George Lantos

Intracerebral haemorrhage: a model for the prediction of outcome.

The hospital charts and CT scans of 112 patients with spontaneous supratentorial haemorrhage were retrospectively reviewed to evaluate factors important to prognosis. A low Glasgow Coma Scale score, coma, ataxic respiration, abnormal pupils, acute hypertension, large haemorrhage size and intraventricular extension of blood were associated with a poor outcome. Multivariate analysis using the technique of logistic regression identified three variables, the Glasgow Coma Scale score, haemorrhage size and intraventricular extension of blood, which were most predictive of outcome. A model was developed from this analysis which accurately estimates the probability of good outcome and the risk of poor outcome based on data available on presentation. With additional validation, this model may be useful in choosing patients for surgical evacuation of haematomas.

AIDS Calcification of the basal ganglia in infants and children

CT or postmortem examination demonstrated calcification of the basal ganglia in eight infants and children with acquired immune deficiency syndrome. Serial CT studies documented progression of both bilateral symmetric calcium densities and cerebral atrophy. Clinical features included progressive encephalopathy with dementia, and pyramidal tract signs. Postmortem examination of four children revealed variable degrees of calcific vasopathy of the basal ganglia, involving predominantly the putamen and globus pallidus.

Early seizures following intracerebral hemorrhage: Implications for therapy

Seizures occurred in 19 of 112 patients (17%) with nontraumatic, supratentorial intracerebral hemorrhage (ICH). All seizures occurred at ICH onset; patients without seizures at hemorrhage onset remained seizure-free until the last recorded follow-up. Seizures were significantly associated with extension of blood into the cerebral cortex. We found no association between seizures and hemorrhage size or the presence of subarachnoid or intraventricular blood. These data suggest that (1) seizures, in ICH, occur at hemorrhage onset, (2) patients without seizures at hemorrhage onset are at very low risk for subsequent seizures during their hospitalization, (3) hemorrhage involving the cerebral cortex, regardless of site of origin, predisposes to seizures, and (4) the prophylactic use of anticonvulsants in the acute management of these patients appears unwarranted, especially in patients without cortical extension.

Cortical blindness due to osmotic disruption of the blood‐brain barrier by angiographic contrast material CT and MRI studies

Numerous experimental studies have demonstrated disruption of the blood-brain barrier by the hyper osmolar, iodinated contrast agents in common use for intravascular injection during radiologic studies. We report 4 cases in which cortical blindness occurred after cerebral angiography. The patients underwent x-ray CT within 1 hour. CT showed abnormal contrast enhancement in the occipital regions in all 4 instances. Two patients underwent MRI; 1 of these manifested abnormal high-signal intensity in the occipital lobes on T2-weighted images. Only 2 previous cases documenting immediate contrast enhancement within the brain substance on CT following angiography are in the literature.

Increased prevalence of the cavum septum pellucidum in magnetic resonance scans and post-mortem brains of schizophrenic patients

A cavum septum pellucidum (CSP) has been regarded as an incidental finding of little clinical importance. However, an association between this developmental anomaly and a diagnosis of psychosis has previously been reported. We determined the prevalence of the CSP in parallel studies of brain scans obtained with magnetic resonance (MR) imaging and in the post-mortem brains of schizophrenic patients compared with normal controls. We found a significantly increased prevalence of the CSP in both the MR scans and post-mortem brains of schizophrenic patients compared with controls. In the MR study, 17 of 81 (21%) schizophrenic patients but only 1 of 46 (2%) control subjects had a CSP. In the post-mortem study, 17 of 28 (61%) schizophrenic patients and 12 of 39 (31%) normal controls had a CSP. The increased prevalence of a CSP in schizophrenic patients further indicates that anomalous development of the limbic system is an important aspect of this disorder.

