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One hundred consecutive cranial computed tomographic scans were reviewed in children aged 0-2 years, presenting to the Royal Belfast Hospital for Sick Children. The mean age at scanning was 8.3 months and 73% of the scans were abnormal. The majority of scans were performed electively (78%). The commonest indication for a scan was seizures (31) and the diagnostic yield was highest where they were associated with other neuro-developmental symptoms. The usefulness of the CT scan was not limited to the abnormal studies but contributed to management in children with normal scans by excluding important intracranial pathology. Developmental CNS malformation (16 scans) and cerebral atrophy (15 scans) were the most frequent CT abnormalities encountered.

The introduction of noninvasive imaging techniques allowed diagnosis of intracranial pathology in the newborn infant during life, which previously was only possible at postmortem. This has stimulated new interest in correlating pathology with the pathophysiological changes that lead to these events, the neurological signs associated with them, and their ultimate effect on the neurological state of the survivors.

Introduccion. El tuberculoma cerebral constituye una forma clinica importante de neurotuberculosis con una elevada morbimortalidad y una notable dificultad diagnostica. Caso clinico. Unico caso de tuberculoma cerebral gigante en un nino de 3 anos, que comenzo con crisis epileptica y se trato quirurgicamente por sospecha diagnostica de tumor cerebral. Conclusion. Los tuberculomas cerebrales pueden confundirse muchas veces con tumores cerebrales cuando no se incluyen en el diagnostico diferencial.

Focal nodular hyperplasia of the liver, neoplasia of the brain, and intracranial vascular malformations have recently been described as a new syndrome. We report three cases of focal nodular hyperplasia of the liver with intracranial vascular anomalies. Two patients died from ruptured berry aneurysm. It is important to consider intracranial pathology in patients with focal nodular hyperplasia of the liver.

Management of children and infants with severe intracranial pathology is often a discouraging prospect, and clinicians naturally are eager to discover the breakthrough as they search for ways to ameliorate the outcome of these unfortunate patients. Over the past decade and a half, the subject of cerebral resuscitation has sprung from these roots, and numerous therapies, both heroic and ordinary, have been proposed to help preserve neuronal function following various illnesses or injuries. At the outset of this discussion, brain resuscitation can be divided into two categories: non-controversial and controversial. Most of this discussion will concern the latter, but a few words are in order about the non-controversies in this area.

Transplantation is a successful, cost effective treatment for terminal organ failure limited by a shortfall of donor organs to meet the need. This is currently estimated at over 5700 organs for the United Kingdom and Republic of Ireland.1 2 A confidential audit of all deaths in intensive therapy units has shown that even if all patients diagnosed as brainstem dead became donors the need could not be met.3 This led to the Exeter protocol for interventional ventilation of patients with rapidly progressive intracranial pathology which was expected to be fatal.4 Worldwide estimates suggest about 40 potential candidates for interventional ventilation per million population, which would greatly improve the outlook for those awaiting a transplant.5 The age of donor organs acquired in this way is greater but the proportion …

A British author has put forward a new explanation for Joan of Arc's behaviour. This author suggests that the voices Joan of Arc heard were due to the presence of a temporal lobe tuberculoma in the context of widespread chronic tuberculosis (exposure to bovine tuberculosis, amenorrhoea, heart and intestines incombustible). We consider that some elements are incompatible with widespread tuberculosis. It is difficult to draw final conclusions, but it would seem unlikely that widespread tuberculosis, a serious disease, was present in this 'patient' whose life-style and activities would surely have been impossible had such a serious disease been present.

Mechanical ventilation with PEEP is the cornerstone of treatment of patients with ALI and ARDS, but it is not free of adverse effects. This study aims to examine the effect of varying levels of PEEP on the intraocular pressure in critically ill patients with intracranial pathology.

SYNOPSIS Forty-six migraineurs and 69 age- and sex-matched controls referred for MRI scans of the brain were evaluated for the incidence of intracranial pathology. Axial long TR/short TE and long TR/Iong TE and sagittal short TR/short TE scans were performed in all patients. Enhancement with Gd-DTPA was performed in all controls and in nine migraineurs. Six of 46 (13%) of the migraineurs had white matter lesions versus three of 69 (4.3%) of the controls. The white matter lesions in migraineurs were seen in a younger age group than in the controls. These findings agree with recent MRI studies. Ischemia or an immune-based white matter demyelination are possible mechanisms for the white matter lesions.

