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Rasmussen's encephalitis, originally thought to be a chronic form of viral encephalitis, is now thought to be an autoimmune disease of the brain and is more properly termed Rasmussen's syndrome. Starting in one area of one side of the brain, the disease appears to gradually and progressively involve that side of the brain causing progressive and intractable focal seizures, a hemiparesis, and expressive aphasia when the left hemisphere is involved. Immune therapy with steroids, immunoglobulins, or plasmaphoresis provide only temporary relief from seizures. Neither antibodies to Glu-R3 nor cortical biopsy are helpful in the diagnosis. Hemispherectomy of one form or another is the only curative therapy, and there is no evidence that one form of hemispherectomy is preferable to another. Immuno-ablative therapy may be a therapy of the future.

A 19-year-old woman with no significant past medical history presented to the hospital after a 1-week illness. Her symptoms began with 2 days of vomiting, diarrhoea and decreased sensation in the fingertips. She subsequently developed emotional labiality and auditory hallucinations characterised by a persistent background humming. On the fifth day of her illness, she developed dysarthria and expressive aphasia. Initial examination approximately 1 week from symptom onset was significant for expressive and receptive aphasia, inattention and disorganisation, and fluctuating mental status consistent with delirium, with no obvious motor deficits. Brain MRI revealed a left medial temporal T2 hyperintensity without enhancement on FLAIR (figure 1A). Cerebrospinal fluid (CSF) revealed 129 nucleated cells with a lymphocytic predominance and no red blood cells. Extensive …

Introduction. Section 1. Alternative Forms of Output. Introduction: When There's No Spoken Output. D. Harding, C.Pound, Needs, Function and Measurement: Juggling with Multiple Language Impairment. J. Hunt, Drawing on the Semantic System: The Use of Drawing as a Therapy Medium with a Woman with Severe Expressive Aphasia. R. Lawson, M. Fawcus, Increasing Effective Communication Using a Total Communication Approach. Section 2. Word Retrieval Therapies. Introduction: Therapies for Word Finding Utilising Orthographic Relay Strategies. J. Mortley, Evaluating the Efficacy of an Intensive Strategy Based Therapy Programme for Spelling Impairment. M. White-Thompson, Naming Therapy for an Aphasiac with Fluent Empty Speech. J. Sheriden, A Treatment Programme for an Impairment in Reading Function Words. Section 3. Beyond the Single Word Therapies. Introduction: Therapies Addressing the Impairments in Processing Verbs and Sentences. J. Marshall , Doing Something About Verbs and Sentences: Two Therapy Approaches. A. Greenwood, Early Stages in Treating a Person with Non-fluent Aphasia. J. Marshall, 'Who Ends Up With the Fiver?' A Sentence Production Therapy. K. Swinburn, An Informal Example of a Successful Therapy or a Sentence Processing Deficit.

A 28-year-old man arrived for an outpatient cardiac MRI (CMR) study to evaluate cardiac structure. At the age of 24 the patient presented with acute onset expressive aphasia and was diagnosed with ischaemic stroke. Echocardiography at that time was reported as ‘apical wall thickening consistent with apical hypertrophic cardiomyopathy’. CMR revealed a moderately dilated left ventricle with abnormal appearance of the left ventricular (LV) apical segments. Further evaluation was consistent with a diagnosis of LV non­compaction (LVNC) cardiomyopathy with a ratio of non­compacted to compacted myocardium measuring 3. There was extensive delayed hyperenhancement signal involving multiple segments representing a significant myocardial scar which is shown to have a prognostic role. Our patient, with no significant cerebrovascular risk factors, would likely have had an embolic stroke. This case demonstrates the role of CMR in accurately diagnosing LVNC in a patient with young stroke where prior echocardiography was non­diagnostic.

A 63-year-old man with an isolated infarction of the corpus callosum developed expressive aphasia in addition to the deficits traditionally associated with a disconnection syndrome.

Transient focal neurological deficits have been described in sojourners to high altitude. We present two cases of transient expressive aphasia in well-acclimatized high altitude climbers. We speculate that this type of transient focal neurological impairment may represent migraine aura, and we discuss other reports of transient focal neurological deficit at high altitude.

