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A number of studies have come to the conclusion that delaying radiation in younger patients may avoid the consequences of dementia and hypopituitarism (see editorial by Peterson and DeAngelis) blood pressure medication causes nightmares cheap lasix online visa, but others have suggested that the tumor itself and anticonvulsant drugs cause more difficulty than high-dose radiation blood pressure is normally greater in your lasix 100 mg on-line. Lacking any clear benefit on survival arrhythmia associates fairfax purchase lasix 100mg visa, it seems to us that radiation should be withheld initially blood pressure chart too low order lasix 40mg fast delivery. Nevertheless, an increase in seizures or worsening neurologic signs then presses one to turn to radiation or further surgery. Repeated operations prolong life in some patients; chemotherapy has as yet no established place in the treatment of low-grade pure astrocytomas. However, tumors with an oligodendroglial component may respond well to combination Gliomatosis Cerebri In this variant of high-grade glioma there is a diffuse infiltration of neoplastic glial cells, involving much of one or both cerebral hemispheres with sparing of neuronal elements but without a discrete tumor mass being identified. Whether this type of "gliomatosis" represents neoplastic transformation of multicentric origin or direct spread from one or more small neoplastic foci is not known. For these reasons, the tumor is impossible to classify (or to grade) using the conventional brain tumor schemes. Many small series of gliomatosis cerebri have been reported since Nevin introduced the term in 1938, but no truly distinctive clinical picture has emerged (Dunn and Kernohan). Impairment of intellect, headache, seizures, and papilledema are the major manifestations and do not set these cases apart on a clinical basis from the malignant astrocytoma, in which the tumor may also be more widespread than the macroscopic picture suggests. If there is a syndrome that can be associated early on with gliomatosis, in our experience it has been a nondescript frontal lobe abnormality, sometimes mistaken for depression or a subacute dementia, or pseudobulbar palsy may be the first manifestation. Imaging studies characteristically show the tumor crossing and thickening the corpus callosum. There is slight enhancement at the edges of the lesions after gadolinium infusion, and the corpus callosum is thickened. Treatment these tumors are too infrequent for categorical judgments to be made regarding therapy, but the overall response to any treatment has been disappointing and the prognosis, as mentioned, is very poor. Corticosteroids have little clinical effect, possibly because of a paucity of edema. Most trials have suggested a benefit of radiation treatment, but the absolute prolongation of life has been only several weeks (Leibel et al). The addition of chemotherapy may confer a marginal further benefit when survival at one year is considered. When a large region is infiltrated, particularly in the temporal lobe, surgical debulking may prolong life, but otherwise surgery is futile. Oligodendroglioma this tumor was first identified by Bailey and Cushing in 1926 and described more fully by Bailey and Bucy in 1929. The tumor is derived from oligodendrocytes or their precursor cells and may occur at any age, most often in the third and fourth decades, with an earlier peak at 6 to 12 years. It is relatively infrequent, constituting about 5 to 7 percent of all intracranial gliomas. From the time of its original descriptions, it was recognized as being more benign than the malignant astrocytoma. In some cases the tumor may be recognized at surgery by its pink-gray color and multilobular form, its relative avascularity and firmness (slightly tougher than surrounding brain), and its tendency to encapsulate and form calcium and small cysts. Most oligodendrogliomas, however, are grossly indistinguishable from other gliomas, and a proportion- up to half in some series- are mixed oligoastrocytomas, suggesting that their precursor cell is pluripotential. The neoplastic oligodendrocyte has a small round nucleus and a halo of unstained cytoplasm ("fried egg" appearance). The cell processes are few and stubby, visualized only with silver carbonate stains. Microscopic calcifications are observed frequently, both within the tumor and in immediately adjacent brain tissue. The most common sites of this tumor are the frontal and temporal lobes (40 to 70 percent), often deep in the white matter, with one or more streaks of calcium but little or no surrounding edema. Sometimes the tumor presents in a lateral ventricle; it is rarely found in other parts of the nervous system.
