy. The site of reactivation from latency is the geniculate ganglion. Virus most likely enters the ganglion during chickenpox, via the sensory branches of the facial nerve located on the ear and tongue. Retrospective reviews suggest that patients with VZV-related facial nerve palsy have poorer outcomes than other cases of Bell's palsy. Therefore treatment with acyclovir is suggested when VZV reactivation i slikely.

Optic neuritis: a novel presentation of Schilder's disease

The clinical features of a 7-year-old girl who presented with unilateral optic neuritis are presented. Magnetic resonance imaging (MRI) showed lesions in the affected optic nerve and the centrum semiovale bilaterally. Biopsy of one of the cerebral lesions was consistent with a diagnosis of Schilder's disease. Visual acuity returned to normal, and the demyelinating MRI lesions improved markedly with corticosteroid treatment. Optic neuritis is a novel mode of presentation in Schilder's disease.

Childhood Guillain-Barré syndrome: clinical and electrophysiologic features predictive of outcome

The hospital records of 27 children with the diagnosis of Guillain-Barré syndrome were retrospectively reviewed. Based on the time to recovery, patients were divided into two groups: group 1 consisted of children whose times to complete or partial recovery extended beyond 2 months from onset of the disease; group 2 consisted of children who attained a full recovery within 2 months from onset of the disease. The clinical and electrophysiologic features of the two groups were statistically compared for their predictive value of outcome. Three clinical features (maximum disability score at presentation, intubation, and cranial nerve involvement) were predictive of poor outcome, whereas one electrophysiologic feature (conduction block) was predictive of favorable outcome. There was also a significant correlation between maximum disability score at presentation and the probability of intubation.

Presentation, management and follow-up of Schilder's disease

Schilder's diffuse myelinoclastic sclerosis is a rare demyelinating disease which often mimics intracranial neoplasm or abscess. We have treated 3 patients with this disorder in the past 5 years and followed their postoperative course. Certain distinct features of this disease will allow neurosurgeons to preoperatively entertain this diagnosis. We discuss postoperative treatment and propose a new hypothesis regarding the variable prognoses of this disorder. Schilder's disease constitutes an important diagnosis for any neurosurgeon to be aware of (especially those treating the pediatric age group) which has not received adequate coverage in the neurosurgical literature.

Enlarged Virchow-Robin spaces along the medullary perforators in a child with seizures

Enlarged Virchow-Robin spaces along the medullary perforators on brain magnetic resonance images (MRIs) of a 4-year-old, neurologically intact child with seizures are described. The differential diagnosis of cystic spaces in the centrum semiovale is discussed. The sparse MRI literature on bright signal intensities in childhood is reviewed.

Myelinoclastic diffuse sclerosis (Schilder's disease): report of a case and review of the literature

The clinical, neuroimaging, and neuropathologic features of Schilder's disease in a 17-year-old girl are presented and compared to 11 well-documented cases reported since 1912. The evolution of knowledge about Schilder's disease and the confusion in nomenclature are reviewed. Signs and symptoms in this case and others reported in the literature are nonspecific and may mimic mass lesions. Neuroimaging studies also may mimic brain tumor or abscess; however, the absence of significant edema, the irregular and incomplete ring enhancement, the discrepancy between size of the lesions and the associated mass effect, and the absence of other lesions elsewhere in the brain may help differentiate Schilder's disease from neoplasm, infection, and other demyelinating lesions. Although frozen sections of these lesions are often interpreted as astrocytoma, the inflammatory, primarily histiocytic, nature of Schilder's disease is more easily recognized in paraffin-embedded material. Unique features of this case include multiple unilateral lesions and the cyst-like degeneration present in both lesions. Multiple lesions in Schilder's disease are characteristically bilateral. The examination of aspirated fluid is the first such report in Schilder's disease. The limitation of multiple lesions in our case to one hemisphere calls for reexamination of the restrictive 1985 criteria of Poser for the diagnosis of Schilder's disease.