BACKGROUND During the past decade there has been increasing use of omental transposition to the brain of patients who experienced neurologic sequelae after a cerebral infarction. This paper reports the long-term neurologic effects seen in a patient who underwent omental transposition 31 months after a stroke. Her postoperative follow-up period has been 13 years. CASE DESCRIPTION The patient had an expressive aphasia, a right hemiparesis and the inability to read which occurred immediately after her stroke. After surgery she demonstrated subjective and objective improvement in her speech and mobility. She also regained her ability to read shortly after surgery. CONCLUSION The patient demonstrated that omental transposition to the brain can improve neurologic function in the presence of a long-standing cerebral infarction and that the clinical improvement can be maintained over an extended period.

Approximately one-third of patients with glioblastoma multiforme experience aphasia (Kraemer & Bullard, 1994). This loss of language abilities can be a major source of frustration for patients. Their quality of life is affected by the inability to interact with others. In this paper, an examination of the phenomenon of expressive aphasia will be conducted through the application of the content methodology process. Content methodology is a process for developing nursing knowledge, which strives to bridge the gap between theory, research and practice (Dawson & Wells, 1992). This process will guide in the development of substantive content for practice. An assessment tool and intervention plan will be presented.

Thrombotic thrombocytopenic purpura (TTP) is an uncommon and potentially fatal disease that is characterized by endothelial cell abnormalities, platelet dysfunction, microangiopathic hemolysis, fever, neurological abnormalities, and renal involvement. Before the introduction of plasmapharesis in the 1970s, TTP was fatal. This case report is presented to illustrate how subtly TTP can present, to discuss the updated criteria for TTP diagnosis, and to emphasize that with effective treatment now available, accurate and early diagnosis is essential to decrease morbidity and mortality.

Methamphetamine use may be associated with increased risk of stroke in young adults. We describe two cases of carotid artery dissection and ispilateral middle cerebral artery (MCA) stroke following methamphetamine use. ### Patient 1. A 36-year-old right-handed woman had sudden onset of speech difficulty and right-sided weakness while eating lunch. She presented to the emergency department within 30 minutes. Her medical history was significant for migraine and oral contraceptive and methamphetamine use. She was smoking methamphetamine with some left neck pain over the preceding two nights. Her initial examination was remarkable for global aphasia, left gaze preference, and right hemiplegia without Horner syndrome. The NIH Stroke Scale (NIHSS) score was 21. The initial head CT was unremarkable. IV tissue plasminogen activator (tPA) was started within 80 minutes of symptom onset. She improved significantly with only moderate expressive aphasia and mild right hemiparesis 8 hours after tPA therapy. A follow-up diffusion-weighted MRI of the brain showed a small infarct in the …

[][1] Figure. (A) Baseline DWI image on a 96-year-old man with expressive aphasia. Acute infarct in the left middle cerebral artery territory. (B) Although clinically asymptomatic, there is a new lesion in the left anterior cerebral artery territory. Coutts et al. analyzed the risk of recurrent imaging events in 143 patients with minor stroke or TIA. Imaging was completed at baseline and at 1 month. Patients had evidence of recurrent lesions on MRI (9.8%). Of these, 43% were asymptomatic. see page 513 Labovitz et al. studied the incidence of deep and lobar intracerebral hemorrhage in white, black, and Hispanic patients living in Northern Manhattan. Higher risk of intracerebral hemorrhage accounted for the difference in intracerebral hemorrhage risk between men and women but not for differences between race/ethnic groups. see page 518 Van Gestel et … [1]: /embed/graphic-1.gif

A 47-year-old gentleman with a medical history of long-standing migraine presented with temporary total body paralysis and expressive aphasia for 4 h. It was also associated with worsening severe unilateral pulsating pain, nausea, photophobia, blurred vision, hearing disturbance and neck stiffness. All these symptoms were resolving gradually after 4 h and had resolved completely after 1 day. Investigations were unremarkable. Migraine was made as a diagnosis of exclusion.

✓ A 26-year-old man presented with expressive aphasia, weakness of the right arm, and anemia but there was no family history of hereditary hemorrhagic telangiectasia. Computerized tomography (CT) of the head demonstrated an enhancing left frontal mass, which was aspirated and on culture yielded multiple organisms. Pulmonary arteriovenous fistulae identified in both lungs by chest radiography, CT, and angiography were treated with coil embolization. Treatment of pulmonary arteriovenous fistulae and prolonged surveillance are necessary to prevent future neurological complications.

