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Following a brief presentation of the clinical picture of major depression, attention is directed to different forms of missed diagnosis. The clinical picture of major depression is characterized by marked uniformity and includes 2 highly typical disturbances: pronounced diurnal fluctuations and early or very early awakening. Other central features include a feeling of hopelessness, the disappearance of all prospects for the future, and feelings of guilt sometimes assuming absurd proportions. In addition, there are many other accompanying manifestations. Yet, despite this, it is not easy to recognize depression, particularly since the patient's gloomy and dejected mood often occupies the background of the picture. Cross-cultural psychiatric studies reveal that in non-Western cultures expression often mainfests itself in the form of a wide variety of somatic complaints, including pain. The term "masked depression" has come into common use to describe what are cases where, in the presence of predominantly physical signs and symptoms, an underlying depressive state goes unrecognized. This applies particularly to syndromes of which headache and pains in the chest, abdomen, and limbs are prominent features. It is unclear as to what extent somatic manifestations of depression are on the increase in the Western world. Yet, clearly, many patients deny that they suffer from depression and cling firmly to their physical complaints. Although depression may lurk behind a series of poorly defined physical complaints, essential characteristics of genuine depression emerge upon further diagnostic exploration. Secondary accompaiments to depression include periodic abuse of alcohol or medicines and disturbances affecting sexual behavior. In the elderly, the differential diagnosis of dementia and depression may give rise to confusion. Anxiety emerges as a frequent accompanying manifestation in depressive patients, yet all anxious patients do not suffer with depression. Additionally, many manifestations of anxiety and depression closely resemble one another, adding to the confusion. There is limited awareness of phobic and compulsive phenomena as manifestations of depression. These phenomena may disappear in response to treatment for the depression and are by no means always related to a premorbid compulsive personality structure. The issue of the application of the term "depression" to conditions that most likely are not depressive are considered from the standpoints of endocrinopathy and of pharmacology. The problem posed by depressive syndromes occurring in oral contraceptive (OC) users is more complex. When the progesterone content is high in relation to the estrogen component, the patient may sometimes suffer from loss of libido and loss of pleasure in sex or life in general. These changes respond favorably to a change in the type of OC.
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PMID:Depression--a diagnosis sometimes missed and sometimes mistaken. 357 25

In a study of 60 elderly patients in a general hospital referred for psychiatric assessment, the commonest psychiatric disorders were depressive illness (41.6%) and dementia (35.0%). Patients with depression (mean age 69.5 years) were a younger age group compared with dementia (mean age 75.8 years)--this difference is statistically significant (p less than 0.01). Seven patients with depression were admitted for attempted suicide and 5 were referred because of headache and chest discomfort. The main reasons for referral of patients with dementia were disturbed and confused behaviour. The other psychiatric disorders in the sample were delirium (6.7%), paraphrenia (6.7%), alcohol dependence syndrome (5.0%) and anxiety neurosis (5.0%).
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PMID:Psychiatric referrals of elderly patients in a general hospital. 359 77

Dementias which are either reversible or avoidable are discussed in the light of the literature. The frequency is between 6 and 32%. The most important etiological groups are immunological vasculopathies, hyperlipidemia, some types of encephalitis and, mainly, progressive dementia of the insane, benign tumors and in particular meningioma, low pressure hydrocephalus, intoxications due to drugs, industrial products and alcohol, metabolic disturbances, encephalopathy in dialysed patients, ileo-jejunal-bypass encephalopathy and encephalopathy due to neoplasms. Dementias are also seen in endocrinological disturbances and particularly in hypothyroidism. Vitamin B12 and folate deficiency, as well as epilepsy, may be causes of dementia. Depression may mimic a state of dementia. Some features of reversible dementias are listed, including in particular the somewhat more rapid onset, the younger age of patients, and accompanying neurological symptoms such as headache, gait disturbances, ataxia, polyneuropathy, myoclonus or epileptic fits.
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PMID:[Reversible and preventable dementias]. 361 87