Pressure on the heels and elbows can be avoided by padding the splints and by turning the patient frequently or by asking the patient to do so blood pressure 4080 purchase lasix on line. In the mildest cases there may be a considerable restoration of motor function in a few weeks hypertension causes and treatment buy genuine lasix. In severe forms of the disease hypertension complications purchase cheap lasix online, several months may pass before the patient is able to walk unaided blood pressure journal lasix 40mg low price. The sensory features and pain in particular may be slower to recover, having taken a year on one of our recently observed patients. The slowness of recovery creates a special problem for the alcoholic patient, in whom the great danger to continued recovery is the resumption of drinking and inadequate diet. Suitable arrangements must therefore be made for close supervision during the long and tedious convalescence. Since 1940, its has diminished greatly because of the general practice of enriching bread with niacin. Nevertheless, among the vegetarian, maize-eating people of underdeveloped countries and among the black population of South Africa, pellagra is still a common disease (Bomb et al, Shah et al, Ronthal and Adler). In developed countries, pellagra is practically confined to alcoholics (Ishii and Nishihara, Spivak and Jackson, Serdaru et al). Clinical Features in Typical Cases In its fully developed form, pellagra affects the skin, alimentary tract, and hematopoietic and nervous systems. Insomnia, fatigue, nervousness, irritability, and feelings of depression are common complaints; examination may disclose mental dullness, apathy, and an impairment of memory. Pellagra may not only produce insanity but occasionally result from it, by virtue of the anorexia and refusal of food that accompany certain mental illnesses. The dermatologic feature, often permitting one to make a confident diagnosis, is a scaly dermatitis in sunexposed areas. Diarrhea and glossitis or other forms of mucous membrane disorder may be accompaniments. The spinal cord manifestations have not been clearly described; in general, the signs are referable to both the posterior and lateral columns, predominantly the former. Signs of peripheral nerve affection are relatively less common and are indistinguishable from those of neuropathic beriberi. Pathologic Changes these are most readily discerned in the large cells of the motor cortex, the cells of Betz, and are seen to a lesser extent in the smaller pyramidal cells of the cortex, the large cells of the basal ganglia, the cells of the cranial motor and dentate nuclei, and the anterior horn cells of the spinal cord. The affected cells appear swollen and rounded, with eccentric nuclei and loss of the Nissl bodies (frequently referred to as "axonal reaction"). In the pathologic material of Hauw and associates, the chromatolytic changes were most pronounced in the brainstem nuclei (upper reticular and pontine) and not in the Betz cells. They concluded that these changes were not due to a retrograde axonal lesion but did not comment on the status of the spinal cord. The spinal cord lesions in pellagra take the form of a symmetrical degeneration of the dorsal columns, especially of Goll, and to a lesser extent of the corticospinal tracts. Such a posterior column degeneration, affecting a specific system of fibers, is likely to be secondary to degeneration of the dorsal root ganglion cells or posterior roots. The few studies of the peripheral nerves in pellagra have disclosed changes like those in alcoholics and other patients with nutritional deficiency. Etiology It has been known since 1937- when Elvehjem and coworkers showed that nicotinic acid cured black tongue, a pellagra-like disease in dogs- that this vitamin is effective in the treatment of pellagra. Many years before, Goldberger had demonstrated the curative effects of dietary protein and proposed that pellagra was caused by a lack of specific amino acids (see Terris). Now it is known that pellagra may result from a deficiency of either nicotinic acid or tryptophan, the amino acid precursor of nicotinic acid. One milligram of nicotinic acid is formed from 60 mg of tryptophan, a process for which pyridoxine is essential. It should be pointed out that, in experimental subjects, only the cutaneous-gastrointestinal-neurasthenic manifestations of pellagra have been produced by the feeding of tryptophan- or niacindeficient diets; neurologic abnormalities were not produced by these diets (Goldsmith). As a corollary, only the dermal, gastrointestinal, and neurasthenic manifestations respond to treatment with niacin and tryptophan; neurologic disturbances in pellagrins have proved to be recalcitrant to prolonged treatment with nicotinic acid, although the peripheral nerve disorder may subsequently respond to treatment with thiamine. In monkeys, degeneration of peripheral nerves as well as the unique cerebrocortical changes of pellagra were induced by a deficiency of pyridoxine (Victor and Adams, 1956).