Basal ganglia: functional anatomy and physiology. Part 2

Advances in knowledge about basal ganglia function and circuitry are reviewed. Despite the voluminous available literature on this subject, the role of basal ganglia in health and disease remains controversial. Experimental data on the effects of stimulation and ablation of the basal ganglia are summarized. The roles of the basal ganglia in the preparation for and execution of cortically initiated movement are described. Newer roles ascribed to the basal ganglia in sensory-motor gating, cognition, emotion, and motivation are discussed. The old and current concepts of information flow between the cerebral cortex, striatum, pallidum, thalamus, and back to the cerebral cortex are reviewed. The "funnel" system of information flow has been discarded in favor of several parallel and largely segregated loops pertaining to motor, oculomotor, cognitive, and limbic functions. The anatomic substrate of each of these loops is described. The specific roles of the striatum, pallidum, substantia nigra, and thalamus in information flow as related to movement are described. The roles of the basal ganglia in reinforcing wanted behavior and suppressing unwanted behavior via direct and indirect striatal loops are discussed. The implications of these loops in the genesis of Parkinson's disease and Huntington's chorea are described. Alteration in basal ganglia neurotransmitters and neuromodulators in Huntington's chorea, Tourette's syndrome, and Parkinson's disease are described.

Basal ganglia: functional anatomy and physiology. Part 1

Advances in knowledge about basal ganglia structure and connectivity from 1925 to date are reviewed. Current concepts about neuronal populations, transmitters, and input and output of each of the basal ganglia nuclei are presented. The portrayal by Wilson, in 1925, of the striatum as a simple homogeneous structure has been replaced by the recognition, based on staining characteristics, connectivity, and function, that the neostriatum is compartmentalized into striosomes, matrisomes, and matrix compartments. Electrophysiologic studies have further shown the existence, in the neostriatum, of neuronal clusters that represent basic functional units much like the functional columns described much earlier for the cerebral cortex. Whereas the neostriatum is considered the major receiving area of the basal ganglia, the globus pallidus and substantia nigra pars reticulata constitute the major output nuclei. Combined neuroanatomic and neurophysiologic studies have revealed precise somatotopic organization throughout the basal ganglia system such that the leg, arm, and face areas of the cerebral cortex related to respective topographic areas within the striatum, pallidum, substantia nigra, and subthalamus. The previous concept of an inhibitory role for dopamine on striatal neurons has been modified. It is now acknowledged that dopamine exerts an inhibitory effect on striatal neurons that project to the external pallidum and a facilitatory effect on striatal neurons that project to the internal pallidum and substantia nigra pars reticulata. The previous concept of serial connectivity of the neostriatum (funnel concept) has been replaced by the concept of parallel connectivity. Within the internal connectivity of the basal ganglia, there is a fast system in which the neurotransmitter is gamma-aminobutyric acid (GABA) and a slow system modulated by neuropeptides. The slow system is believed to give identity to an otherwise homogenous GABAergic system.

The landry-guillain-barré strohl syndrome 1859 to 1992 a historical perspective

The history of the development of knowledge about Guillain-Barré-Syndrome (GBS) is reviewed. The clinical profile, including characteristic CSF findings, were established by Laundry in 1859 and Barre in 1916. Pathologic features of GBS were defined ill three landmark papers by Haymarker and Kernohan in 1949, Waksman and Adams in 1955, and Asbury, Arnason and Adams in 1969. Although GRS is considered to be an immune-mediated disorder, the exact immune mechanism(s) leading to demyelination is riot yet well established bill probably involves both cellular and humoral responses. Treatment modalities have progressed from massages and volatile liniments used by Landry to anticipatory and supportive care, plasma exchange, and intravenous immunoglobulin. Outcome continues to be generally favorable as originally emphasized. Clinical and electrophysiologic predictors of unfavorable outcome have been identified.

Tests for juvenile myasthenia gravis: comparative diagnostic yield and prediction of outcome

