Two cases of parkinsonism after recurrent obstructive hydrocephalus due to idiopathic aqueductal stenosis are reported. In both patients an extrapyramidal syndrome was noted in the absence of contemporaneous evidence of hydrocephalus or shunt failure. One of the patients underwent a shunt operation, but showed no clinical improvement. However, both patients improved after the administration of dopaminergic therapy. The seven previously reported cases of this syndrome were reviewed and it is concluded that the prognosis of the parkinsonism is good, usually with total, or near total, resolution. It is recommended that if a patient with idiopathic aqueduct stenosis develops hydrocephalus or evidence of shunt malfunction in association with acute parkinsonism their shunt should be replaced. If there is no evidence of hydrocephalus or shunt malfunction they should initially be treated with domaminergic medication. (J Neurol Neurosurg Psychiatry 1998;64:657-659) Keywords: Parkinsonian syndrome; hydrocephalus; aqueductal stenosis Parkinsonism is a rare complication of obstructive hydrocephalus. [1][2][3][4][5][6][7][8] There are only seven patients reported with an extrapyramidal syndrome secondary to non-neoplastic aqueductal stenosis.1-4 8 9 Lack of awareness of this association may cause diagnostic diYculty and unnecessary shunt revision. We report two further cases to emphasise the association of parkinsonism and recurrent obstructive hydrocephalus. Case histories CASE 1A 57 year old racehorse trainer presented with a one year history of unsteadiness of gait associated with general lethargy. He had a lifelong history of asthma, requiring intermittent courses of oral steroids in addition to regular inhaled steroid and bronchodilator therapy. He admitted heavy and long standing alcohol consumption. Neurological examination showed a generalised hyperreflexia and equivocal planters. Sensory testing disclosed reduced appreciation of vibration sense at both ankles.Brain CT showed dilatation of the lateral and third ventricles. Subsequent MRI confirmed this, and showed a normal sized fourth ventricle with aqueductal stenosis. Routine blood tests were normal.Gait and cognitive function deteriorated over the next three months, necessitating insertion of a ventriculoperitoneal shunt. This operation was successful allowing him to return to his previous occupation. Sixteen months later he gradually deteriorated, developing blurred vision, problems with upgaze, and loss of drive. Over the next eight months he continued to deteriorate with increasing unsteadiness of gait. Repeat neurological assessment disclosed complete absence of upgaze to command, although vertical movements on the doll's head manoeuvre were preserved. Despite the clinical deterioration MRI showed that the ventricles were of normal size. On neurosurgical assessment the shunt reservoir failed to empty and refill satisfactorily. This was presumed to account for his deterioration. Subsequent shunt replacement was initially followed by clinical improve...
The authors report five patients with damage to the distal spinal cord following spinal anesthesia. The patients developed leg weakness and sensory disturbance. MRI of the lumbosacral spine showed an abnormal area of high signal within the conus medullaris in all patients. Symptoms and signs persisted at 1- to 2.5-year follow-ups. Incorrect needle placement and type of needle used are possible factors leading to spinal cord injury.
A series of 33 patients with 35 acoustic nerve tumors is reviewed. Tumor size was estimated from computerized tomography (CT) scans, and its influence on anatomical and functional preservation of the facial nerve was assessed. Six tumors (one invading the petrous bone, three medium and two large tumors) were not detected on CT scans. The translabyrinthine approach was used in seven instances (one small and six medium tumors) and the suboccipital transmeatal approach for 28 tumors (seven medium and 21 large tumors). Anatomical preservation of the facial nerve was achieved in 83% of operations for tumor removal, two of which were subtotal. A further two patients underwent subtotal removal, but the facial nerve was destroyed. Large tumors carried an increased risk of damage to the facial nerve, but even in this group the nerve was preserved anatomically intact in 70% of cases. Damage to the facial nerve occurred more frequently in patients with preoperative evidence of facial weakness; however, this factor did not appear to influence functional recovery of the facial nerve, provided that the nerve was intact at the end of the operation. A simple grading system for facial nerve function is described. Ony 76% of anatomically intact facial nerves showed any evidence of function 1 month after surgery. Postoperatively, facial function improved with time. At the latest review, 45% of these patients had normal facial function or mild facial weakness (Grades I and II).
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