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Hyperphagia in patients with a hypothalamic tumour
195 FPIDURAI. HAEMATOMA ( .M-‘.(I.M.FRENKEN (Tilburg).
BETWEEN
1973 AND
1983. REPORT
OF 143 CASES
from 19’73 to 1983 143 epidural haematoma were treated in the neurosurgical department of the St. t-lisabeth Hospital. Tilhurg. The Netherlands. In this study the history of these patients is reviewed in relation to outcome. Also included are the age and sex of the patients. the injury. presence of cerebral lcrions and skull fractures. The data were compared with those of otherstudies (London, 1960. Brisbane. 196X. Oslo. 197X and Madrid. 1981). For the whole series the mortality was 16%. Over the last five years the mortality decreased f 12%). More than 505 of the mortality appears to involve patients who had a lucid period after the accident. They may hc avoidable deaths. Another subject of study was the relation between mortality or serious disablhty on the one hand. and the state of consciousness just before operation. abnormality of the pupil-reaction. passage of time between accident and operation and finally the progress of the clinical image between accident and operation on the other hand. The patients were classitied in four groups: 1. con\ciour throughout - 227 2. uncon\cions throughout ~ 237 3. classical progress. i.e. unconscious to lucid to unconscious - 177 4. at lirst lucid. then a decrease of consciousness - 38$. l‘heaegroup\ differ clearly in mortality rate: none in group I. 22g c tn group 2,28% in group 3 and 177 in the last group. The high mortality of the classical group (3) is very remarkable. The conclusion 15 that a number of patients are still operated upon too late. not because of lack of equipment or insufficient surgical service. but because of inadequate application of knowledge about the signs and \~[ilpt(~tns of the damaged hrain. It should not hc too difficult to lower the mortality rate ofepidural haematoma to less than 10%. maybe even to 5’;. provided there 1s adequate observation and diagnosis. It might also be possible to avoid serious di\ahilitv in half of the cases.
SCJBARACHNOID HAEMORRHAGE I). WIlNA1.1~4 and IS. IX SMUT (Tilburg).
AND NEUROPSYCHOLOGICAL
DISORDERS
Since 1978 14X patients with ruptured intracranial aneurysms have been treated with nlicrosurgcr~. (St. t‘lisabcth Hospital. Tilburg. The Netherlands). The mortality was 2q. the post-operative morbidity 6%. Recently wr started as ;I routine examination 3 months after operation a neuropsychological examination L,ombined with CT scannmg and EEG. Of62 patlent> who were examined. 13 had shown an aneurysm of the Internal carotid artery (2 I F). 30 of the anterior cerebral arterv (48%). I I of the middle cerebrai arten- (18%) and 8 of the vertebral-basilar artcr! ( 13’;). There were two kinds of psychological deficits: emotional and intellectual. In 55% of the examined patients there were emotional problems: though aspecific. they often formed a barrier in for example the resumption of work. The intellectual deficits consisted of disturbances m attention. memory, tempo. kpccch. ~irithnlctic and \patiaI orlentati~~n. The rcsuits were scored in: normal outcome. minor disturbances and global deterioration. It hccame evident. that there was an almost linear correlation between this outcome and the post - SAH prading according to Hunt and Hess. We alho found a good relation between a good outcome and location <)f the aneurvhm on the proximal arteries. Specific dvsfunction was more often found in patients with :meurysms. seated more deep& in the brain.
HYPERPHAGIA IN PATIENTS WITH A HYPOTHALAMIC U.M. WLLBERGEN-VLAM and C.W.G.M. FRENREN (Tilburg).
TUMOUR
In addition to its role in the regulation of the pituitary gland, the hypothalamus homeostatic~lly controls water balance and body temperature, and influences consciousness. sleep. emotion and behavior. ‘Two cases of patients( 6 4.9 32 year-old) with hyperphagia and obesity, due to a hypothalamic turnout, XC pre\ented. Lesions of the ventromedial nucleus (VMN) of the hypothalamus cause increased eating. while electric stirn~llati~~n stops feeding. Contrarily. lesions of the lateral hypothalamus (LH) lead to a decrease in food intake. which suppose a reciprocal interaction.