Superior oblique myokymia (SOM) is an uncommon ocular motility disorder characterized by intermittent uni-ocular vertical or torsional oscillations with periodic remissions and exacerbations. Although generally idiopathic in origin, isolated case reports have documented its association with intracranial pathology. We present a case of superior oblique myokymia associated with a dural arteriovenous fistula.

The clinical utility of paramagnetic metal ion chelates for contrast enhancement in MRI of the brain is well established. Contrast administration provides both improved sensitivity and specificity with respect to diagnosis in neoplasia, infection, demyelinating disease, infarction, and arteriovenous abnormalities. On the basis of results from prospective studies, use of enhanced scans, in addition to baseline precontrast T1- and T2-weighted scans, is advocated in all patient studies in which there is a high index of suspicion with respect to intracranial pathology.

There is a widespread belief amongst clinicians and some pathologists that modern technology has made the necropsy irrelevant. Thi3 misconception does no service to our profession. The physician who avoids the feedback provided by a careful post-mortem examination will forever nurture the illusion that he is infallible. Validation of the cause of death, education, quality assurance, technology assessment and risk management are all assisted. For HIV infections the establishment of all diagnoses, information as to the correctness or otherwise of diagnoses and hence the appropriateness of treatment, the answering of unresolved problems relating to AIDS and its complications and the evaluation of the effects of new treatments. Postmortem studies on AIDS oases are particularly rewarding because of the peculiar problems which such cases present especially with intracranial pathology. It has een shown that clinically relevant unsuspected diagnoses will be found in about 75% of cases. Diagnoses most likely to be missed Include CMV, fungi, MAI, Kaposi sarcoma, herpes, CNS lymphoma and tuberculosis. Although there have been no cases of HIV infection so far amongst mortuary staff who have assisted with postmortems on HIV positive cases, it is prudent to be careful especially to avoid the risk of needle stick injury and a protocol for the safe performance of postmortem examinations on infectious cases will be presented.

The hypothalamus and myocardium of 12 patients who had died after a subarachnoid haemorrhage, and of six patients who had died from other intracranial pathology were examined. Only in the patients who had died from subarachnoid haemorrhage were histological lesions found in both the hypothalamus and myocardium. The possible significance of these findings is discussed with particular reference to the sympathetic nervous system.

The object of this study was to determine the sensitivity of magnetic resonance (MR) for imaging intracranial lesions with heavily T2-weighted images compared with that of computed tomographic (CT) and T1-weighted images. Fifty-five patients with known intracranial pathology consisting of primary neurogenic tumors, brain infarcts, demyelinating disease, and metastases were studied by MR and CT. Patients were studied with either 0.6 or 1.5 T systems with T1- and T2-weighted radiofrequency pulse sequences. The heavily T2-weighted images were found to be superior to the T1-weighted images in terms of sensitivity, with 168 lesions found versus 86 by CT and 104 by T1-weighted imaging.

The sonographic appearance of normal neonatal cerebral sulci may mimic that of significant intracranial pathology. An echogenic pseudolesion can be seen when a sulcus is imaged through its long axis. Criteria are discussed for the differentiation of this normal variant from true parenchymal lesions with their attendant serious clinical implications.

The management and evaluation of neurosurgical intracranial catastrophes requires a multidisciplinary approach to afford patients the best chance for favorable outcome. Intracranial pathology must be rapidly evaluated, both clinically and radiologically. Simultaneously, medical therapy for the control of intracranial hypertension must be undertaken immediately, beginning with provision of an adequate, protected airway and support of cardiopulmonary function. Intraoperative management, including choice of anesthetic agents, is based on support of systemic and cerebrovascular hemodynamics. There should be a seamless transition from the discovery of the patient in extremis through the period of medical stabilization, operative intervention, and ultimate delivery of the patient to the intensive care facility for extended treatment.