The clinical picture, family history, laboratory data, treatment modalities, and outcome in 27 juvenile myasthenics seen over a 25-year period are presented. Onset was after 10 years of age in the majority of patients. Half presented with ocular signs, the other half with generalized-onset myasthenia. Half of those with ocular-onset myasthenia progressed to generalized myasthenia. The female-to-male ratio was 3.5:1. Myasthenia gravis was reported in the mother of one patient. Ptosis was the most common presenting sign. It was unilateral at onset in 33% of patients and remained unilateral in 11%. Pharmacologic tests (neostigmine methylsulfate and edrophonium chloride) were positive in 92% of patients. Serology was positive in 63%, whereas repetitive nerve stimulation was positive in 33% when distal nerves were stimulated and in 66% when proximal and distal nerves were stimulated. Seropositivity tended to increase with generalization of the myasthenic process. No statistically significant difference in seropositivity was noted between males and females. Anti-striated muscle antibodies were detected in two patients, neither of whom had thymoma. The yield of repetitive stimulation increased with generalization of the myasthenic process and when proximal nerves were stimulated. No statistically significant difference was noted in the decremental response between seropositive and seronegative patients. The majority of ocular myasthenics were treated with pyridostigmine bromide monotherapy. With generalization of the myasthenic process, other modes of medical and surgical therapies were needed. All patients given corticosteroids ultimately underwent thymectomy. The mean age at presentation and the duration of symptoms at presentation were longer in thymectomized patients than in those without thymectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictive value of electromyography in diagnosis and prognosis of the hypotonic infant

To investigate the diagnostic validity of electromyography in the hypotonic infant, 79 children aged 0 to 12 months, seen over a 20-year period, were studied retrospectively. The diagnoses using clinical, muscle biopsy, and laboratory characteristics were: 25 central hypotonia, 20 spinal muscular atrophy, 20 myopathy, four myotonic dystrophy, four benign congenital hypotonia, two congenital muscular dystrophy, two myasthenia gravis, one infantile inflammatory myopathy, and one arthrogryposis multiplex congenita. Using strict criteria, electromyography accurately predicted the final diagnosis in 65% of infants with spinal muscular atrophy and was consistent with the diagnosis in another 25%. In contrast, electromyography accurately predicted the final diagnosis in only 10% of infants with myopathy and was normal in 88% of infants with central hypotonia. In infants with spinal muscular atrophy, there was no difference in the predictive value of electromyography when performed in the newborn compared to older infants. Normal distal nerve conduction velocities in infants with spinal muscular atrophy may predict prognosis, since these infants had a longer survival. Electromyography thus has a high predictive value for infantile spinal muscular atrophy but not for myopathy.

Etiology of lateral rectus palsy in infancy and childhood

The etiologies of lateral rectus palsy in 132 infants and children seen over a period of 22 years in a university medical center were retrospectively reviewed and compared with similar reports in the literature. Unlike most reports, which lump children with adults, this study focuses on childhood etiologies of lateral rectus palsy. In contrast to the only two studies in the literature on childhood lateral rectus palsy, which reflect a purely ophthalmologic perspective, this study reflects experiences of pediatric neurology and pediatric neurosurgery, as well as ophthalmology. Most lateral rectus palsies were unilateral, almost equally distributed between right and left sides. Trauma, tumor, and congenital etiologies were the most prevalent. The relative frequency of each of these etiologies varies by service (neurology, neurosurgery, ophthalmology). In 10.6% of patients, etiology could not be determined. The majority of patients had an isolated lateral rectus palsy. Association of lateral rectus palsy with other cranial nerve palsies and/or long tract signs characterized trauma and tumor. The majority of tumors were primary and infratentorial. A small number of patients had benign recurrent lateral rectus palsy.

Brain tumors occurring before 1 year of age: a retrospective reviews of 22 cases in an 11-year period (1977-1987)

Congenital brain tumors have been reported infrequently and their management remains ill defined. An 11-year review (1977-1987) of all children with brain tumors with the onset of symptoms before 1 year of age was completed. Twenty-two children with the following histological diagnoses were treated: astrocytoma (7 patients), primitive neuroectodermal tumor (6 patients), papilloma or carcinoma of the choroid plexus (3 patients), malignant teratoma (2 patients), dermoid tumor (2 patients), embryonal rhabdomyosarcoma (1 patient), and chloroma (1 patient). Fifteen tumors were supratentorial in location, and 7 were infratentorial. Initial symptoms were hydrocephalus (32%), focal neurological deficit (23%), asymptomatic increase in head circumference (18%), failure to thrive (14%), and seizures (4.5%). The goal of treatment was a radical excision when possible, with primary chemotherapy in the last 6 years of the review period. Radiation therapy was the adjunct to surgery in the initial 5-year period. All patients with papillomas of the choroid plexus and dermoid lesions underwent a total resection with no recurrence. All 7 astrocytomas were supratentorial, with 6 occurring in the diencephalon. Five of the seven patients with astrocytomas survived more than 5 years. The 6 primitive neuroectodermal tumors were located equally between the supra- and infratentorial spaces. Four of the 6 infants with these tumors received chemotherapy (2 received chemotherapy alone; 2 received chemotherapy and radiation therapy) and are tumor free 2 to 9 years later. A fifth child received radiation therapy alone early in the series and survived only 4 months. The family of the other child refused adjunctive treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Brain Tumors Occurring before 1 Year of Age: A Retrospective Review of 22 Cases in an 11-Year Period (1977-1987)

