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417.Full.Pdf Postgrad Med J: first published as 10.1136/pgmj.38.441.417 on 1 July 1962. Downloaded from POSTGRAD. MED. J. (I962), 38, 4I7 THE SO-CALLED GENERAL SYMPTOMS OF INCREASED INTRACRANIAL PRESSURE Clinico-pathological Report Based on a Study of 100 Cases FATHY W. TADROS, PH.D., M.R.C.P.(Edin.), D.P.M. 0. H. SEROUR, M.CH. S. A. ZAKI, M.D., B.Sc. RASHAD SAKR, M.D., D.CH. From the Faculty of Medicine, Cairo University THERE has been much controversy regarding the in the cerebellum, brain stem and around the pathogenesis of the so-called general symptoms of aqueduct and 22 in the cerebrum; I2 cases were brain tumours. They are often ascribed to one or meningiomas, nine parasagittal, one in the lateral more factors which produce an increase in the sphenoid ridge, one suprasellar and one infra- intracranial pressure. It is generally accepted that tentorial in the pineal region. The rest comprised these factors are: firstly, the increase in the IO tuberculomas, eight cerebellar and two hemi- contents of the intracranial cavity produced by spherical; four pinealomas; two neurinomas; the size of the tumour and the surrounding cedema; two choroid carcinomas; one cranio-pharyngioma; secondly, the effect on the vascular system, one cholesteatoma; four hamangioblastoma cere- producing rise in the venous pressure; and, belli and two chronic abscesses, one cerebellar and thirdly, the effect on the flow of the cerebrospinal one temporal. fluid. In each case serial coronal sections of the braincopyright. The present work is devoted to the study of were made and the extent of the lesion verified. the general hydrocephalic symptoms in ioo con- The ventricles were examined with particular secutive cases of increased intracranial pressure. attention to their size and position. Paraffin An attempt at clarification of the controversies sections stained with H. and E. were prepared with regard to the pathogenesis of these symptoms, from the lesion, parts of the affected and contra- based on the pathological changes encountered in lateral hemispheres, including the basal ganglia these cases, is made. and diencephalon, and the brain stem. The optic http://pmj.bmj.com/ nerves and chiasma from six cases showing papill- Material and Methods cedema and six cases of post-papilkedemic optic The material presented comprises ioo con- atrophy were examined histologically, using H. secutive cases of increased intracranial pressure, and E. and Smith Queigley stains. 56 with infratentorial and 44 with supratentorial The clinico-pathological data relevant to our lesions. Of the 56 infratentorial cases, 32 were issue and discussions of the pathogenesis of the cerebellar tumours, one subarachnoid cyst between general symptoms of increased intracranial pres- the tentorium and superior surface of the cere- sure will be presented in two separate parts, the on September 26, 2021 by guest. Protected bellum, five pineal region tumours, five brain-stem first dealing with the factors responsible for the tumours, four cerebellopontine angle tumours, production of hydrocephalus in space-occupying five post-meningitic hydrocephalus, two choroid lesions, while the second deals with the patho- plexus tumours in the fourth ventricle and two genesis of the individual manifestations of the cases of gliosis of the aqueduct of Sylvius. Supra- so-called general symptoms of increased intra- tentorial lesions comprised nine parasagittal menin- cranial pressure. giomas, six thalamic tumours, five temporal, one occipital, four pariet-occipital, five frontal lobe Factors Responsible for Production of Hydro- tumours, four extensive tumours in one hemi- cephalus in Space-occupying Lesions sphere, two lateral ventricle tumours, two supra- Pathology sellar tumours, one case of corpus callosum At autopsy all the cases showed the presence of tumour, four cases of secondary metastatic nodules tonsillar herniation, indicating a downward shift irregularly dispersed in the cerebral hemispheres of the whole brain. Tumours in the supratentorial and one case of chronic subdural hematoma. space showed, in addition, displacement of the Fifty-one cases were gliomas, of which 29 were cerebral hemispheres to the contralateral side and Postgrad Med J: first published as 10.1136/pgmj.38.441.417 on 1 July 1962. Downloaded from 418 POSTGRADUATE MEDICAL JOURNAL Ju-ly I 962 uncal herniation that was more marked on the side In 23 cases lumbar puncture was performed and of the lesion. CSF pressure and chemistry were recorded. The All cases, whether the tumour was supra- or pressure was increased in io out of these 23 cases infratentorial, central or lateral, were associated (41'7%). At autopsy it was confirmed that those with internal hydrocephalus which was either com- cases with normal pressure of CSF had complete municating or partially so. Tumours arising in or obstruction to its flow with a non-communicating near ventricles, as those of the third