The results obtained in 179 encephalographies using the i.v. urea technique of Ruggiero and Pacifico are reported. A solution of 30% urea in 5% glucose was used in 49 cases; in the remaining 130 cases 40% urea in 10% mannitol was employed. The administration rate was 60 drops per min and the total amount of urea injected never exceeded 40 g. A definitive radiological diagnosis was made in all cases. 103 received further verification, either at operation or at necroscopy. The technique proved to be more useful in: a) single than multiple, b) supratentorial than infratentorial, c) extracerebral than intracerebral, d) lateralized than midline, expanding lesions. Urea does not modify the encephalographic picture of non-neoplastic intracranial pathology.

Computer tomography has been applied in a material of six patients meeting the criteria for cerebral death. The primary intracranial pathology, haemorrhages, infarction and contusions were demonstrable. No generalized reduction of the attenuation characteristic of infarction was found in spite of angiographic arrest of the intracranial circulation. Compression and obstruction of small brain vessels may in some cases be the primary cause of arrest of the brain circulation in cerebral death and not an increase of the intracranial pressure to levels approaching or surpassing the mean systemic arterial pressure.

The authors CAT-scanned 45 people admitted to the psychiatric ward of a large general hospital with a first episode of psychosis. Forty-two scans showed no evidence of intracranial pathology, and three scans showed positive findings that correlated with neuropsychiatric symptomatology. Ordering a head CAT scan in a first episode psychotic illness remains an option based on clinical judgment as opposed to routine protocol.

The clinical correlates and EEG characteristics of rolandic positive sharp waves in neonatal EEG have been studied systematically. Morphologically similar positive sharp waves have been reported to occur in the temporal areas (PTS). Their significance is, however, unclear. We reviewed fifty-two EEGs on patients from the Neonatal Intensive Care Unit of the University of Arkansas for Medical Sciences. Twenty-one of the EEGs which were reviewed had PTS. We correlated the PTS with the results of ultrasound of the head and with clinical evaluations. PTS are more strongly correlated with the occurrence of non-hemorrhagic than of hemorrhagic intracranial pathology.

Unsuspected intracranial pathology was demonstrated in 12 of 136 chronic schizophrenic patients examined by computed tomography (CT). Seven cases of cerebral infarction were found, and one each of porencephalic cyst, meningioma, cystic enlargement of the pineal body, and two of subdural haematoma. Attention is drawn to the value of CT in demonstrating organic disease in schizophrenia.

✓ The authors describe a fast method for estimating the elastance of the intracranial system in man. The method consists in constructing the so-called amplitude-pressure (Amp-P) curve which describes the relationship between the amplitude of pulse-related oscillations in cerebrospinal fluid pressure and the basic level of intracranial pressure. The Amp-P curve consists of two straight lines, and the point of intersection of these lines is thought to indicate the intracranial pressure level at which there occurs a qualitative change in the functioning of compensatory mechanisms of the intracranial system. The authors applied the method to examine the Amp-P curves of 10 patients without intracranial pathology and found that they provide a good description of the state and dynamics of the intracranial system. Preliminary data obtained in patients with intracranial pathology indicate that the method is a valuable tool in the diagnosis and treatment of neurosurgical patients.

As new and elaborate tools for medical diagnosis are developed, time-honored and simpler methods are often neglected. This we believe to be true of the technique of transillumination, as applied to the diagnosis of intracranial pathology. Illumination of the cranial cavity by sunlight and candle was described as early as 1831 by Richard Bright 1 (Fig. 1). In 1910, Strasburger 2 commented on its use in evaluation of the hydrocephalic child, and during the early part of this century von Bokay 3 developed the technique of transillumination to a remarkable degree. More recently, there has been renewed interest in this technique, but the majority of physicians still employ it only rarely and are unaware of its considerable value in neurologic diagnosis. During the past few years, the routine use of transillumination in the examination of infants and children with neurologic disease on the wards of the Children's Service of the