A 56-year-old black woman had 3 months of tinnitus and then left arm and leg paresthesias. Over the past month, she has experienced short-term memory loss, expressive aphasia, change in mood, and impaired calculation ability. Magnetic resonance imaging (MRI) showed a solitary large frontotemporal tumor with surrounding edema, and a subsequent craniotomy revealed adenocarcinoma. Postoperatively, her moods have been more stable. Chest X-rays and breast examination were normal. An ovarian cyst and a colonic polyp were removed in the past.

Summary Objective: To present a case of cerebral infarction following thoracic herpes zoster presenting as Gerstmann's syndrome. Clinical features: A 61 year old male developed herpes zoster of T 1-2 dermatomes. Four months later he developed a confusional state together with expressive aphasia, dyscalculia, dysgraphia and finger agnosia with no long tract signs. CT scan of head showed recent infarction of this left parietal lobe. He recieved a five day course of acyclovir 800mg four times daily and showed slow but steady improvement Conclusion: Herpes zoster is uncommonly followed by cerebral infarction. Acyclovir may have a role in therapy of this complication.

A 78-year-old right-handed woman with a history of atrial fibrillation, prior transient ischemic attacks, and cerebrovascular disease developed expressive aphasia. She immediately began writing a note to a companion. Her first 2 attempts (Figure, A and B) demonstrated expressive aphasia …

Ischemic stroke following snake bite is rare. We report an 18-year male who developed right hemiplegia with expressive aphasia following a Russell's viper bite. T2-weighted magnetic resonance imaging revealed infarct in the left middle cerebral artery territory. The possible mechanisms for cerebral infarction in this scenario include disseminated intravascular coagulation, toxin induced vasculitis and endothelial damage.

Multicentric glioblastoma is a uncommon brain malignant tumour. We report the case of a 43-years-old woman, born in Ukraine and living in Italy, who manifested an initial isolated epileptic seizure and subsequent atypical psychiatric symptoms. Clinical neurological examination, Brain Computed Tomography and standard EEG examinations were negative at the moment of admission. A month later, she presented apathy, apraxia, psychomotor slowdown and expressive aphasia. A Magnetic Resonance Imaging examination showed a bi-frontal lesion. The patient underwent to two neurosurgical removals of the lesions: histological examination demonstrated the presence of a grade IV glioblastoma. Clinical onset, diagnostic and therapeutic problems are discussed. In case of atypical psychiatric presentation, it should be taken into consideration neoplastic, inflammatory or infective causes. Despite the absence of focal neurological signs and basal CT scan and EEG alterations, complementary imaging examinations, such as MRI and contrast enhancement CT, are necessary, especially when the conditions become quickly worse

We describe the clinical, radiologic, neuropsychological, and neuropathologic features of a 69-year-old man with a 3-year history of progressive transcortical expressive aphasia. Neuropsychological testing showed progressive dysfunction of expressive language. Neuropathologic examination demonstrated focal cortical degeneration involving the left superior frontal gyrus, with swollen achromasic neurons and no evidence of Alzheimer9s disease, Pick9s disease, Creutzfeldt-Jakob disease, Lewy-body disease, or other dementing disorders. This case adds to the known heterogeneity of the underlying pathology of patients with primary progressive aphasia.

A 31-year-old white male was first admitted to the Ohio State University Hospital after the sudden onset of expressive aphasia and right arm weakness. He had been healthy until several months prior when he developed scrotal edema followed by anasarca. While hospitalized elsewhere for evaluation he denied any symptoms of gastrointestinal, rheumatic, cardiopulmonary, or systemic illness as well as medications or allergies. Findings included anemia (Hct = 32%), thrombocytopenia (53,000/cm3), renal insufficiency (creat = 2.2; creat clr = 58ml/min), nephrotic syndrome (32 gm protein/24 hr, cholesterol = 408, total protein = 3.5 gm), a normal IVP, and a cerebral CT that was reportedly negative. When focal neurologic deficits, appeared he was transferred.