Progression of the disease was very slow; after 10 years or so some wasting of proximal muscles was seen in a few of the patients blood pressure medication voltaren cheap lasix 100mg with visa. Welander dystrophy has been linked to chromosome 2p13 arteria bologna 23 novembre order lasix 100 mg on-line, near the locus for the below described Miyoshi myopathy blood pressure glucose chart cheap 40mg lasix otc. Markesbery and colleagues reported a late-onset distal myopathy in which weakness began in the distal leg muscles (tibialis anterior) and later spread to the hands; there was also cardiomyopathy and heart failure hypertension 9 code purchase lasix 100mg otc. Identical distal myopathies have been described in Finnish patients by Udd and colleagues and found to be caused by dominant mutations in the "titin" gene. A form beginning in childhood described by Laing and colleagues was shown to be due to a mutation in the gene for myosin heavy chain. Miyoshi Dystrophy A second type of distal dystrophy characterized by an autosomal recessive pattern of inheritance is particularly prevalent in Japan (Miyoshi et al, Nonaka et al), but numerous cases exist in all parts of the world. Onset of the disease is in early adult life, with weakness and atrophy of the leg muscles, most prominent in the peroneal or the gastrocnemius and soleus muscles. Over many years the weakness extends to the thighs, gluteal muscles, and arm muscles, including the proximal ones. In this "Miyosh type" of dystrophy the mutation leads to an absence of the muscle protein dysferlin. Dysferlin is a membrane protein that does not interact with any of the dystrophin-binding elements. Whereas dystrophin and its binding partners are believed to confer tensile strength the muscle membrane, dysferlin and its associated proteins. Of interest is the fact, mentioned earlier, that one of the limb-girdle dystrophies (2B) has been linked to the same chromosomal locus and also lacks the dysferlin protein. The Miyoshi myopathy is the one we have encountered most often among the distal muscular dystrophies. An apparently separate form of distal myopathy with autosomal dominant inheritance and onset before 2 years of age has been described by Magee and DeJong and by van der Does de Willebois and coworkers. Whether these infantile-onset cases represent a true muscular dystrophy has not been established beyond doubt. Several even rarer distal myopathies with linkage to specific genetic sites are summarized in the review by Illa but most are not well enough characterized to require elaboration here. Congenital Muscular Dystrophy (Fukuyama, Walker-Warburg, Merosin Deficient, Rigid Spine, and Other Types) (See Table 50-4) Early in the twentieth century there were scattered reports of congenital myopathy, but the status of this condition was difficult to evaluate, mainly because of a lack or incompleteness of pathologic examinations. Some cases may have represented congenital myotonic dystrophy, or one of the congenital myopathies described in Chap. In 1957 Banker, Victor, and Adams described two patients (siblings), one dying 11/2 h after birth and the other at the age of 10 months of a congenital muscular dystrophy with arthrogryposis. The pathologic changes consisted of muscle fiber degeneration, variation in fiber size, fibrosis, and fat cell replacement. The severity of the degenerative changes was such that a developmental disorder of muscle could be excluded. Pearson and Fowler, in 1963, reported a brother and sister with similar clinical and pathologic findings, and Walton et al described yet another patient, aged 4 years. By 1967 Vassella and colleagues were able to collect 27 cases from the medical literature and to add 8 cases of their own. The high incidence of sibling involvement pointed to an autosomal recessive inheritance. Defined as a muscle dystrophy already present at birth, often with contractures of proximal muscles and trunk, the severity of the weakness and degree of progression have varied widely. Of the 8 cases reported by Rotthauwe and others, one had a benign course, but the others all had weakness and hypotonia at birth, and difficulty in sucking and swallowing had interfered with nutrition. Their oldest patients, aged 14 and 23 years, and several others had walked, but at a late age. In the Finnish series of Donner and associates, congenital dystrophy accounted for 9 percent of the 160 cases of neuromuscular disease seen at their hospital over a decade. This group of dystrophies began to come into focus in the 1960s with a series of articles from Japan relating the details in over 100 patients with congenital dystrophy (Fukuyama et al). It is the second most common muscular dystrophy in Japan but it is rare elsewhere.