Radioactive Iodinated Serum Albumin (RISA) was given intrathecally to 83 neurological and neurosurgical patients. In order to evaluate the distribution of RISA in the subarachnoid space and its disappearance from it, AP and lateral brain scans were performed after 4, 24 and 48 h, and in some cases after 5 days. This method was called RISA cisternography by Di Chiro et al. (1964). This paper reports on 100 consecutive examinations by this method. The results of the investigation contributed significantly to diagnosis in patients with communicating hydrocephalus and with some other kinds of presenile dementia, in post-traumatic conditions and in other patients suffering from local obstruction or dilatation of the subarachnoid space. Eighteen patients without definite intracranial pathology or obstruction of the spinal subarachnoid space, showed pictures considered to be normal. Sterile meningitis developed in 3 patients, and 3 other patients showed brief transient pyrexia without subjective complaints. There are reasons to suppose that these complications can be avoided if the RISA is used within 6 days of delivery.

sBrain scanning using various radiopharmaceutical complexes is now well established as an invaluable diagnostic tool in the delineation of intracranial lesions. In this paper 300 cases with suspected intracranial pathology are presented and a comparative analysis of the 48 positive pick ups made with EEG and skull X-ray results.

1. The 1950 perceptanalytic alpha formula designed to aid in the differentiation between psychosis and neurosis(8) was tested on a new group of 145 patients, 100 schizophrenics, and 45 neurotics. All patients were followed for at least 3 years and were rediagnosed by Nolan D. C. Lewis. Their condition at the end of the 3-year period subsequent to the original Rorschach examination was evaluated in terms of improved, essentially unchanged, and worse. 2. An alpha formula score of 3 points or more indicates a mental condition more serious than a mere psychoneurosis, i. e., a schizophrenia, a manic-depressive psychosis, or intracranial pathology. If the alpha score is less than 3 points, a diagnosis of psychoneurosis indicated. The 1950 formula (Table 2) agreed with the independently made clinical psychiatric follow-up diagnoses in 83% of the 145 cases. The formula was as accurate in the diagnosis of schizophrenia as of neurosis provided both technical Rorschach requirements were met: ∑c≥∑C and W 7. If only o...

Echoencephalography is an established procedure for the detection of the position of the midline structures in the assessment of intracranial pathology. It is also important at craniotomy for localizing intracerebral lesions, which may then be approached without unnecessary and potentially hazardous intracerebral exploration.

Five cases of acute gastroduodenal ulcers in patients over 58 years of age, in which there was associated intracranial pathology due to cerebral arteriosclerosis, are reported. Evidence is adduced to emphasize the fact that the incidence of gastric ulcer and organic brain disease in the series is higher than can be accounted for merely or solely on the basis of coincidence. From clinical observation and experimental evidence in the literature, the suggested center in the brain responsible for such alimentary pathology appears to be localized in the diencephalon, particularly in the hypothalamus.

The activity of the enzymes, glutamic-oxalacetic transaminase and lactic dehydrogenase, in the cerebrospinal fluid and plasma was studied in 54 normal full-term newborn infants from 2½ to 240 hours of age, and in 20 newborn infants suspected to have intracranial pathology. The normal range of activities of these enzymes in cerebrospinal fluid and plasma are described. In the infants with suspected intracranial pathology, the average glutamic-oxalacetic transaminase activity of cerebrospinal fluid was 82% higher than in the normal newborn infant, and plasma glutamic-oxalacetic transaminase activity, had an 18% mean increase over normal. In the cerebrospinal fluid of the abnormal infants, lactic dehydrogenase activity had a mean increase of 309% over normal, and plasma lactic dehydrogenase activity revealed an increase of 11% over normal. Enzyme determinations in cerebrospinal fluid, particularly lactic dehydrogenase, may be useful in the study of newborn infants suspected of intracranial pathology.

SUMMARY Intravenous ketamine anaesthesia induced abrupt increases in intracranial pressure levels ranging from 25 to 82 mm Hg on nine occasions in five patients with abnormal cerebrospinal fluid flow dynamics and/or other intracranial pathology. The mean gain in intracranial pressure in patients with cerebral abnormalities was 41.5 (SD 16.6) mm Hg. This is compared with a ketamine-induced mean pressure increase of 19.4 (SD 6.9) mm Hg found by other investigators in a group of neurologically normal patients. Intravenous injection of thiopentone may terminate intracranial pressure elevations caused by ketamine.