A 64-year-old man with IgM kappa restricted Waldenstrom macroglobulinemia (WM) presented with right frontal headache and transient expressive aphasia. MRI demonstrated regions of enhancement within periventricular white matter with associated FLAIR hyperintensity and no restricted diffusion (figure). CSF analysis showed leukocytes 2 cells/mm3 (71% lymphocytes), …

Dichotic listening (DL) performance to consonant-vowel (CV) syllables is reported in an aphasic right-handed male patient. The patient suffered initially from a complete expressive aphasia after an intracerebral hemorrhage caused by the rupture of an arteriovenous malformation (AVM) underlying Broca's area. The patient was tested three times with DL; one week after the hemorrhage, five weeks after, and after at about 6 months. At the first test he could not speak, but understood well. At the second test he uttered one-syllable words, and could answer "yes" and "no" to questions. At the third test he could speak whole sentences, although slow and "stutter-like." Dichotic listening performance showed an almost perfect match with speech recovery. At the first test he showed a left ear advantage which changed to no ear advantage at the second test, and to a right ear advantage at the third test. The overall performance was markedly reduced at the first test, but improved at the following test. It is concluded that dichotic listening may be a valid complement to traditional language assessment procedures after unilateral brain lesions.

The pathogenesis of migraine is thought to follow a defined temporal and spatial sequence of events. Brainstem activation and stimulation of meningeal blood vessels by trigeminal sensory nerves causes release of vasoactive substances and vasodilation of intracranial extracerebral blood vessels. Further irritation of the peripheral trigeminal sensory nerves establishes a cyclical pathway and persistent headache.1 Here, we describe a case of prolonged aura during migraine with neuroimaging that demonstrates increased perfusion and leakage of contrast into the subarachnoid space. A 66-year-old white woman had a long-standing history of migraine with onset at age 9 years and was being treated with verapamil. Family history was notable for migraine in both the patient’s daughter and mother. Prior evaluation including MRI of the head was unremarkable. Her typical episodes lasted 1 day and were associated with visual scotoma followed by transient expressive aphasia, but no weakness. One week before the current hospitalization, she stopped taking verapamil and subsequently presented with her typical migraine symptoms, which then progressed to include nausea, vomiting, and global aphasia over the ensuing days. Given the extended duration of her headache, she was taken to the emergency department where her workup included an unremarkable head CT and lumbar puncture, but also fever and leukocyte esterase positive urinalysis. She was administered meperidine and hydroxyzine with ceftriaxone. She was discharged with a diagnosis of migraine, exacerbated by a urinary tract …

A case of pure word mutism, often called "small Broca's aphasia," in a 44-year-old woman with a psychiatric history and a long history of unresolved, vague neurologic symptoms is presented. Although hysterical reaction was high on the list of differential diagnoses due to the patient's medical history, cranial computed tomography performed in the emergency department revealed an infarct in the distribution of the middle cerebral artery, which probably caused her condition. The patient improved slightly during hospitalization and was discharged on the sixth hospital day with a moderate expressive aphasia for which she received intensive speech therapy.

The capacity of aphasic patients to communicate a sequence of events by drawing is explored in a preliminary way and examples given of such communication, both spontaneous and elicited, obtained from a case of severe and persistent expressive aphasia. It is evident from these that ideational processes in aphasia may be substantially intact in spite of severe defect in spoken and written expression.

This study describes a case of developmental expressive aphasia where the acquisition of basic reading skills was associated with a parallel improvement in language functioning generally, suggesting a central nervous system interaction and structural transfer at the syntactic‐symbolic level. The study implies that in cases of expressive aphasia where there is some impairment of syntactic structuring, it may be possible to stimulate the formation of such an organisational capacity by direct teaching intervention through a reading programme that emphasises grammatical features of language. Furthermore, the observed outcomes of the reading program in this case can be explained in terms of Chomsky's theory of language acquisition and Luria's theory of the regulative function of speech on neural organisation. The study, therefore, has implications both for a more complete explanation of the nature of aphasic dysfunction and for the effective use of reading as a form of language therapy.

An 11-year-old previously healthy boy had an abrupt onset of partial complex, focal, multifocal, and generalized seizures, with interictal expressive aphasia, extreme emotional lability, agitation, and complex visual and auditory hallucinations. EEGs showed frequent runs of rhythmic high-voltage delta over the right and subsequently over the right and left temporal and frontal regions. All other studies were negative (repeated computed tomography, spinal fluids, viral titers, and cultures). Nadir during the second month showed virtual unresponsiveness, prolonged rhythmic motor and apneic seizures, total anorexia, and sleeplessness. Remission of the electrical and clinical seizure activity and a gradual improvement through a state of agitation and emotional lability occurred during the third and fourth months. One year later he was entirely normal. Compared with the other previously documented cases of prolonged partial complex status, this case is notable for its florid and severe symptomatology, long duration, and final benign outcome.