Congenital brain tumors have been reported infrequently and their management remains ill defined. An 11-year review (1977-1987) of all children with brain tumors with the onset of symptoms before 1 year of age was completed. Twenty-two children with the following histological diagnoses were treated: astrocytoma (7 patients), primitive neuroectodermal tumor (6 patients), papilloma or carcinoma of the choroid plexus (3 patients), malignant teratoma (2 patients), dermoid tumor (2 patients), embryonal rhabdomyosarcoma (1 patient), and chloroma (1 patient). Fifteen tumors were supratentorial in location, and 7 were infratentorial. Initial symptoms were hydrocephalus (32%), focal neurological deficit (23%), asymptomatic increase in head circumference (18%), failure to thrive (14%), and seizures (4.5%). The goal of treatment was a radical excision when possible, with primary chemotherapy in the last 6 years of the review period. Radiation therapy was the adjunct to surgery in the initial 5-year period. All patients with papillomas of the choroid plexus and dermoid lesions underwent a total resection with no recurrence. All 7 astrocytomas were supratentorial, with 6 occurring in the diencephalon. Five of the seven patients with astrocytomas survived more than 5 years. The 6 primitive neuroectodermal tumors were located equally between the supra- and infratentorial spaces. Four of the 6 infants with these tumors received chemotherapy (2 received chemotherapy alone; 2 received chemotherapy and radiation therapy) and are tumor free 2 to 9 years later. A fifth child received radiation therapy alone early in the series and survived only 4 months. The family of the other child refused adjunctive treatment. A radical resection with chemotherapy appears to be the rational approach, keeping additional operations and radiation therapy as options for recurrent disease while avoiding the effects of irradiation on the developing brain.

Recurrent lateral rectus palsy in childhood

Five patients with recurrent, lateral rectus palsy in childhood, examined at the University of Iowa Hospitals over a period of 22 years, are reported. During the same period, 131 abducens nerve palsy patients, younger than 18 years of age, were evaluated. Eighteen similar patients, most single case reports, are reviewed from the literature. All reported patients, including our own, shared the following features: spontaneous recovery within 6 months in the majority of patients, ipsilateral recurrence, and painless palsy. There is female and left-sided preponderance. Etiology is undetermined. Hypotheses include viral etiology, neurovascular compression by aberrant artery, and migraine.

Computed tomography and magnetic resonance imaging of the brain in Hurler's disease

Computed tomographic (CT) and magnetic resonance imaging (MRI) scans of the brain in five patients with Hurler's disease are described and compared to the few available reports in the literature. Computed tomographic scans revealed low attenuation areas in the centrum semiovale and peritrigonal white matter. Ventriculomegaly was not a prominent feature in our patients, compared to those previously reported. In two patients, CT were normal. The most prominent magnetic resonance imaging abnormalities were the presence of radially oriented cystic areas in the centrum semiovale, peritrigonal white matter, corpus callosum, and pericallosal region. Magnetic resonance imaging abnormalities were present in all patients, even when CT scans were normal. Abnormalities on CT and MRI scans tended to be more prevalent in the posterior regions. Magnetic resonance imaging proved to be a more reliable imaging method in Hurler's disease. T1-weighted images delineated the cystic areas more clearly, whereas T2-weighted images were more sensitive in detecting small white-matter abnormalities. Magnetic resonance imaging abnormalities correlated well with known neuropathologic alteration in this disease. It is suggested that the cystic areas seen on MRI correspond to perivascular lacunae seen in histopathologic material.