ventricle and hydrocephalus. On the other hand, the lesion in suprasellar, pineal, cerebellar and cerebello- the cases showing rise of pressure was located in pontine angle tumours, produced obstruction to such situations as to cause only partial obstruction the flow of the CSF. In these cases the ventricular to the flow of CSF producing communicating system above the level of the obstruction was hydrocephalus (Table i). Somewhat conflicting re- dilated and central in position. Supratentorial sults are reported from examination of spinal fluid tumours away from the cavity of the third ventricle pressure, e.g. Ayer (1929) and Puusepp (1928) re- showed dilatation of the third and of the two ported normal fluids in only a few cases of their lateral ventricles only. The ventricular system was series, while Greenfield and Carmichael (I925) and shifted to the opposite side of the lesion. There Mandelboim (1930) found normal or even sub- was a kink at the upper end of the cerebral aque- normal pressures in the majority of their cases. duct near its opening in the third ventricle (Figs. i and 2). This part of the aqueduct was flattened Discussion from side to side with obliteration of the flow of Considering the pathological findings in the I00 CSF. This finding was noted irrespective of the cases of brain tumours presented in this report, site of the tumour in the hemisphere, whether we are ofthe following opinion: firstly, obstruction frontal, temporal or occipital, peripheral or central to the flow of the CSF is the main factor in the (Figs. 3, 4, 5 and 6). pathogenesis of increased intracranial pressure. Naked-eye examination of the brain stem This is produced either by the presence of the showed the presence of multiple hemorrhage tumour along the route of flow of the CSF, as irregularly dispersed in 23 cases (Figs. 7, 8 and 9). in the majority of infratentorial and intraventricularcopyright. In two of these cases there was hamorrhages in tumours, or by displacement of the brain, as in the diencephalon as well, on the same side of the supratentorial tumours. If we recall that the lesion (Fig. 6). Histological examination revealed cranial cavity is divided by the tough falx cerebri the presence of ischamic infarcts in 6i cases. and tentorium cerebelli into three compartments, The infarcts were of recent origin. Some showed two supratentorial and one infratentorial, the con- early necrosis, others presented complete break- tents of either of the supratentorial compartments down of tissue, while others still showed the are increased when a space-occupying lesion presence of compound granular corpuscles (Fig. reaches a certain size. Faced with the bony cal- http://pmj.bmj.com/ Io). varium and tough dural membranes, the swollen Himorrhages only were present in i2 cases, brain can only escape laterally under the falx to infarcts in 50 and both together in ii. Thus the contralateral side and downwards through the vascular changes in the brain stem were present tentorial opening. The lateral and downward shift in 73 cases. Out of these 73 cases, 32 were supra- of the brain would kink the junction of the third tentorial, i.e. 72.7% of supratentorial cases and 44 ventricle with the aqueduct. Obstruction at this infratentorial, of infratentorial cases. It i.e. 73.2% site with consequent internal hydrocephalus on September 26, 2021 by guest. Protected is evident from these percentages that vascular results. It is worthy of mention that hydro- changes in the brain stem occur with equal cephalus arising by the mechanism just described frequency in supra- and infratentorial cases. depends on the size rather than the site of tumour (Edema in the tumour and surrounding brain in the various lobes, or its being deeply seated or tissue was present in 26 cases: nine supratentorial, superficial in position. The attempt at correlation i.e. 20.5% of supratentorial cases, and i6 infra- between the site of the tumour and time of tentorial, i.e. 28.5% of infratentorial cases. appearance of hydrocephalic manifestations is thus Cerebral cedema associated with brain tumours rendered futile. The only factor determining the was therefore absent in a large number of cases in early or late appearance ofhydrocephalic symptoms our series. When present it was seen in the in relation to focal manifestations, in our opinion, tumour as well as in the rest of the affected is the presence of the tumour in a dominant lobe hemisphere. It is noteworthy that edema was or a silent area. present only in cases that were surgically treated. Secondly, we believe that the role of the in- The cases that were not interfered with surgically crease in contents of the intracranial cavity caused or subjected to lumbar puncture or ventriculo- by the size of the tumour and the surrounding graphy did not show cedema. cedema in the production of increased intracranial Postgrad Med J: first published as 10.1136/pgmj.38.441.417 on 1 July 1962.
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