The VMN mcludes glucoreceptor elements capable of sensmg rising glucose level\. ‘these glucll\tat neuronsdetermine food drove and arc supposed to he responsable for short-term regulation offood tnr.tkc It is postulated that long-term c.tlortc balance i\ primarily medtated by a’lipostatic’ mechanicm, uhit.h IX still unknown. Lesions of the VMN producr hyperphagia and weight gam which later stabihrcs at a new elcvatcd setpoint. VMN-lesioned obese human beings are lecc active and eat only more when food is easilv to obtain. The regulation of food intake tncludes also elements responsive to btogenic ammes.‘l’hc VMN is specrtic inhibited by a-agonist activation. and the LH by R-agonist activation. This is illustrated h:, the mecham\m ofdrugs as amphetamtne and fentluraminc.
A CASE REPORT OF SAGITTAL (EVALUATION OF COMPUTED THERAPY) J.P.rt?R BRUGGEN (Tilhurg).
SINUS THROMBOSIS TOMOGRAPHIC FINDINGS
IN DIAGNOSIS
RELATED
TO
A case of aseptic superior sagittal sinus (s.s.~.) thrombosis believed to be associated with oral contraception, is presented. A 4l-year-old female was admitted to our clinic on August 16. 1982 because of progressive headache. She complained of severe headache. vomiting and vertigo since 2 days. At that time bilateral choked discs and hypertension .?05/ 1IO were found. CT scan on the first day after admission revealed an asymmetric ventricular system only. By lumbar puncture a pressure of 22 cm H,O. high protein (0.62 mg/I) and a bitirubin excess of0.40 umolll were found. Repeated CT scan at August 13. revealed the so called empty delta sign (Buannano 1978). No biochemical abn~~rmalitics were found, antithrombin III was normal so there was no generalised hyperc(~a~ulabilit~. The diagnosis S.S.S. thrombose was confirmed by angiography. On oral medication: depakine (4 x 300 mgr). dexamethasone (4 x 5 mgr). there was a good recovery. Because of the risk of progresston of micro-intracerebral haematomas by high venous pressure no anticoagulant therapy was given. According to Bernett and Hyland (1953) the s.s.s thrombosis 1s considered as essential haemorrhagic. Control CT scan. September I. was normal, Angiography showed a normal filling of the s.s.s.. with thromhosis of I vessel of the median cerebral artery. As soon as the diagnosis S.S.S.thrombosis IS suspected. we advise to do CT scan. with special attention to the cord and empty delta sign.
CARDIAL
ARHYTHMLAS iN GUILLAIN (Tilhurg).