Seizure-induced miosis and ptosis: association with temporal lobe magnetic resonance imaging abnormalities

Two patients with seizure-associated miosis and ptosis are described. In both there are magnetic resonance imaging abnormalities of the temporal lobe. In one patient, increased magnetic resonance imaging signal intensity is present in the temporal lobe contralateral to ptosis and miosis. In the other, there is temporal lobe asymmetry with the smaller temporal lobe ipsilateral to the miotic pupil and ptotic lid. The relevant human and experimental literature related to cortical control of pupil size and lid movement is reviewed. Based on the available literature and the findings in these two patients, it is proposed that the increased signal intensity in the temporal lobe of one patient represents an irritative stimulus causing contralateral miosis and ptosis, whereas the temporal lobe hypoplasia in the second patient permitted impulses from the contralateral normal temporal lobe to predominate, resulting in miosis and ptosis homolateral to the hypoplastic temporal lobe.

Autosomal recessive cerebellar hypoplasia

Cerebellar hypoplasia is found in association with a variety of neurologic and systemic disorders. It is the primary finding in the uncommonly reported condition of autosomal recessive cerebellar hypoplasia. We describe two siblings with cerebellar hypoplasia documented in both by magnetic resonance imaging (MRI) and review the clinical features of previously reported cases of autosomal recessive cerebellar hypoplasia. The most common findings in this disorder are nonprogressive ataxia, strabismus, mental retardation, and speech delay with dysarthria. Previously reported cases have been confirmed by autopsy, pneumoencephalography, or computed tomographic (CT) scans. MRI clearly documents diffuse cerebellar hypoplasia and aids in distinguishing autosomal recessive cerebellar hypoplasia from other disorders. The pathophysiology of this disorder is uncertain, however, studies of the weaver mutant mouse (an animal model of autosomal recessive cerebellar hypoplasia) suggest that an abnormality of the Bergmann glia may lead to the observed granule cell layer deficiency in these patients. This diagnosis should be considered for children with nonprogressive ataxia and families should be made aware of the 25% recurrence risk.

Aqueductal stenosis and neurofibromatosis: a rare association

Three cases with rare association of neurofibromatosis, hydrocephalus, and aqueductal stenosis seen at the University of Iowa during the past 20 years are presented. The literature on nontumoral hydrocephalus and aqueductal stenosis in neurofibromatosis is reviewed. Possible explanations for the association of aqueductal stenosis and neurofibromatosis are discussed. It is concluded that aqueductal stenosis, though not common, should nevertheless be considered in the differential diagnosis of hydrocephalus in neurofibromatosis.

Hypothermia-induced reversible polyneuropathy: electrophysiologic evidence of axonopathy

A 2 1/2-year-old child developed peripheral polyneuropathy following exposure to hypothermia. Serial electrophysiologic studies over the next 10 months revealed progressive recovery from severe axonopathy. The literature on cold-induced neuropathy is reviewed. The two electrophysiologic studies reported previously in cold-induced polyneuropathy patients are discussed and compared with findings of our patient.

Accelerated myelination in early Sturge-Weber syndrome demonstrated by MR imaging

Magnetic resonance imaging of the brain in two infants with Sturge-Weber syndrome has demonstrated a pattern of accelerated myelination in the abnormal cerebral hemisphere. The extent of myelination was most apparent on the T1-weighted inversion recovery sequence while the T2-weighted images demonstrated concomitant changes in hydration of the brain. We propose an explanation for this finding based on cerebral ischemia underlying the leptomeningeal angioma.

Cerebral hemiatrophy, hypoplasia of internal carotid artery, and intracranial aneurysm. A rare association occurring in an infant

A 4-month-old child with a very rare association of primary (congenital) left cerebral hypoplasia, hypoplasia of the left internal carotid artery, and giant anterior communicating artery aneurysm was seen. The aneurysm was detected and treated before rupture. We briefly reviewed the literature on agenesis (hypoplasia) of the internal carotid artery, intracranial aneurysms in childhood, and primary cerebral hypoplasia. It is proposed that cerebral arteriography, cranial computed tomography, or magnetic resonance imaging be performed in all children with primary cerebral hemihypoplasia to establish an etiologic diagnosis and, more importantly, to detect and treat possible associated intracranial aneurysms before they become symptomatic.

