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A NUMBER of observers have reported untoward reactions following lumbar puncture in patients with tumors of the brain or with increased intracranial pressure due to other causes.* These untoward reactions have been attributed to temporal lobe herniation or herniation of the cerebellar tonsils. In some of the cases death is reported to have occurred immediately from presumed compression of vital centers, and in others a train of symptoms have developed which are presumed to indicate a more gradual compression.The statement is frequently seen that lumbar puncture is dangerous and is contraindicated whenever papilledema is present. This conclusion is reached on the basis of untoward reactions in individual cases, and to our knowledge there has not been an analysis of the results in a large series of cases. This study was undertaken in order to determine the frequency of untoward reactions in a large series of patients with tumors of the brain on whom a lumbar puncture was performed. MATERIALAll of the available brain tumor cases (965) at the Neurological Institute of New York, from January, 194S, to July, 1953, were reviewed ; only those patients who had lumbar puncture performed prior to arteriography, air studies, or surgery were included. A total of 401 histologically verified cases were available for this study, with the exception of 15 brain stem neo¬ plasms that were verified by surgery or air studies.For this survey, the status of all the patients was carefully evaluated from the time of the lumbar puncture until arteriography, air studies, or surgery. A careful search was made for the presence of symptoms or signs indicating an adverse effect of the lumbar puncture, with special attention to signs of temporal lobe herniation or herniation of the cerebellar tonsils. Particular attention was given to the following : third nerve involvement as evidenced by pupillary dilatation or extraocular muscle paralysis ; changes of the blood pressure, pulse, respirations, and tempera¬ ture; the appearance of convulsions; decerebrate rigidity; changes in the state of consciousness, and unexpected progression in neurologic deficit. RESULTSDivision of the cases according to the anatomical location and histologie type is shown in Table 1. There were 164 tumors in the anterior fossa, 140 in the middle fossa, 74 in the posterior fossa, 10 in the sellar and parasellar region, and 13 multiple metastatic lesions. The general histologie distribution of these cases followed that reported in other large series of cases of brain tumors.From the Neurological Institute of the Presbyterian Hospital, New York.References 1 through 5. Downloaded From: http://archneurpsyc.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/25/2015
A NUMBER of observers have reported untoward reactions following lumbar puncture in patients with tumors of the brain or with increased intracranial pressure due to other causes.* These untoward reactions have been attributed to temporal lobe herniation or herniation of the cerebellar tonsils. In some of the cases death is reported to have occurred immediately from presumed compression of vital centers, and in others a train of symptoms have developed which are presumed to indicate a more gradual compression.The statement is frequently seen that lumbar puncture is dangerous and is contraindicated whenever papilledema is present. This conclusion is reached on the basis of untoward reactions in individual cases, and to our knowledge there has not been an analysis of the results in a large series of cases. This study was undertaken in order to determine the frequency of untoward reactions in a large series of patients with tumors of the brain on whom a lumbar puncture was performed. MATERIALAll of the available brain tumor cases (965) at the Neurological Institute of New York, from January, 194S, to July, 1953, were reviewed ; only those patients who had lumbar puncture performed prior to arteriography, air studies, or surgery were included. A total of 401 histologically verified cases were available for this study, with the exception of 15 brain stem neo¬ plasms that were verified by surgery or air studies.For this survey, the status of all the patients was carefully evaluated from the time of the lumbar puncture until arteriography, air studies, or surgery. A careful search was made for the presence of symptoms or signs indicating an adverse effect of the lumbar puncture, with special attention to signs of temporal lobe herniation or herniation of the cerebellar tonsils. Particular attention was given to the following : third nerve involvement as evidenced by pupillary dilatation or extraocular muscle paralysis ; changes of the blood pressure, pulse, respirations, and tempera¬ ture; the appearance of convulsions; decerebrate rigidity; changes in the state of consciousness, and unexpected progression in neurologic deficit. RESULTSDivision of the cases according to the anatomical location and histologie type is shown in Table 1. There were 164 tumors in the anterior fossa, 140 in the middle fossa, 74 in the posterior fossa, 10 in the sellar and parasellar region, and 13 multiple metastatic lesions. The general histologie distribution of these cases followed that reported in other large series of cases of brain tumors.From the Neurological Institute of the Presbyterian Hospital, New York.References 1 through 5. Downloaded From: http://archneurpsyc.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/25/2015
Background:Pseudotumor cerebri (PTC), which has a prevalence in the general population of 1 to 2 out of 100,000, presents with raised intracranial pressure (ICP) but generally lacks a space occupying lesion.Case Description:Patient 1 is a 32-year-old woman with a history of multiple meningiomas. Upon presentation to our institution, her clinical exam was notable for a right sixth nerve palsy. An integrated diagnosis of PTC was made and shunting for the cerebrospinal fluid (CSF) diversion was recommended. Approximately 6 weeks after surgery, the patient exhibited complete symptom resolution and discontinued all medications. Patient 2 is a 40-year-old woman with history of meningioma causing partial obstruction of the right transverse sigmoid sinus. She agreed to undergo surgery for the left ventriculoperitoneal (VP) shunt placement, for management of her PTC. Postoperatively, the patient reported that her vision significantly improved. Patient 3 is a 49-year-old woman with history of meningioma who presented with left visual field cut. A right frontal VP shunt was recommended for the treatment of PTC. Postoperatively, the patient reported significant symptom improvement and resolution of visual complaints.Conclusion:This case series demonstrates that it is important to keep PTC in the differential diagnosis even when mass lesions such as meningiomas are discovered. Although PTC, as the name indicates, is classically diagnosed in patients without intracranial tumors, it is critical that this not be used as an absolute exclusion criterion. Finally, this case series supports the hypothesis that venous obstruction can result in PTC.
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