Movement of the patient's head during computed tomographic studies with the EMI scanner causes some degradation of the quality of the examination. With sufficient movement, major artifacts appear which may obscure intracranial pathology. A simple method of head fixation, utilizing a dental mold, greatly reduces the incidence of unsatisfactory scans.

Diabetes insipidus (DI) is thought to be a relatively common complication after craniotomy procedures. To identify subsets of patients at risk for this problem, the postoperative courses of 135 consecutive patients undergoing craniotomy were scrutinized retrospectively. All patients received similar anesthetic management and all were hospitalized in the ICU postoperatively. DI developed in 9 (5 transient, 4 permanent) of 135 patients (6.7%). All 9 patients developing DI had undergone craniotomy for treatment of a pituitary disorder. It is concluded that postcraniotomy DI is a problem almost exclusively observed in patients with pituitary/hypothalamic disease and that DI rarely occurs in patients with other types of intracranial pathology.

Magnetic resonance imaging and evoked potential studies were performed on an infant with hydranencephaly. Magnetic resonance imaging demonstrated the absence of cortical tissue with a structurally intact mid- and hind-brain. Evoked potentials confirmed the loss of cortical activity with preservation of brainstem function. These diagnostic tests gave efficient and precise information concerning the extent of the intracranial pathology and prognosis.

1.1. Two cases of cerebrovascular accidents following the subcutaneous injection of 0.5 c.c. of epinephrine hydrochloride (1:1,000 solution) are presented. 2.2. Although the vasoconstriction of cerebral vessels is an established pharmacologic action of epinephrine, such factors as hypersusceptibility, dosage, cumulative effect, and a technical error in producing an intravenous injection and unrecognized intracranial pathology are important considerations in the production of these lesions. 3.3. The awareness of these possibilities and the exercise of due caution in the administration of epinephrine are recommended.

A case of hyperadrenocortirism in association with prostatic cancer is described. This rare condition was complicated further by markedly increased severity of previously controlled diabetes. Hypokalemic alkalosis, secondary to these conditions, progressed to coma mimicking intracranial pathology. The severity and complexity of these relations indicates the importance of considering cancer as a process with multiple metabolic overtones.

Transient rises in cerebro-spinal fluid pressure (CSFP) and cerebral blood volume (CBV) occur after mannitol infusion in patients with brain tumors and normal CSFP (Cottrell et al. 1977). This increase could be detrimental in patients with an already elevated CSFP. The effect of mannitol on CSFP was therefore studied in two populations of patients with similar intracranial pathology, those with a normal CSFP and those with an elevated CSFP.

The introduction of computed axial tomography has been of tremendous importance in the evaluation of intracranial pathology in children. The broad spectrum of cystic intracranial lesions of congenital, infectious, traumatic, vascular and neoplastic origin are discussed. Their CT findings, pathology and pathogenesis are emphasized.

Among patients categorized as suffering from severe head injury there is a great heterogeneity in both the clinical course and the type of intracranial lesion (Becker et al. 1977, Clifton et al. 1980, Gennarelli et al. 1982, Jennett et al. 1979, Miller et al. 1981) and it is necessary to separate they into meaningful subgroups in order better to analyse the factors influencing outcome. Segregation of cases may be achieved by different criteria and a pathological classification based on the computed tomography (CT) findings, seems to be rational and appropriate (Clifton et al. 1980, Gennarelli et al. 1982). Although post-traumatic intracranial lesions are not always mutually exclusive, by defining a principal lesion in cases with multiple intracranial pathology a practical, simplified subdivision may be built.

Computed tomography (CT) is ideally suited for detection of intracranial pathology, whereas plain radiography is limited to the bony structures. Distinguishing surgical and nonsurgical lesions is quite feasible with CT. Follow-up examinations are non-traumatic and carry minimal risk to the critically ill patient. In the great majority of head trauma cases, the recognition of pathology is unequivocal, thus facilitating proper management.

An algorithm was devised for the evaluation of patients with acute head trauma. The effectiveness of this strategy was tested with a retrospective chart review of 608 patients seen in a community hospital emergency room. The results of the algorithmic approach were compared to the original management of the patients. A financial savings of 65% was achieved and no significant intracranial pathology was missed using this approach.