Magnetic resonance imaging of the spine in children

We reviewed the magnetic resonance imaging (MRI) scans of the spine of 42 children who had neurologic signs compatible with lesions of the spinal cord. Twenty-three of the children had abnormalities identified by MRI. The spectrum of abnormalities included posttraumatic lesions, tumor, tethered cord, and syringohydromyelia. Tethered cord with or without lipoma and syringohydromyelia were the most common findings, affecting six and four children, respectively. Thirteen children studied by MRI also underwent conventional metrizamide myelography and/or computed tomography. In 12 cases, the findings of MRI were comparable to those of myelography and computed tomography. These observations indicate that MRI effectively detects lesions of the spinal cord in children. Because MRI can be performed on an outpatient basis and avoids the risks of metrizamide myelography, we conclude that MRI should be considered to be the preferred screening technique for children with suspected spinal cord disorders.

Neurogenic muscular atrophy in Behcet's disease

A child is reported with Behcet's disease who presented with skin and joint manifestations, oral ulcers, brainstem syndrome and neurogenic muscular atrophy. The neurogenic muscular atrophy was confirmed by electrophysiologic, histologic and histochemical studies. Electron microscopy of muscle showed a vasculopathy. The possible etiology of the muscle lesions is discussed. The relevant literature on muscle and peripheral nerve involvement in Behcet's disease is reviewed. It is proposed that neuromyopathy be added to the neurological manifestations of Behcet's disease. To our knowledge, this is the first case of neurogenic atrophy reported in Behcet's disease.

Familial spinocerebellar degeneration with corneal dystrophy

We report on two sisters born to normal but consanguineous parents, with the unusual combination of spinocerebellar degeneration and corneal dystrophy. Their manifestations include mental subnormality, bilateral corneal opacification starting in the second year of life and leading to severe visual impairment, and slowly progressive cerebellar abnormalities with variable dorsal column and upper motor neuron involvement. A third sister had only minor spinocerebellar signs but no eye findings, and three other sibs were completely normal. Both affected sisters underwent penetrating keratoplasty and their vision improved. Histologic examination showed findings of corneal dystrophy including corneal edema, thickening of Descemet membrane, and degenerative pannus. High-resolution light and electron microscopy of muscle and sural nerve performed on both patients was abnormal. It is suggested that, in this family, the corneal dystrophy and spinocerebellar degeneration are pleiotropic manifestations of an autosomal-recessive disorder.

Partial (localized) lipodystrophy. Report of a case with muscle and skin abnormalities

The light and electron microscopic myopathologic and dermatopathologic features in one patient with the partial (localized) type of lipodystrophy are described. The myopathologic changes involve both the contractile elements and the intracellular organelles, especially mitochondria that show hyperplasia and structural alterations of cristae. The dermatopathologic changes consist of a reduction in subcutaneous fat, intercellular edema, and the presence of intracytoplasmic lipid droplets. This is the first report in the literature in which the myopathologic features and detailed electron microscopy of skin in this condition are described. The myopathologic features of partial lipodystrophy are compared with those of congenital generalized lipodystrophy. It is proposed that a myopathy may be one of the manifestations of partial lipodystrophy.

Clofibrate-induced myotoxicity in rats. Temporal profile of myopathology

In this report, the temporal sequence of myopathology during a clofibrate-induced muscular syndrome and its recovery in rats is described using histopathologic, histochemical and electron microscopic technics. Two stages of myopathology are described: an early stage characterized by myopathic features, and a later stage characterized by neurogenic features. Although muscle histology returns to normal after 1 week of discontinuing the drug, electron microscopic abnormalities persist through the second week. It is proposed that clofibrate, in addition to its myotoxic effect, may be neurotoxic.

Survey of neuromuscular disorders in Lebanon. I. Profile of the genetically determined muscular dystrophies

The clinical and laboratory profiles of 130 cases of muscular dystrophy in Lebanon collected over 35 years (1947-1982) are presented. Data collection included hospital records; registries in the department of pathology, hospital laboratories, electron microscopy facility and electromyography laboratory; and records from a private hospital neurosurgical unit. The yield from each of these sources is presented. The data was fed into an Apple II computer and analyzed using thirty seven parameters. The results are discussed and compared with three other similar studies from India and America.