Four cases of cerebral cysticercosis are reported, occurring in an immigrant population. Two patients presented with periodic epileptic fits and cerebral calcifications. One patient presented with an acute hemiparesis associated with lymphocytic meningitis and cerebral calcifications; the fourth patient had chronic meningitis with epileptic fits. Three patients were treated with praziquantel: an acute reaction occurred during treatment in two cases with an increase in the titres of the immunological reaction of hydatid cyst disease in one case. The authors suggest classifying this condition in three types: acute (parenchymatous or subarachnoid), chronic (chronic meningitis, hydrocephalus, progressive dementia), and sequelae (epilepsy with or without headaches). This classification seems the most appropriate way of summarizing the variable clinical presentation of this condition which is rarely observed in France. The most valuable diagnostic investigation is CT brain scanning. Immunological reaction to hydatid cyst (CSF and blood) are sometimes negative. Treatment with praziquantel often causes an acute reaction with a rise in antibody titres; this is a clinically benign reaction, and it could be used as a diagnostic test.
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PMID:[Cerebral cysticercosis: 4 cases]. 363 31

Three cases of intraspinal tumors associated with hydrocephalus were encountered and treated. This review includes 67 cases, including these 3 cases, and discusses the pitfalls associated with intraspinal tumors presenting with hydrocephalus. These tumors are not easily diagnosed, especially in cases where the chief complaint, due to hydrocephalus, is headache or dementia, and does not include back pain. Among the 67 cases reviewed, symptoms suggesting normal pressure hydrocephalus were particularly noticed in patients over 40 years old. In cases presenting with headaches or dementia, back pain corresponding to the tumor location may appear after a shunt operation or external ventricular drainage. This postoperative back pain is important in indicating the presence of an intraspinal tumor.
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PMID:Intraspinal tumors associated with hydrocephalus. 369 9

Posterior inferior cerebellar artery (PICA) aneurysms constitute approximately 3-6% of all intracranial aneurysms. Especially, aneurysms which originate from distal portion of PICA are very rare. We experienced 4 cases of distal PICA aneurysm, 3 cases of which were giant sized. The clinical and radiological features of cases of a giant aneurysm of distal PICA are analyzed in this study. They consisted of 2 male and 1 female, ranging in age from 37 to 66. They had suffered from headache, disturbances of cranial nerves, cerebellar disorders and dementia, caused by subarachnoid hemorrhage and mass effects of aneurysms. Aneurysmal cavity without organization was shown as a large hyperdensity area in enhanced CT scans, but organized cavity was not enhanced. Angiograms showed that two giant aneurysms in our cases originated from the cranial loop of PICA. Vascular abnormalities such as the vertebral artery terminating as PICA in one case and multiple aneurysms in another case were also seen. As for the treatment, in two cases proximal ligation resulting no neurological deficit was performed. In another case, because of complete organization of the aneurysmal cavity and adhesion between the aneurysm and the brain stem, extirpation of the aneurysm could not be done. In one patient who had symptomes of cerebellar disturbance, removal of the thrombus resulted in good recovery.
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PMID:[Three cases of giant aneurysm of the distal posterior inferior cerebellar artery]. 370 33