A 63-yr-old man with conduction aphasia was asked to repeat 4 monosyllables, 1 polysyllable, and a sentence under normal conditions and under Delayed Auditory Feedback (DAF). In 20 normal controls, DAF produced louder and slower speech and linguistic errors similar to those found in mild expressive aphasia. In contrast, the patient with conduction aphasia showed little increase in intensity and spoke faster and with fewer linguistic errors under DAF than under normal conditions. The paradoxical improvement inducedby DAF in this patient suggests that abnormal auditory feedback may cause some of the features of conduction aphasia.

The speech therapy in fifteen aphasic patients was studied. The group consisted of 8 male and 7 female patients and their ages ranged from less than ten to more than fifty years. In eleven cases the aphasia was due to cerebrovascular disease and in the remaining four cases to traumatic injury to the brain. Predominantly expressive aphasia accounted for five patients while in the others a comparable degree of receptive and expressive deficits existed. Six patients had their therapy programme started within the first three months after the acute phase and the rest of the group started it after more time had elapsed. Eleven patients showed a satisfactory recovery regardless the inicial deficit severity, the patients age, the pathology of the lesion or the period of time which elapsed from the beginning of the disease to the start of the therapy. The speech therapy in aphasic patients is effective although a firm prognosis cannot be established at the beginning of the programme. Useful information concerning prognosis only can be taken from the follow-up and after thoroughly retesting the patients.

One hundred subjects (50 men, 50 women), of whom 80 had suffered a unilateral cerebrovascular accident (40 left, 40 right), were tested on the WAIS. In the case of left hemisphere damage the male patients showed lower Verbal than Performance Scale IQ scores; for the right brain damaged men Performance Scale scores were Lower than their scores on the Verbal Scale. Women with unilateral brain damage showed no such reliable discrepancies between their Verbal and Performance Scale scores. This difference in the patterning of WAIS IQs in male and female stroke patients persisted even after the scores of those few patients with any significant degree of expressive aphasia had been excluded from consideration.

A 54-year-old male was admitted in April, 1983, because of progressive neurological symptoms. On neurological examination, the patient was stuporous, had right hemiparesis, expressive aphasia, bilateral papilledema and right sixth cranial nerve paresis. A computerized tomography (CT) scan demonstrated a mass in the left thalamus with a marked enhancement after contrast administration. Left carotid angiography showed a vascular stain in the same region. Prednisolone was given intramuscularly, at a dose of 20 mgday. Ten days later, an improvement of neurological findings were observed. A CT scan at this time revealed the mass lesion was markedly decreased in size. In June, a stereotaxic biopsy of the mass in the thalamus showed a malignant lymphoma. After this procedure, whole brain irradiation at a total dose of 4, 000 rad and a local dose of 2, 000 rad was given. Prednisolone therapy was continued. A CT scan taken after irradiation demonstrated disappearance of the tumor mass and also, improved neurological symptoms. Seven cases of primary malignant lymphoma of the brain which showed remission in conjunction with the administration of glucocorticoids have been previously reported. It is thought that glucocorticoids may have a direct cytotoxic effect on the lymphoma cell or that glucocorticoids may favorably alter the biologic activity of tumor tissue in some cases.

We report on a 38-year-old patient with intractable complex partial seizures originating in the dominant left medial temporal region. In the work-up for seizure surgery, arrays of subdural electrodes were placed, and electrical stimulation revealed marked language interference in a 2 X 2-cm area in the left basal temporal fusiform gyrus (3.5 to 5.5 cm posterior to the temporal tip). Complete receptive and expressive aphasia, inability to repeat, agraphia, and alexia were elicited, but visual memory was preserved, and no constructional apraxia was noted. Stimulation of the basal temporal gyrus at lower stimulus intensities produced a relatively selective and severe anomia.