Brief clinical report and review: the Marden-Walker syndrome

We have studied a sibship with one confirmed and three probable cases of the Marden-Walker syndrome (MWS). Our patient had the major manifestations of blepharophimosis and squint; narrowly arched palate with micrognathia; small mouth and mouth-breathing; facial deformities and distortions; congenital muscle weakness with resulting scoliosis; mild pectus excavatum; camptodactylies and hip and finger joints subluxation. In addition, he had small, apparently low-set and slightly malformed auricles with a unilateral preauricular tag. However, he had no apparent renal or cardiovascular involvement. Results of CPK, EMG, and of histochemical, light microscopic, and ultrastructural studies of muscle biopsy do not suggest a primary myopathy but rather CNS related weakness/hypotonia with small muscle mass and hypoactive DTRs. This pathogenetic hypothesis is confirmed by the presence of severe mental retardation and minor brain changes suggesting cortical atrophy. In five previously reported cases there has been microcephaly. Phenotype analysis does not convince that the MWS is a true malformation syndrome, but rather hints at the possibility of a congenital metabolic dysplasia. Genetic analysis demonstrated autosomal-recessive inheritance in this and two other instances; primarily sporadic occurrence leaves open the possibility of genetic heterogeneity.

Postganglionic cholinergic dysautonomia: report of muscle findings in 1 case

Heretofore unreported findings in skeletal muscle in a 4th case of pure postganglionic dysautonomia are described. They consist of variation in fiber size, Z line and myofilamentous disorganization, intracytoplasmic inclusions and honeycomb formations. The most striking alterations, however, was excess lipid accumulation without concomitant mitochondrial alterations. Sural nerve histology and cytology were normal. The mechanism of lipid accumulation in skeletal muscle of patients with dysautonomia remains unexplained.

Efferent connections of the pulvinar nucleus in the cat

Discrete unilateral electrolytic lesions were placed in the pulvinar nucleus of cats using the stereotaxic approach. The pathways of the degenerated fibres and their terminals were traced to the cerebral cortex and to subcortical nuclei by the method of Fink-Heimer (anterograde degeneration). The cortical projection sites of the pulvinar are the following: suprasylvian cortex, lateral cortex, ectosylvian cortex, cingulate gyrus, area postsubicularis and retrosplenial gyrus. However, the bulk of the cortical projections of the pulvinar nucleus were to mid- and posterior gyri of the suprasylvian cortex. In this study subcortical projections of the pulvinar have been seen to terminate in the superior colliculus, pretectal area, and the following thalamic nuclei: posterior, suprageniculate, dorsolateral, posterolateral, reticular, centromedian, centrolateral, parafascicular and dorsomedial. One of the purposes of this study was to explore possible anatomical connections of the pulvinar that might explain its presumed role in the pain mechanisms. The results of the present study, on subcortical connections of the pulvinar, provide a possible anatomical substrate for such a role where connections of the pulvinar to one or more of the thalamic nuclei implicated in pain mechanisms, the reticular, the intralaminar (centromedian, centrolateral and parafascicular) and the posterior could constitute the necessary anatomical pathway or pathways. Furthermore, the extensive projections of the pulvinar to several cortical regions including the cingulate gyrus could represent another means by which the pulvinar might influence cortical and limbic structures which are known to modify pain sensation.

The myopathology of Behçet's disease--a histochemical, light-, and electron-microscopic study

The myopathology of Behçet's disease is described in 7 patients using conventional light microscopy, histochemistry, high-resolution light microscopy and electron microscopy. Two patients had clinical evidence of peripheral neuropathy: 5 patients had no clinical evidence of neuromuscular involvement. Histochemical profile of muscle in all patients was normal. Abnormalities in muscle histology using conventional light microscopy were found in only 1 patient. High-resolution light microscopy revealed abnormalities in 3 patients whereas electron microscopy revealed abnormalities in muscle of all 7 patients. The myopathology of Behçet's disease includes thickening of capillary basement membrane, excessive pleating of sarcolemma, subsarcolemmal aggregates of mitochondria and glycogen, disorganization and breakdown of myofibrils, central nucleation and the presence of a variety of cytoplasmic inclusions. No virus particles were present.