In proportion to a rapid increase of dialysis patient, death caused by neurological complications is increasing annually among long-term hemodialyzed patients. A case of chronic subdural hematoma during long-term hemodialysis is presented. A 35-year-old male had undergone hemodialysis three times weekly for four years. He had marked changes in body-weight and blood pressure between hemodialysis. In March 1983, he had a headache, vomiting, and left hemiparesis. The CT scan showed a right subdural hematoma. He was admitted to our hospital 10 days later because of progressive hemiparesis and speech disturbance. The neurological examination showed left hemiparesis with sensory deficit and dysarthria. The CT scan showed an increase in the size of the subdural hematoma. Bleeding time was over 10 minutes. A right-sided burr hole was made and altered blood was removed and irrigated. After operation, headache and weakness rapidly subsided, but the next morning, attacks of convulsion occurred. The CT scan showed the rebleeding in the subdural space. After correcting the level of serum potassium by hemodialysis, a right parietal craniotomy was performed. Hematoma of about 100 g was removed and the capsule of the hematoma showed organized tissue histologically. Postoperatively, although attacks of convulsion occurred temporarily, he gradually improved. The levels of serum potassium and BUN were controlled by several treatments of hemodialysis. He was discharged with only mild hemiparesis. Subdural hematoma caused by hemodialysis is a very important complication. Chronic subdural hematoma is sometimes very difficult to differentiate from dysequilibrium syndrome or dialysis dementia. The CT scan is a very valuable examination to rule out subdural hematoma.
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PMID:[A case of chronic subdural hematoma in a hemodialyzed patient]. 372 77

The incidence, site and clinical aspects of cerebral arteriovenous malformation (AVM) are examined with particular reference to symptoms like epilepsy and headache that enter into the differential diagnosis between this and other pathologies of the central nervous system. The clinical presentation of the AVM beside includes dementia-type syndromes and subarachnoid haemorrhage.
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PMID:[Clinical aspects of cerebral arteriovenous malformations]. 372 41

A case of Paget's disease in an elderly female who had a favourable evolution following ventriculoperitoneal (V-P) shunt is reported. On May 28, 1983, a 52-year-old female was transferred and admitted to us from the Dept. of Neurology because of headache in the occipital region and ataxic gait. On admission, neurological examinations revealed remarkably increased tendon reflexes, ataxic gait, and mild dementia. Headache was also observed, but urinary incontinence was not present. Skull X-ray showed "cotton wool appearance", which was characteristic of Paget's disease. On chemical analysis of blood and urine, serum Al-P and urinary OH-proline level were elevated, which established a diagnosis of Paget's disease. Triventricular dilatation was found on CT scan, and neck tomography showed basilar impression. After admission, the patient was treated with calcitonin, but it was interrupted because of side effects such as nausea and vomiting. Then she gradually took a turn for the worse, particularly dementia became severer. On July 25, 1983, V-P shunt was performed. After operation, "soft landing maneuver" was employed, namely the intraventricular pressure was checked and was gradually lowered with external CSF drainage system for 7 days. Thereafter the patient's head was elevated gradually from supine to sitting position through 7 days. Her hospital course after operation was that of gradual improvement. The purpose of this maneuver was to prevent sudden change of intraventricular pressure that causes aggravation of basilar impression and sudden respiratory arrest.
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PMID:[Hydrocephalus in Paget's disease--a case report]. 374 85

We analyzed 26 cases of primary lymphoma of the central nervous system. There were 14 males and 12 females ranging in age from 5-76 years (median age 51 years, mean age 50.2 years). None had received organ transplantation or immunosuppressive therapy. The most common presenting symptoms were headache, mental changes, nausea, vomiting, and convulsions. The main neurological findings were hemiparesis, papilledema, visual field defects, and cranial nerve palsies. The most common finding in the cerebrospinal fluid (CSF) was high protein content; CSF cytology was positive in only one case. Computerized tomography was done in 14 cases; all showed a contrast-enhancing lesion. Angiography generally revealed an avascular mass. The most common location above tentorium was the frontal lobe; in four cases the tumor was infratentorial (cerebellum, 3 cases). In five cases there was diffuse involvement of the brain; all had severe dementia and diagnosis was not made until the autopsy. Histologically, the most common type was diffuse histiocytic or immunoblastic lymphoma according to Rappaport and the Working Formulation classification respectively. Radiation therapy alone in five patients gave a median survival of 17 months. Five patients received radiation and chemotherapy, and median survival was 16 months. Two patients developed ocular lymphoma 8 and 36 months later that was treated by radiation.
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PMID:Primary lymphoma of the central nervous system: a clinicopathologic analysis of 26 cases. 376 91


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