 of the ascending inhibitory system, the consciousness disorders and its modular aspect, a group of fifteen patients has been subjected to evaluation or surgery within National Institute of Neurology and Neurovascular Diseases in Bucharest. Thirteen of them have been diagnosed, respectively, with brain tumor, one patient with limbic encephalitis, and another one with brain cysticercosis. Patients’ average age was 41.5 years, the youngest being 21 and the oldest 73.
Ten (66.6%) of the patients were male. In 14 patients, the main examination was computed tomography (CT) and magnetic resonance imaging (MRI).
In the following, we will present the clinical symptomatology of every patient.
Case 1. A 21-year-old man presented himself with a sudden onset coma. MRI-scan revealed a bilateral ponto-mesencephalic hemorrhage triggered by a cavernoma. After total resection of the cavernoma and hematoma, patient’s status has improved significantly, presenting only a remaining minimal right side weakness and hemisensory deficit. Now the patient is a student, and his state is excellent.
Case 2. A 38-year-old woman was admitted with a history of logorrhea syndrome, with hyperkinesia, hyperwakefulness and hyperprosexia. The patient could sleep for only a short time, and then awake and was unable to fall back asleep. MRI-scan revealed a left petroclival meningioma which significantly compresses the superior part of the brainstem.
The postoperative evolution was very good. She remained for five weeks with mild hypoesthesia on the left face but logorrhea syndrome with hyperkinesia disappeared.
Case 3. A 36-year-old man presented with intermittent increased intracranial pressure, paralysis of the conjugate upward gaze (Parinaud’s sign), pseudo-Argyll-Robertson pupil and arousal disorders. A contrast-enhanced CT-scan revealed a tumor of the pineal area. Only 15% of the patients with tumors of the pineal area, which are compressing the dorsal part of the mesencephalon, also experienced arousal disorders. Postoperative, the patient remained clinically intact and arousal disorders disappeared.
Case 4. A 27-year-old man was admitted in the department of neurosurgery with headache, memory impairment, endocrinopathy (gonadal insufficiency, loss of libido and reduced masculine hair growth) and bitemporal hemianopsia. Neurobehavioral abnormalities manifested with intermittent hypersomnia, apathy, depression, and flatting of affect. Preoperative MRI demonstrates a large supraselar, paraselar and intraselar mass with a few calcifications (craniopharingiomas). Symptoms reflect the tumor’s close proximity to hypothalamic region, pituitary gland, optic apparatus, third ventricle and intracranial vessels.
The hypothalamus and its surrounding structures are especially important for the ascending activatory and inhibitory system and for the anatomy, physiology and pathology of the consciousness. Upward grown into the region of the hypothalamus, this tumor affected overall endocrine control.
After radical subfrontal resection, the patient remained in an excellent state and returned to full activity.
Case 5. A 29-year-old woman presented with left hemiparesis by compression of the adjacent internal capsule, palsies of vertical and lateral gaze, absence of convergence, retraction nystagmus, and mild sensory deficit in the opposite side of the body, including the trunk. Pain and thermal sensation were more affected than touch, vibration and position.
Involvement of ventral posterolateral and posteromedial nuclei of the thalamus causes loss or diminution of all forms of sensation on the opposite side of the body. Contrast medium-enhanced coronal and axial MRI shows a big right thalamic tumor.
The tumor was fully resected and thirty-five days after surgery was started radiation therapy using a 10 MeV linear accelerator. The clinical examination performed thirteen month after surgery, demonstrated a good health condition of the patient. However she remained with a mild sensory deficit and a hemiparesis, but she returned to an independent life.
Case 6. A 27-year-old woman complained of headaches which progressed to double vision, nausea and vomiting. At the neurologic examination, the presence of a slight Parinaud’s syndrome was discovered.
Contrast-enhanced Tl-weighted magnetic resonance images show a well-demarcated and homogeneously enhanced pineal body tumor. After its surgical resection, the final histological diagnose was of pineocytoma. Immunohistochemistry for neurofilament (68 kDa) showed numerous positive cell processes.
Immunohistochemistry of GFAP showed strong positivity in interstitial cells. Post-surgical evolution was excellent.