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The various cranial nerve and brainstem syndromes in which the fifth nerve is involved are listed in Tables 47-1 hypertension 180120 lasix 40mg low cost, 31-4 hypertension patient teaching cheap 40 mg lasix with visa, and 34-3 prehypertension que es best lasix 100mg, the last in relation to stroke syndromes of the brainstem pulse pressure chart cheap 100 mg lasix otc. Diseases Affecting the Fifth Nerve A variety of diseases may affect the peripheral branches of the trigeminal nerves, the gasserian (semilunar) ganglion, and the roots (sensory and motor). Trigeminal Neuralgia (see also page 161) the most frequent, and at the same time the most elusive disease of the fifth nerve from the standpoint of its pathologic basis, is trigeminal neuralgia (tic douloureux), which is also discussed in Chap. This condition has been known since ancient times, having been described by Arateus in the first century A. The mean age of onset is 52 to 58 years for the idiopathic form and 30 to 35 years for the symptomatic forms, the latter being caused by trauma or vascular, neoplastic, and demyelinative diseases. In the last decade it has become apparent, mainly from the work of Jannetta, that a proportion of cases is due to compression of trigeminal nerve rootlets by small branches of the basilar artery. This compression casues demyelination of the proximal nerve root (see Love and Coakham). The diagnosis of "idiopathic" trigeminal neuralgia and its differentiation from other forms of intermittent facial pain described bePrincipal sensory low- as well as from cluster headache, dental neuralgia, Motor nucleus nucleus N. V temporomandibular pain, and atypical facial pain- is usually not difficult, especially if there is a trigger point Gasserian ganglion and no demonstrable evidence of sensory or motor impairment. The vascular compressive form, still usually subsumed in the category of idiopathic, is diffficult to Motor root fibers diagnose without exposure at operation. I In rare instances, trigeminal neuralgia is preceded or Motor nucleus accompanied by hemifacial spasm, a combination that N. Trigeminal Neuropathies and Neuritis Of the conditions that damage the branches of the trigeminal nerve, facial and cranial injuries and fractures are probably the Spinal V most common but they do not often come to the attention Nucleus N. The most superficial branches of the nerve- the supratrochlear, supraorbital, and infraorbital- are the ones usually involved. The sensory loss is present from the time of the injury, and partial regenNucleus spinal V eration may be attended by constant pain, often demanding nerve block or sectioning. Of the various inflammatory and infectious diseases that affect the trigeminal nerves or ganglia, herpes zoster ranks first (pages 163 and 642). This subject is Ramon y Cajal S: La Textura del Sistema Nervista del Hombre y los Vertebrados, Madiscussed in Chap. Middle ear infections the mental nerve) as the first indication of metastatic carcinoma of and osteomyelitis of the apex of the petrous bone may spread to the the breast and prostate and from multiple myeloma. Massey and ganglion and root, also implicating the sixth cranial nerve (Gradencolleagues have described 19 such cases ("numb-chin" syndrome). Neurologists often encounter instances of slowly evolving the trigeminal root may be compressed or invaded by intraunilateral or bilateral trigeminal neuropathy in which sensory imcranial meningiomas, acoustic neuromas, trigeminal neuromas pairment is confined to the territory of the trigeminal nerve, some(Fig. Loss of facial sensation can occur as part of a widespread may also implicate the nerve, causing pain and a gradually prosensory neuropathy that occurs as a remote effect of cancer or as gressive sensory loss. The ophthalmic division of the fifth nerve part of Sjogren disease (pages 586 and 1141). Tumors of the spheLecky and colleagues, 9 had either scleroderma or mixed connecnoid bone (myeloma, metastatic carcinoma, squamous cell carcitive tissue disease, and a similar number had either organ- or nonnoma, and lymphoepithelioma of the nasopharynx) may involve organ-specific serum autoantibodies. The symptoms may involve branches of the trigeminal nerve at their foramina of entry or exit. Hughes has also reported cases of triThe mandibular division may be compressed by the roots of an geminal neuropathy with scleroderma, lupus erythematosus, impacted third molar (wisdom) tooth. Pathologic data are limited but point to an inflammatory lesion of the trigeminal ganglion or sensory root. Stilbamidine and trichloroethylene are known to cause sensory loss, tingling, burning, and itching exclusively in the trigeminal sensory territory. Four of their 16 patients had an associated paranasal sinusitis, but subsequent reports have failed to substantiate a causal relationship between sinusitis and cranial neuritis.
