Tenotomy of the psoas muscle in slow reduction of congenital hip dislocations

PURPOSE OF THE STUDY: The aim of this study was to relate the efficacy of cutting the psoas tendon in case of high congenital hip dislocation treated by slow reduction according to Somerville-Petit. MATERIAL: Twenty psoas tenotomies were realised between 1982 and 1992. The average age was 11 months 15 days old, they were 15 girls and 5 boys. Among them, only 9 patients had never been treated. METHOD: By a short surgical approach close to the lateral lip of Scarpa's triangle, we cut the psoas tendon at the musculotendinous junction doing this suppresses the obstacle that interferes with the femoral head coming down. RESULTS: Results have been evaluated on clinically and especially radiologically. All hips remain stable except one case. A graduated subluxation of the hip occured after removal of the plaster. 18 hips have been revised between the third and fifth year. Clinical results were excellent, on radiological controls 5 hips were considered flawless, 11 satisfying, and 2 were imperfect. Only 2 children have been seen ten years later with excellent clinical and radiological results. DISCUSSION: The hypertrophic psoas tendon interposes between the femoral head and the acetabulum creasing the capsule and the limbus. Cutting tendon of the psoas will decrease the numerous unexplained failures that occured during slow reduction according to Sommerville-Petit method. The use of these surgical techniques may make more outstanding the tenotomies time. CONCLUSION: Tenotomy of the psoas tendon realized by a short surgical approach without any articular effraction, allowed us to obtain complete reduction of the hips dislocation in these 20 patients.     

Infection by Toxoplasma gondii in children with infantile cerebral palsy

An analytic relationship between positivity of the indirect immunofluorescent test (IIFT) for toxoplasmosis and clinical findings in a population of 328 children with cerebral infantile palsy (CIP) was performed. Children were distributed by age in one of four groups: I (0-2 years); II (3-6 years); III (7-12 years) and IV (13-18 years). One control group of 168 children with no PCI clinical findings was included. 125 sera were positive at 1:64 dilutions. The study of the binomial mother-child of 40 cases rendered 26 mothers with significant titer values. The majority of positive mothers to IIFT correlated with the youngest children (Groups I, II and III), mainly with group I (70.0%), which showed the highest titer ranges. Correlation between positive IIFT and clinical features was as high as 100.0%.     

Muscular lengthening of the triceps by successive casts in children with cerebral palsy

ThinPrep processing, an automated cytopreparatory method, has been reported to show good correlation with conventional preparations and to reduce the rate of false-negative diagnoses. In a retrospective review of 230 consecutive nongynecologic cytology cases, we compare the ThinPrep (TP) method with conventional preparations (CP). There were 129 fine-needle aspiration (FNA) specimens from various sites, including 51 breasts, 40 thyroids, 14 lungs, 8 livers, and 16 miscellaneous sites. The sources of 101 body cavity fluids included 68 pleural/peritoneal effusions, 25 peritoneal/pelvic washings, and 8 miscellaneous sites. Each case was evaluated for cellularity, morphologic, details, and obscuring background material. Diagnoses of the TP slides were classified as insufficient, normal, benign, suspicious, or malignant. Each case was then correlated with the tissue diagnosis when available. In TP slides, cellular arrangements, nuclear details, and nuclear cytoplasmic ratio were preserved, while blood and diathesis were eliminated. There was no statistically significant difference between TP and CP in the diagnostic categories. However, in six cases of "insufficient for diagnosis" on FNA by CP, TP yielded sufficient cells and tissue fragments for diagnosis. One case each of FNA and body fluid with a diagnosis of "suspicious for malignancy" by CP was considered "positive" on TP slides. The overall sensitivity of TP was 97.6%, and the specificity was 92.9%. The positive predictive value was 93.0%. We conclude that the ThinPrep method shows good correlation with conventional preparations in both FNA and body fluids.     

Strabismus in children with cerebral palsy

In 48 children with cerebral palsy the characteristics of the squint and amblyopia were analyzed, also with respect to the features of cerebral palsy and to birth weight. Strabismus of congenital esotropia type was found to be common, as was also exotropia of early onset. Spontaneous alternation or an accommodative component of the squint was present only in a few cases. There was no evidence of an accumulation of any strabismus type in the different subgroups of cerebral palsy, whereas amblyopia or an obvious risk for amblyopia was found in the great majority of the cases. Some kind of amblyopia treatment was given to 34. Most of them showed improvement of the visual capacity which encourages treatment of amblyopia, even in children with cerebral palsy.     