The histories of 12 children who suffered acquired hemiplegia with aphasia have been reviewed. Although in four the onset was prolonged, it was usually not sufficiently characteristic to allow diagnosis and treatment prior to the development of the complete syndrome. The dominant hemisphere, as demonstrated by the lesion, did not correspond accurately with socially described handedness. Arteriograms were successful in demonstrating vascular malformation or thrombosis in six of seven children on whom they were attempted. Recovery has been followed in 10 children over a period of years. All regained speech spontaneously, and four appear intact, or virtually so. All of the others show psychologic and neurologic residue. Psychologic steps during recovery have been briefly indicated, and one child having an expressive aphasia has been more fully described. Two children have had recurrent seizures.

A case of expressive aphasia resulting from right middle cerebral artery occlusion in a fully right-handed woman without sinistral antecedents is reported. The significance of the findings in relation to cerebral dominance is discussed.

A study of seventy-five cardiac patients, including periodic medical, psychiatric, neurologic and psychologic examinations, was made, with a four-year follow up. A preoperative history of cerebral vascular accidents was elicited in five (8.9 per cent) of the fifty-six patients with rheumatic heart disease. Thirty-three of these patients underwent mitral commissurotomy. In the period immediately after commissurotomy, cerebral vascular complications (strokes) developed in three (9.1 per cent) patients. Thus, the incidence of known cerebrovascular complications rises to 18 per cent in the patients with rheumatic heart disease undergoing mitral surgery. Consequently, almost one in five such patients may suffer cerebral involvement, in either the pre- or immediate postoperative period. Detailed examinations were made preoperatively, and repeated postoperatively at three weeks, six months and yearly, up to four years. Psychologic tests included measures of intelligence, organic involvement of the brain and projective technics. Psychiatric history, mental status and neurologic examinations were also repeated periodically. Medical follow-ups included recatheterization studies and exercise tests. The psychiatric and psychologic evaluations prior to cerebral vascular accidents revealed that these patients were adjusting in a manner in keeping with their cardiac illness. Neurologic examination at that time revealed no major signs of central nervous system deficit in the three patients in whom cerebral complications developed following commissurotomy. In two patients undergoing commissurotomy evidence of serious neurologic involvement developed within the first two days, and in the third patient on the twelfth postoperative day. While the immediate impact of these complications resulted in pronounced neurologic deficits, follow-up studies showed gradual recovery. Of two patients with initial expressive aphasia, one retained only a mild paresis of the left arm, while the other showed some degree of residual expressive aphasia, even after three and a half years. The third patient, with initial hemiplegia, achieved almost complete recovery. The psychologic retests indicated definite impairment associated with the occurrence of cerebral vascular accidents and a gradual recovery of psychologic functioning to the pre-operative level, with minor residuals remaining in perceptual motor abilities and personality functioning after three years. Intelligence, as measured by the Wechsler-Bellevue test, indicated almost complete return to the preoperative level within two years. Psychiatrically, two of three patients with postoperative neurologic deficit made satisfactory readjustments and returned to previous occupations; while the third (with residual aphasia) had definite rehabilitation difficulties and could not return to her full-time professional job. Improvement in cardiac dynamics following the surgery was uniformly disappointing in these three cases. Among many factors influencing readjustment, outstanding was availability of supportive individuals in the patient's milieu and his ability to utilize them in his day-to-day rehabilitative efforts.

We report a child with HUS complicated by stupor, hemiparesis, expressive aphasia and focal seizures. CAT scan of the brain demonstrated 2 large cerebral non-hemorrhagic infarcts. Despite the severe neurological involvement the child eventually made a good recovery.

A transient expressive aphasia associated with focal slowing in the electroencephalogram, is described in a patient with documented Mycoplasma infection. The hypothesis that ischemia is a mechanism for the transient clinical findings is considered in relation to animal studies.

A 16-year-old boy presented with a 9-day history of intermittent severe generalized headaches and confusional state. On the day of hospitalization, the patient had several focal seizures involving the right side of the body; he subsequently became increasingly lethargic and developed an expressive aphasia. Examination revealed a lethargic, febrile patient with a mild right hemiparesis and expressive aphasia.