BARRE
SYNDROME
P.c.I..A. LAMBREWS
From January 1972 to Deeember 1982 47 patients with Guillain Barre syndrome (GBS) were treated in the Sint Elisabeth Hospital Tilburg. The oecurence of cardiac arhythmia was examined in a retrospective study. IS Patients had weakness of the limbs only. 7 had also cranial nerve involvement. Artificial ventilation (AV) was necessary in 25 cases. Arhithmias in patients with known coronary artery disease and arhythmias in association with electrolyte and acid-base disorders were excluded. One out of 22 patients without respiratory failure and I8 out of 25 patients in the AV group showed paroxysmal arhythmias. Severe bradycardia was only seen in the latter group in 14 patients and an asystolic period occurred in three. Three patients underwent temporary demand-pacemaker insertion because of asystolia or severe bradycardia with atroventricular block. In all patients but one arhythmta only occurred at the end of progressive period of the disease and during the period at maximum impairment (l-6 weeks). Once improvement started, no arhythmias were seen, except in one case. Five patients died. three of them due to complications of artificiai ventilation (trachea haemorrhage. pneumothorax and sepsis). One patient with a history of coronary artery disease died of myocardial infection. One patient probably died ofcardiac arrest,
BETWEEN
1973 AND
1983. REPORT
OF 143 CASES
from 19’73 to 1983 143 epidural haematoma were treated in the neurosurgical department of the St. t-lisabeth Hospital. Tilhurg. The Netherlands. In this study the history of these patients is reviewed in relation to outcome. Also included are the age and sex of the patients. the injury. presence of cerebral lcrions and skull fractures. The data were compared with those of otherstudies (London, 1960. Brisbane. 196X. Oslo. 197X and Madrid. 1981). For the whole series the mortality was 16%. Over the last five years the mortality decreased f 12%). More than 505 of the mortality appears to involve patients who had a lucid period after the accident. They may hc avoidable deaths. Another subject of study was the relation between mortality or serious disablhty on the one hand. and the state of consciousness just before operation. abnormality of the pupil-reaction. passage of time between accident and operation and finally the progress of the clinical image between accident and operation on the other hand. The patients were classitied in four groups: 1. con\ciour throughout - 227 2. uncon\cions throughout ~ 237 3. classical progress. i.e. unconscious to lucid to unconscious - 177 4. at lirst lucid. then a decrease of consciousness - 38$. l‘heaegroup\ differ clearly in mortality rate: none in group I. 22g c tn group 2,28% in group 3 and 177 in the last group. The high mortality of the classical group (3) is very remarkable. The conclusion 15 that a number of patients are still operated upon too late. not because of lack of equipment or insufficient surgical service. but because of inadequate application of knowledge about the signs and \~[ilpt(~tns of the damaged hrain. It should not hc too difficult to lower the mortality rate ofepidural haematoma to less than 10%. maybe even to 5’;. provided there 1s adequate observation and diagnosis. It might also be possible to avoid serious di\ahilitv in half of the cases.
SCJBARACHNOID HAEMORRHAGE I). WIlNA1.1~4 and IS. IX SMUT (Tilburg).
AND NEUROPSYCHOLOGICAL
DISORDERS
Since 1978 14X patients with ruptured intracranial aneurysms have been treated with nlicrosurgcr~. (St. t‘lisabcth Hospital. Tilburg. The Netherlands). The mortality was 2q. the post-operative morbidity 6%. Recently wr started as ;I routine examination 3 months after operation a neuropsychological examination L,ombined with CT scannmg and EEG. Of62 patlent> who were examined. 13 had shown an aneurysm of the Internal carotid artery (2 I F). 30 of the anterior cerebral arterv (48%). I I of the middle cerebrai arten- (18%) and 8 of the vertebral-basilar artcr! ( 13’;). There were two kinds of psychological deficits: emotional and intellectual. In 55% of the examined patients there were emotional problems: though aspecific. they often formed a barrier in for example the resumption of work. The intellectual deficits consisted of disturbances m attention. memory, tempo. kpccch. ~irithnlctic and \patiaI orlentati~~n. The rcsuits were scored in: normal outcome. minor disturbances and global deterioration. It hccame evident. that there was an almost linear correlation between this outcome and the post - SAH prading according to Hunt and Hess. We alho found a good relation between a good outcome and location <)f the aneurvhm on the proximal arteries. Specific dvsfunction was more often found in patients with :meurysms. seated more deep& in the brain.
HYPERPHAGIA IN PATIENTS WITH A HYPOTHALAMIC U.M. WLLBERGEN-VLAM and C.W.G.M. FRENREN (Tilburg).
TUMOUR
In addition to its role in the regulation of the pituitary gland, the hypothalamus homeostatic~lly controls water balance and body temperature, and influences consciousness. sleep. emotion and behavior. ‘Two cases of patients( 6 4.9 32 year-old) with hyperphagia and obesity, due to a hypothalamic turnout, XC pre\ented. Lesions of the ventromedial nucleus (VMN) of the hypothalamus cause increased eating. while electric stirn~llati~~n stops feeding. Contrarily. lesions of the lateral hypothalamus (LH) lead to a decrease in food intake. which suppose a reciprocal interaction.