Case 7. A 56-year-old man presented with a sudden onset of coma and fever. Coronal and axial Tl-weighted MRI scans revealed edematous, demyelination symmetrical infra- and supratentorial changes which involved the entire midbrain, both thalamic formations, bilateral basal ganglia, two-side temporo-occipital convolution and hippocampus; these were determined by encephalitis (limbic encephalitis). After 9 days of coma the patient died.
Case 8. A 56-year-old man, with a history of severe headaches, presented with taste and smell disorder, excessive euphoria accompanied by peculiar kind of compulsive, shallow and childish humor (moria), irritability, hypomania and puerilism.
The patient also shown disorders of attention and motility, distractibility, hyperreactivity, hyperkinesia, perseveration, emotional lability, cognitive dysfunction that impede the initiation and temporal organization of actions, and lack of initiative, wrong decision and instinctual disinhibition (sociopathy).
Contrast-enhanced computed tomography (CT) scan shows a giant size olfactory groove meningioma and displacement of anterior brain. Post-surgery, after complete resection of the tumor, the orbitofrontal syndrome disappeared almost completely.
Case 9. A 35-year-old woman was admitted to the department of neurosurgery with a bilateral meningioma of the anterior falx which compressed dorsolateral premotor and prefrontal cortex (Brodmann’s areas 6, 8, 9, 10, and 46).
As symptoms, she had attention disorder directed to a particular item of sensorium or inner experience, and the capacity to suppress from inner experience items that can interfere with what is currently on focus. She was apathetic, disinterested in herself and in the world around her. Visuospatial neglect along with gaze abnormalities were also present because the lesion encroaches on area 8.
According to our experience, the apathy is present in all lateral-damage conditions, and is mostly apparent after large bilateral lesions of the frontal convexity.
Perseveration, dysexecutive syndrome with attention, working-memory and planning disorders were among the symptoms. Language disorders were directly linked to failure of temporal integration.
In this patient, depression was secondary to cognitive disorder. Postoperative, the frontal syndrome disappeared.
Case 10. A 42-year-old man presented with a 2-year history of subtle but progressive sensory aphasia, the inability to designate or name the different fingers of the two hands, and the inability to calculate and write (an incomplete Gerstmann’s syndrome). The patient also showed constructional apraxia, alexia and misdirected and dissymmetric movement of the opposite limbs. MRI prior to surgery showed a left side parietal cystic astrocytoma. After extirpation of the tumor, all symptoms disappeared.
Case 11. A 39-year-old man was admitted with progressive left hemiparesis, tactile inattention, constructional apraxia, dressing apraxia, dysprosody, and anosodiaphoria. Preoperative CT-scan showed a tumor in the right parietal region.
Post-surgery, the patient improved his motor strength and was discharged after 3 weeks in a very good state, while the CT-scan demonstrates the complete removal of the tumor (fibrillary astrocytoma).
Case 12. A 46-year-old man was admitted with olfactory hallucination (“uncinate fits”) often accompanied by a dreamy state of mind, auditory elementary hallucination when the patient heard the sound of running water, impaired recognition of melodies in the absence of words, and the usual tendency for the patient to report the current date as an earlier one. Coronal Tl-weighted, gadolinium-enhanced MRI prior to surgery showed a large right-sided temporobasal tumor (astrocytoma).
After complete removal of the tumor, the patient remained in a very good state. The patient improved very much and was discharged after 2 weeks.
Case 13. A 42-year-old woman was admitted to the department of neurosurgery with a failure to precisely grasp or touch an object under visual guidance (optic ataxia). This optic ataxia was detected when she tried to reach for an object. Patients with such unilateral lesions typically demonstrate greater impairment when reaching for items located in the hemispace, that is contralateral to the lesion, using the contralateral hand. Another symptom was visual inattention (simultanagnosia) which affected mainly the periphery of the visual field. Simultanagnosia was considered to be a disruption in spatial attention, which was associated with the inability to direct one’s attention to more than one or to a few objects at the time.
The presence of simultanagnosia was tested by asking the patient to carry out tasks such as looking at a series of objects, and connecting a series of dots by a line or to examine and describe the events depicted in a complex visual image. Once he focused on one object in his visual field, the patient ignored or neglected all the other objects.
Therefore, optic apraxia and visual inattention have been described within a single visual