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remaining cells showed the Alzheimer neuro brillary change; Lewy bodies were not observed, however The neuro brillary changes were scattered diffusely through the cerebral cortex and brainstem but were most prominent in the mediotemporal gray matter Noteworthy was the absence of discrete senile plaques in this material; however, all cases showed extensive immunoreactive deposits of -amyloid ( diffuse plaques ) In three boxers who developed a parkinsonian syndrome, Davie and colleagues found a reduction of N-acetylaspartate in the putamen and pallidum by protein magnetic resonance spectroscopy This probably re ected a loss of neurons in these regions and was said by these authors to differentiate it from idiopathic Parkinson disease The pathogenesis of the punch-drunk state remains unclear Posttraumatic Hydrocephalus This is an uncommon complication of severe head injury Intermittent headaches, vomiting, confusion, and drowsiness are the initial manifestations Later on, mental dullness, apathy, and psychomotor retardation are seen; by this time the CSF pressure may have fallen to a normal level (normalpressure hydrocephalus) Postmortem examinations have demonstrated an adhesive basilar arachnoiditis Since a similar syndrome is observed occasionally after the rupture of a saccular aneurysm with subarachnoid hemorrhage, the same mechanisms, ie, blocking of the aqueduct and fourth ventricle by blood clot and basilar meningeal brosis, may also be operative in traumatic hydrocephalus Response to ventriculoperitoneal shunt may be dramatic Zander and Foroglou have had extensive experience with this condition and have written informatively about it

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Posttraumatic Nervous Instability (Postconcussion Syndrome)

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This troublesome and frequent sequela of head injury has been mentioned above as well as in the chapter on headache (page 158) When the syndrome is protracted, neurologists are vexed by the condition a problem intensi ed by worried patients and family It has also been called the posttraumatic or postconcussion syndrome, posttraumatic headache, traumatic neurasthenia (Symonds), and traumatic psychasthenia, among many other names Headache is the central symptom, either generalized or localized to the part that had been struck The headache is variously described as aching, throbbing, pounding, stabbing, pressing, or band-like and is remarkable for its variability The intensi cation of the headache and other symptoms by mental and physical effort, straining, stooping, and emotional excitement has been mentioned earlier; rest and quiet tend to relieve it Such headaches may present a major obstacle to convalescence Dizziness, another prominent symptom, is usually not a true vertigo but a giddiness or lightheadedness The patient may feel unsteady, dazed, weak, or faint However, a certain number of patients describe symptoms that are consonant with labyrinthine disorder They report that objects in the environment move momentarily, and that looking upward or to the side may cause a sense of unbalance; labyrinthine tests may show hyporeactivity; far more often they disclose no abnormalities McHugh found a high incidence of minor abnormalities by electronystagmography both in concussed patients and in those suffering from whiplash injuries of the neck; but we nd some of the data dif cult to interpret Exceptionally, vertigo is accompanied by diminished excitability of both the labyrinth and the cochlea (deafness), and one may assume the existence of direct injury to the eighth nerve or end organ

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