The concept of a communicating hydrocephalus was based on the observations that dye injected into a lateral ventricle would diffuse readily downward into the lumbar subarachnoid space and that air injected into the lumbar subarachnoid space would pass into the ventricular system; in other words blood pressure record chart order lasix online now, the ventricles were in communication with the spinal subarachnoid space blood pressure chart cholesterol cheap lasix master card. If the lumbar spinal fluid remained colorless after the injection of dye blood pressure medication history buy lasix 100mg on-line, the hydrocephalus was assumed to be obstructive or noncommunicating arteria ileocolica cheap lasix 100mg online. In actuality, the distinction between these two types is not fundamental, because all forms of tension hydrocephalus are obstructive at some level, and the obstruction is virtually never complete. Acute and complete aqueductal occlusion is said to be incompatible with survival for more than a few days. The authors suggest that a more appropriate terminology is one in which the site of the presumed obstruction is indicated. One foramen of Monro may be blocked by a tumor or by horizontal displacement of central brain structures by a large unilateral mass. The aqueduct of Sylvius, normally narrow to begin with, may be occluded by a number of developmental or acquired lesions with periaqueductal gliosis (genetically determined atresia or forking, ependymitis, hemorrhage, tumor), and lead to dilation of the third and both lateral ventricles. In the hereditary cases reported by Bickers and Adams, the transmission was in three generations of males. If the obstruction was in the fourth ventricle, the dilation included the aqueduct. The latter forms of obstruction result in enlargement of the entire ventricular system, including the fourth ventricle. Another potential obstruction site is in the subarachnoid spaces over the cerebral convexities. Moreover, experiments in animals in which all the draining veins had been occluded, a tension hydrocephalus with enlarging lateral ventricles was produced in only a few cases. Yet Gilles and Davidson have stated that tension hydrocephalus in children may be due to a congenital absence or deficient number of arachnoidal villi, and Rosman and Shands have reported an instance that they attributed to increased intracranial venous pressure. Our hesitation in accepting such examples stems from the difficulty that the pathologist has in judging the patency of the basilar subarachnoid space. This is much more reliably visualized by radiologic than by neuropathologic means. The rarely encountered radiologic picture of enlarged subarachnoid spaces over and between the cerebral hemispheres coupled with modest enlargement of the lateral ventricles has been referred to as an external hydrocephalus. Although such a condition does exist, many of the cases so designated have proved to be examples of sporadic or familial subdural hygromas or arachnoid cysts. Clinical Picture of Chronic Hydrocephalus this varies with the age of the patient and chronicity of the condition. Four main clinical syndromes are recognized- one that occurs very early in life and causes enlargement of the head (overt tension hydrocephalus) and another in which the hydrocephalus becomes symptomatic after the cranial sutures have fused and the head remains normal in size (occult hydrocephalus). A special a form of the latter is arrested or compensated hydrocephalus of late adult life (normalpressure hydrocephalus). Overt Congenital or Infantile Hydrocephalus the cranial bones fuse by the end of the third year; for the head to enlarge, the tension hydrocephalus must develop before this time. Tension hydrocephalus, even of mild degree, also molds the shape of the skull in early life, and in radiographs the inner table is unevenly thinned, an appearance referred to as "beaten silver" or as convolutional or digital markings. The frontal regions are unusually prominent (bossed) and the skull tends to be brachiocephalic except in the Dandy-Walker syndrome, where, because of bossing of the occiput from enlargement of the posterior fossa, the head is dolichocephalic. With marked enlargement of the skull, the face looks relatively small and pinched and the skin over the cranial bones is tight and thin, revealing prominent distended veins. In this type of hydrocephalus, the head usually enlarges rapidly and soon surpasses the 97th percentile. The anterior and posterior fontanels are tense even when the patient is in the upright position. With continued enlargement of the brain, torpor sets in and the infant appears languid, uninterested in his surroundings, and unable to sustain activity. Later it is noticed that the upper eyelids are retracted and the eyes tend to turn down; there is paralysis of upward gaze, and the sclerae above the irises are visible.