Axonal injury caused by focal cerebral ischemia in the rat

The susceptibility of axons to blunt head injury is well established. However, axonal injury following cerebral ischemia has attracted less attention than damage in gray matter. We have employed immunocytochemical methods to assess the vulnerability of axons to cerebral ischemia in vivo. Immunocytochemistry was performed using antibodies to a synaptosomal-associated protein of 25 kDa (SNAP25), which is transported by fast anterograde transport; the 68-kDa neurofilament subunit (NF68kD); and microtubule-associated protein 5 (MAP5) on sections from rats subjected to 30 min and 1, 2, and 4 h of ischemia induced by permanent middle cerebral artery (MCA) occlusion. After 4 h of occlusion, there was increased SNAP25 immunoreactivity, which was bulbous in appearance, reminiscent of the axonal swellings that occur following blunt head injury. Increased SNAP25 immunoreactivity was present in circumscribed zones in the subcortical white matter and in the axonal tracts at the border of infarction, a pattern similar to that previously described for amyloid precursor protein. Although less marked, similar changes in immunoreactivity in axons were evident following 2 h of ischemia. MAP5 and NF68kD had striking changes in immunoreactivity in axonal tracts permeating the caudate nucleus within the MCA territory at 4 h. The appearance was roughened and disorganized compared with the smooth regular staining in axons within the nonischemic areas. Profiles reminiscent of axonal bulbs were evident in MAP5-stained sections. The changes seen with NF68kD and MAP5 were also evident at 2 h but were more subtle at 1 h. There were no changes in axonal immunoreactivity with SNAP25 or NF68kD at 30 min after MCA occlusion. Altered immunoreactivity following ischemia using SNAP25, MAP5, and NF68kD provides further evidence for the progressive breakdown of the axonal cytoskeleton following an ischemic insult. NF68kD and MAP5 appear to be sensitive markers of the structural disruption of the cytoskeleton, which precedes the subsequent accumulation of SNAP25 within the damaged axons. Axonal cytoskeletal breakdown and disruption of fast axonal transport, which are well-recognized features of traumatic brain injury, are also sequalae of an ischemic insult.     

Nutrition in children with cerebral palsy

The previously reported earlier onset of pituitary tumours in cross-bred mice inheriting a mutant Rb-1 allele paternally has been ascribed to imprinting of an Rb-1-linked gene. Here, we demonstrate that, as predicted from this mechanism, there is no effect of the parent of origin of the mutation in inbred mice.     

Clinico-radiological dissociation in cerebral hemorrhage caused by afibrinogenemia

INTRODUCTION: Congenital afibrinogenemia is a very rare hereditary anomaly of coagulation. Only 150 cases have been published. Clinical manifestation in the form of some type of bleeding is similar to that of other congenital coagulopathies, although the pattern of presentation is different. Spontaneous bleeding is rare, but slight injury, which may be unnoticed, may trigger it off. In spite of being a congenital condition, it may be of late onset, as in our patient, with bleeding episodes occurring in the second decade of life. CLINICAL CASE: We describe a woman who had several episodes of bleeding, two of which were intracerebral. The principal feature of this was dissociation between the clinical findings and their detection by neuro-imaging. Substitutive therapy led to the disappearance of symptoms. CONCLUSION: Cerebral haemorrhage in the presence of afibrinogenemia may fail to be detected early on CT. On clinical suspicion of bleeding, early substitutive treatment should be started.     

Common gait abnormalities of the knee in cerebral palsy

Gait abnormalities in children with cerebral palsy are the consequence of contractures across joints, muscle spasticity, and phasically inappropriate muscle action. Though abnormalities involving one of the major joints of the lower extremity will usually have consequences on the function of the other joints, it is possible to recognize certain primary disorders at each joint. The most common gait abnormalities of the knee in patients with cerebral palsy occur in the sagittal plane. Based on the experience gained from performing gait analysis on more than 588 patients with cerebral palsy, four primary gait abnormalities of the knee have been identified: jump knee, crouch knee, stiff knee, and recurvatum knee. In this review, each abnormality is described by its motion analysis laboratory profile (physical examination, motion parameters, electromyography [EMG] data, and force plate data). The most common etiologies and the consequences for gait of each disorder are also considered. Appreciation of the most common pathologic patterns of gait should facilitate accurate and detailed analysis of the individual patient with gait abnormalities.     