The VMN mcludes glucoreceptor elements capable of sensmg rising glucose level\. ‘these glucll\tat neuronsdetermine food drove and arc supposed to he responsable for short-term regulation offood tnr.tkc It is postulated that long-term c.tlortc balance i\ primarily medtated by a’lipostatic’ mechanicm, uhit.h IX still unknown. Lesions of the VMN producr hyperphagia and weight gam which later stabihrcs at a new elcvatcd setpoint. VMN-lesioned obese human beings are lecc active and eat only more when food is easilv to obtain. The regulation of food intake tncludes also elements responsive to btogenic ammes.‘l’hc VMN is specrtic inhibited by a-agonist activation. and the LH by R-agonist activation. This is illustrated h:, the mecham\m ofdrugs as amphetamtne and fentluraminc.
A CASE REPORT OF SAGITTAL (EVALUATION OF COMPUTED THERAPY) J.P.rt?R BRUGGEN (Tilhurg).
SINUS THROMBOSIS TOMOGRAPHIC FINDINGS
IN DIAGNOSIS
RELATED
TO
A case of aseptic superior sagittal sinus (s.s.~.) thrombosis believed to be associated with oral contraception, is presented. A 4l-year-old female was admitted to our clinic on August 16. 1982 because of progressive headache. She complained of severe headache. vomiting and vertigo since 2 days. At that time bilateral choked discs and hypertension .?05/ 1IO were found. CT scan on the first day after admission revealed an asymmetric ventricular system only. By lumbar puncture a pressure of 22 cm H,O. high protein (0.62 mg/I) and a bitirubin excess of0.40 umolll were found. Repeated CT scan at August 13. revealed the so called empty delta sign (Buannano 1978). No biochemical abn~~rmalitics were found, antithrombin III was normal so there was no generalised hyperc(~a~ulabilit~. The diagnosis S.S.S. thrombose was confirmed by angiography. On oral medication: depakine (4 x 300 mgr). dexamethasone (4 x 5 mgr). there was a good recovery. Because of the risk of progresston of micro-intracerebral haematomas by high venous pressure no anticoagulant therapy was given. According to Bernett and Hyland (1953) the s.s.s thrombosis 1s considered as essential haemorrhagic. Control CT scan. September I. was normal, Angiography showed a normal filling of the s.s.s.. with thromhosis of I vessel of the median cerebral artery. As soon as the diagnosis S.S.S.thrombosis IS suspected. we advise to do CT scan. with special attention to the cord and empty delta sign.
CARDIAL
ARHYTHMLAS iN GUILLAIN (Tilhurg).
BARRE
SYNDROME
P.c.I..A. LAMBREWS
From January 1972 to Deeember 1982 47 patients with Guillain Barre syndrome (GBS) were treated in the Sint Elisabeth Hospital Tilburg. The oecurence of cardiac arhythmia was examined in a retrospective study. IS Patients had weakness of the limbs only. 7 had also cranial nerve involvement. Artificial ventilation (AV) was necessary in 25 cases. Arhithmias in patients with known coronary artery disease and arhythmias in association with electrolyte and acid-base disorders were excluded. One out of 22 patients without respiratory failure and I8 out of 25 patients in the AV group showed paroxysmal arhythmias. Severe bradycardia was only seen in the latter group in 14 patients and an asystolic period occurred in three. Three patients underwent temporary demand-pacemaker insertion because of asystolia or severe bradycardia with atroventricular block. In all patients but one arhythmta only occurred at the end of progressive period of the disease and during the period at maximum impairment (l-6 weeks). Once improvement started, no arhythmias were seen, except in one case. Five patients died. three of them due to complications of artificiai ventilation (trachea haemorrhage. pneumothorax and sepsis). One patient with a history of coronary artery disease died of myocardial infection. One patient probably died ofcardiac arrest,