In summary, I have made suggestions for working with staff to promote empathy for the stroke patient presenting with behavior problems. All of us take for granted our "two ways of knowing," the richness of our experience being promoted by the two sides of our brain. When brain damage occurs, the results are sometimes dramatic as with paralysis or expressive aphasia, and sometimes subtle as with receptive aphasia and certain visual-spatial problems. Nursing staff provide the care which otherwise would have been self care. When expectations are low, patients withdraw and staff "care ... less." When expectations are high, patients become symptomatic, staff burned out. The nurse consultant can intervene most effectively by addressing the total milieu, enriching the perspective of staff and family members who are seeing only one side of the whole.

A case of bilateral ophthalmic artery aneurysm of traumatic origin is discussed. The patient presented with progressive loss of vision, memory deficit, and expressive aphasia. A computed tomographic scan revealed enhancing lesions near the region of the optic chiasm. The diagnosis of cerebral aneurysm was confirmed by cerebral angiography. At operation, bilateral ophthalmic artery aneurysms were successfully clipped. (Neurosurgery 21: 86-89, 1987)

A 71-year-old woman with a history of insulin dependent diabetes mellitus and severe peripheral vascular disease was admitted with gangrene of the left big toe. The patient had undergone surgery one month previously for debridement of the toe and adjoining area. There was no history of trauma to the toe but the patient reported multiple infections at the site and had been treated with parenteral antibiotics. For the past year, the patient had experienced pain in her left calf on walking. She had expressive aphasia secondary to a cerebral vascular accident 6 months ago. There was no specific history of cardiac disease; she had never been told of hypertension. She had smoked heavily in the past but had stopped about 2 years ago. She enjoyed an occasional drink. Except for occasional hydrodiuril and “heart tablets,” she did not regularly take any prescribed drugs apart from regular insulin (dosage range 12–40 units, adjusted according to the blood sugar level) and a 2-week course of oxacillin.

The authors encountered three cases of intracerebral hematoma (ICH) occurring early after surgery for chronic subdural fluid collection. A 54-year-old male complained of speech disturbance and facial weakness 22 hours after irrigation of a chronic subdural hematoma (CSH). Computed tomography scan showed an ICH beneath the previously removed CSH. His neurological deficit disappeared with conservative treatment. A 73-year-old male developed expressive aphasia 14 hours after surgery for chronic subdural hygroma. The patient was treated conservatively and the aphasia was still present 1 year after the ictus. A 3-month-old boy developed a left ICH and had a generalized convulsion 60 hours after irrigation of bilateral CSH. With conservative treatment there was no neurological deficit 1.5 months after the episode. Almost all of the reported ICH appeared in the subcortex just beneath a previously evacuated collection of subdural fluid. The symptoms were rapid deterioration of consciousness and focal neurological deficits developing soon after surgery. One possible mechanism of ICH is diapedesis through increased permeability of parenchymal blood vessels due to the sudden increase in cerebral blood flow after longstanding extracerebral fluid collection. The prognosis of this complication is poor. Therefore, subdural fluid should be removed slowly to avoid sudden decompression.

Ten female patients, age 50–70 years, suffering from presenile dementia and showing signs of defective speech function were analyzed. All patients underwent measurements of regional cerebral blood flow (rCBF) by the xenon clearance technique using a 32-detector piece of equipment, and all showed a marked reduction of the hemisphere mean blood flow level. In addition, regional decreases of blood flow of the gray matter was demonstrated. Patients with a marked reduction in the temporo-parieto-occipital regions showed signs of receptive aphasia including alexia and agraphia. Patients with a marked frontal reduction showed signs of expressive aphasia of various types including stereotyped language, voluble speech, echolalia, and mutism in later stages. The results give further support to our previous conclusion that subsymptoms of presenile dementia, apparently also speech disturbances, can be related to local degenerative changes in the brain, which in their turn are accompanied by local reductions of the blood flow of the gray matter. There is pathoanatomical evidence to support this conclusion.

It is generally accepted that regional cerebral blood flow (rCBF) is not homogenous throughout the normal hemisphere under resting conditions (Wilkinson et al., 1969; Ingvar and Schwartz, 1974; Lechner and Ott, 1978). In addition, evidence of regional augmentation of cortical rCBF stimulated by increased brain activity such as speech, reading, memorizing, reasoning, and arm work has accumulated(Olesen, 1971; Risberg and Ingvar, 1973; Ingvar and Schwartz, 1974; Ott et al., 1977; Lechner and Ott, 1978).