Fatal cerebral mycoses caused by the ascomycete Chaetomium strumarium

Three cases of fatal cerebral mycosis in males with prior histories of intravenous drug use from the United States and Australia are reported. Infection in each case was limited to brain abscess; no other sites of infection were observed. The fungus seen by histopathology and isolated from the brain tissue in each case was identified as Chaetomium strumarium. This is the first report of human infection by this species, and C. strumarium is the second species of Chaetomium known to cause primary brain infection. Chaetomium strumarium is unusual among members of the genus Chaetomium in forming ascocarps covered with pale, thin-walled, flexuous hairs, a feature leading to its original placement in the genus Achaetomium. Presence of pinkish exudate droplets and/or crystals associated with hyphae or ascocarps, sometimes accompanied by a pinkish diffusible pigment; good growth at 42 degrees C; and production of small conidia further distinguish this species. The brain abscess isolates were compared with isolates from prior cases of cerebral infection which had been identified as either Chaetomium atrobrunneum or Chaetomium globosum. With reidentification of one isolate originally identified as C. globosum to C. atrobrunneum, only C. strumarium and C. atrobrunneum have been confirmed to cause infection involving the brain.     

Juvenile cerebral ischaemia caused by designer drugs

HISTORY AND CLINICAL FINDINGS: A 29-year-old man reported two episodes, 3 months apart, of dysarthria, each lasting for several hours. It was associated with hypaesthesia over the cheeks. Neurological examination several hours later was unremarkable. On direct questioning the patient reported that he had been taking marihuana and cocaine immediately before each episode. There was also a history of regular abuse of various drugs over several years by this socially well integrated young man. INVESTIGATIONS: Cranial computed tomography, cranial magnetic resonance imaging and cerebral scintigraphy indicated multiple cortical and subcortical ischaemic lesions of different sizes and ages. ECG, long-term ECG monitoring, transoesophageal echocardiography and upper abdominal sonography were normal. Cerebrospinal fluid revealed a slightly abnormal blood-brain barrier (5.3 g/l protein, albumin ratio of 7.3). Auto-antibody titres and coagulation and serological tests for neurotropic bacteria and viruses were normal. Urinary drug screening was positive for cannabinoids. DIAGNOSIS, TREATMENT AND COURSE: We assume that the patient had transitory cocaine-induced ischaemic attacks (TIA) and clinically silent cerebrovascular accidents (CVA). He was discharged without specific treatment after being informed of the severe neurological sequelae of his drug abuse. CONCLUSIONS: The rising abuse of "designer drugs" is of increasing diagnostic significance in TIA-like symptoms and CVAs in young adults, which may be of haemorrhagic or ischaemic aetiology. Thromboembolic, vasospastic or vasculitic factors play a pathogenetic role. Early performance of appropriate blood and urine tests is of great diagnostic importance.     

Association of cerebral palsy with epilepsy

Fifty patients of various types of cerebral palsy were studied to find out an association between cerebral palsy, EEG abnormalities and development quotient. Seventy-six per cent patients had spastic cerebral palsy. Hypotonic cerebral palsy was the next common type (14%). Athetosis and ataxic forms were found to be rare (2% each). Epilepsy was associated with 56% patients. Clinical types of seizures observed were: Generalised tonic-clonic (43%), myoclonic (17.9%), generalised tonic (10.7%), partial simple (10.7%) and partial complex (17.9%). The incidence of seizures was highest in hypotonic type in which 85.7% had epilepsy. Mean developmental quotient of cerebral palsy patients was 34.9% with maximum retardation in hypotonic cerebral palsy (25.14%). Sixty per cent of patients had abnormal EEG, out of these hypotonic patients had maximum (70%) chances of EEG abnormality followed by spastic patients (55%). Developmental retardation was more severe statistically in the patients with abnormal EEG than normal EEG.     

Iliopsoas transfer in cerebral palsy: the long-term outcome

Thirty-three patients with cerebral palsy had iliopsoas transfers as part of their surgery for hip instability. All had total-body involvement, spastic cerebral palsy and none could walk. At the time of surgery, eight hips were subluxated and 39 were dislocated or severely subluxated. Mean follow-up was 8 years in patients between 8-25 years old. Forty-five of the 47 hips were located. Thirty patients had an accompanying scoliosis, and, in 10 patients, the rib cage impinged on the pelvis. Hip flexion had decreased in most patients. Sitting ability had not improved in any patient, and had in fact deteriorated in 50%.     

Transposition of the tendon of pronator teres in cerebral palsy

We have considered the indications for and results of transplanting pronator teres to extensor carpi radialis brevis in cerebral palsy. The operation has some virtue but a very limited application. We achieved satisfactory functional results in six of nine patients and some improvement in one. Two operations failed because of poor selection. In all patients the appearance of the limb was improved.