Efferent connexions of the pars lateralis of the substantia nigra (SNL)

Unilateral lesions were made in the lateral nucleus of the substantia nigra in eight cats and in the zona compacta and reticularis in two cats. After a 10 days survival period, brains were perfused and stored in 10% formalin. Frozen sections were stained with the De Olmos-Ingram and Fink-Heimer silver methods for degenerating axons and terminals. Efferents from the lateral nucleus of the substantia nigra projected to the dorsolateral third of the head of the caudate nucleus, putamen, medial reticular formation, central tegmental tract, amygdala, zona compacta and reticularis of the substantia nigra, ventral anterior and ventral ateral thalamic nuclei. Projections to the amygdala, medial reticular formation and central tegmental tract were seen only in animals with lesions in the lateral nucleus of the substantia nigra. Projections to the caudate and putamen were more abundant when compared to those in the thalamus. Within the thalamus, projections to the ventral lateral nucleus were scanty compared to those in the ventral anterior nucleus. The present study compares for the first time efferent connexions of the lateral nucleus of the substantia nigra and those of the pars compacta and reticularis. The findings suggest a specialization of the different zones of the substantia nigra with regard to their projection sites.

Clofibrate-induced muscular syndrome. Report of a case with clinical, electromyographic and pathologic observations

In this report the clinical features of a case of clofibrate-induced muscular syndrome, as well as the electromyographic, histochemical, light- and electron-microscopic findings are described. The clinical features are similar to those of previously reported cases. Electromyography was consistent with a myopathy. Histochemical profile was normal. The myopathology included breakdown of contractile material, deranged mitochondria, dilated sarcoplasmic reticulum profiles, accumulation of membrane bound dense bodies, discontinuities in sarcolemma and thickening of capillary basement membrane. Macrophages invaded severely affected fibers.

Postganglionic cholinergic dysautonomia

A 9-year-old boy presented with symptoms and signs of marked postganglionic cholinergic autonomic dysfunction manifested by bilateral internal ophthalmoplegia, impaired secretion of tears and saliva, lack of gastrointestinal motility, atony of the bladder, generalized absence of sweating, and hypertension. Clinical and pharmacological studies confirmed that the abnormalities were restricted mainly to the postganglionic cholinergic autonomic system and showed evidence of postdenervation supersensitivity to parasympathomimetic drugs. The patient was treated in the early phase of his illness by the administration of carbachol, and eventually he made a slow and partial spontaneous recovery. Histoimmunofluorescent studies on a skin biopsy specimen suggested an autoimmune origin for his disease, with IgG antibodies being produced against postganglionic cholinergic autonomic fibers.

Nigro-amygdaloid fiber connections in the cat

Relatively discrete unilateral lesions were made in the lateral portion of the substantia nigra of eight cats and in the medial substantia nigra of two. After a 10-day survival period the animals were killed, brains were stored in buffered 10% formalin, and frozen sections were stained for degenerating axons and terminals, or by Weil and cresyl violet methods. Electordes passed through the midial suprasylvian gyrus, pulvinar and/or posterolateral thalamic nucleus and the medial geniculate body. The stria terminalis and hippocampus were undamaged. Degeneration from the lesion followed two paths. One projected through the reticular nucleus into the internal capsule and then ventrolaterally below the putamen to enter the lateral and central amygdaloid nuclei, with degenerated terminals. The second path ran dorsolaterally in the internal capsule to enter the external capsule where some of the fibers spread into the lateral amygdaloid nucleus. It appears that some of the terminals in the lateral amygdaloid nucleus are from the external capsule. Perhaps these connections link the extrapyramidal system to the amygdaloid body.

Autonomous peripheral nerve activity causing generalized muscle stiffness and fasciculations: report of a case with physiological, pharmacological, and morphological observations

A 14-year-old boy with generalized muscle weakness, stiffness and fasciculations associated with profuse and continuous electromyographic (EMG) activity is described. The spontaneous mechanical and electrical muscle activity was unaffected by sleep, general anesthesia, or spinal anesthesia but was abolished by small doses of curare, succinyl-choline, and gallamine. Proximal and distal peripheral nerve block caused moderate and marked reduction of EMG activity, respectively, thus indicating that the disorder is due to autonomous peripheral nerve activity. The delayed motor nerve conduction velocities and the structural abnormalities seen in some of the myelin sheaths by light and electron microscopic studies on sural nerve biopsy preparations constitute further evidence that the peripheral nerve is the site of abnormality in this disorder. Diphenyl hydantoin and carbamazepine maintenance therapy produced adequate clinical relief.