Immunohistochemical Localization of an Hiv Epitope in Cerebral Aneurysmal Arteriopathy in Pediatric Acquired Immunodeficiency Syndrome (AIDS)

A 6-year-old boy with acquired immunodeficiency syndrome (AIDS) developed aphasia and quadriplegia 3 months before his death. Cerebral vascular ectasia and multiple cerebral infarcts were noted on premortem radiological studies. Postmortem evaluation revealed diffuse aneurysmal dilatation of the circle of Willis associated with fresh and organizing thrombi, destruction of the elastic lamina, and marked intimal fibroplasia. Multiple cerebral infarcts and subacute AIDS encephalitis with basal ganglia calcification were also present. Immunohistochemistry with a monoclonal antibody (anti-gp41) to human immunodeficiency virus (HIV) demonstrated positively stained cells in the arterial wall of the circle of Willis and in the cerebral parenchyma. Double immunostaining demonstrated that gp41-positive cells in the circle of Willis were also positive for a macrophage marker or leukocyte-common antigen, but not with an endothelial marker. Some macrophages or microglia in the cerebrum were also colabeled with anti-gp41. These results suggest that HIV may be directly involved in vascular pathology associated with pediatric AIDS.

Neuro‐Behcet's disease CT and clinical correlates

We examined the serial CTs and clinical courses of five patients with neuro-Behcets disease and reviewed ten previously reported cases, all with focal CT abnormalities. The CT lesions were in the brainstem (8 patients), basal ganglia (7), thalamus (4), or hemispheric white matter (7). Of the 13 patients who received contrast, nine had lesions that showed enhancement. In five, lesions were visualized with contrast that were not apparent without it. The CT lesions were usually accompanied by corresponding clinical deficits, although in some patients deficits were more extensive than the CT predicted. In nine patients, contrast enhancement decreased or disappeared over days to weeks, often with associated clinical improvement. In eight patients followed serially, CT abnormalities resolved completely or substantially. Based on these cases, we conclude that (1) CT abnormalities of gray and white matter occur commonly in neuro-Behcets disease with focal deficits, and help support the diagnosis; (2) CT abnormalities, particularly contrast enhancement, correlate well with the activity of parenchymal disease; and (3) the concomitant improvement of clinical and CT abnormalities with resolution of contrast enhancement suggests that partially reversible inflammatory changes associated with breakdown of the blood-brain barrier may produce some of the neurologic and radiographic deficits in this illness.

Lobar vs thalamic and basal ganglion hemorrhage: clinical and radiographic features

SummaryOne hundred and twelve patients with spontaneous supratentorial intracerebral hemorrhages were reviewed to identify features which distinguish lobar intracerebral hemorrhage (LH; n=42) from thalamic or basal ganglionic hemorrhage (TGH; n=70). Chronic hypertension occurred more commonly in TGH (TGH 67%; LH 48%) while bleeding diathesis was more common in LH (LH 19%; TGH 6%). Clinical presentations were extremely variable and not associated with the type of hemorrhage. Bleeding into the ventricles and hydrocephalus occurred more often with TGH. At last follow-up, there were minimal differences between LH and TGH in overall mortality and functional outcome of the survivors. Alertness on admission was associated with a good outcome regardless of the type of hemorrhage, while a low Glasgow Coma Scale score, coma, ataxic respiration, abnormal pupil reactions, acute hypertension, large hemorrhage size and intraventricular blood were associated with a poor outcome. These data confirm etiological distinctions between LH and TGH, but fail to confirm previously reported differences in clinical presentation and outcome.

Magnetic Resonance Imaging of Intradural Spinal Lipoma

Intradural lipomas are rare tumors of the spinal canal. We report the occurrence of this neoplasm in a 19-year-old girl. Magnetic resonance accurately depicted both the exact location within the spinal canal and the precise tumor histology and was more informative than myelography. This case illustrates the value of magnetic resonance imaging in patients presenting with myelopathy. In many instances, this modality may be all that is needed in preoperative planning.

Computed tomography of the brain in the Smith-Lemli-Opitz syndrome

Computed tomographic (CT) scans of the brain in a child with Smith-Lemli-Opitz syndrome revealed enlargement of the ventricular system, hypoplasia of the cerebellum, and abnormal thickening of the gray matter, consistent with pachygyria. These findings have been previously noted in autopsies performed on patients with this disorder. We conclude that CT scanning is a valuable tool in the evaluation of children suspected of having the Smith-Lemli-Opitz syndrome. (J Child Neurol 1987;2:198-200).