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Removal of brain ammonia depends on the formation of glutamine, a reaction that is catalyzed by the ATP-dependent enzyme glutamine synthetase, which is localized in the astrocytes It has been shown in experimental animals that hyperammonemia leads to a depletion of ATP in midbrain reticular nuclei Whether this is the primary cause of coma has not been resolved Numerous alternative theories have been suggested, but most can be discounted or are unproved One is that CNS function in cirrhotic patients is impaired by phenols or short-chain fatty acids derived from the diet or from bacterial metabolism of carbohydrate Another theory holds that biogenic amines (eg, octopamine), which arise in the gut and bypass the liver, act as false neurotransmitters, displacing norepinephrine and dopamine (Fischer and Baldessarini).

convexity of the skull are usually asymptomatic, but those at the base may implicate the cranial nerve roots or the pituitary body Bony metastases are readily recognized on bone and CT scans and most are evident in plain lms Occasionally, a carcinoma metastasizes to the subdural surface and compresses the brain, like a subdural hematoma Others, perhaps most, are asymptomatic Apart from the above, most carcinomas reach the brain by hematogenous spread Almost one-third of them originate in the lung and half this number in the breast; melanoma is the third most frequent source in most series, and the gastrointestinal tract (particularly the colon and rectum) and kidney are the next most common Carcinomas of the gallbladder, liver, thyroid, testicle, uterus, ovary, pancreas, etc, account for the remainder Tumors originating in the prostate, esophagus, oropharynx, and skin (except for melanoma) almost never metastasize to the substance of the brain.

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gers while standing and walking In mild form it is best seen as the patient walks between obstacles or along a straight line, turns suddenly, or halts To correct the instability, the patient places his feet and legs wide apart, exes his body slightly, and repeatedly contracts the extensor muscles of his feet as he sways (la danse des tendons) In moving forward, the patient ings his stiffened leg abruptly, and the foot strikes the oor with a resounding thump in a manner quite unlike that seen in the ataxia of cerebellar disease The patient clatters along in this way with eyes glued to the oor If his vision is blocked, he is rendered helpless When the ataxia is severe, walking becomes impossible despite relatively normal strength of the leg muscles Trophic lesions, perforating ulcers of the feet, and Charcot joints are characteristic complications of the tabetic state.

From a somewhat different point of view, certain neoplasms are particularly prone to metastasize to the brain 75 percent of melanomas do so, 57 percent of testicular tumors, and 35 percent of bronchial carcinomas, of which 40 percent are small-cell tumors (Posner and Chernik) According to those authors, the cerebral metastasis is solitary in 47 percent of cases, a somewhat higher gure than that observed in our practice and reported by others (see Henson and Urich) The metastatic tumors most likely to be single come from kidney, breast, thyroid, and adenocarcinoma of the lung Small-cell carcinomas and melanomas tend to be multiple Generally the cerebral metastasis forms a circumscribed mass, usually solid but sometimes in the form of a ring (ie, cystic), that excites rather little glial reaction but much regional vasogenic edema.

Zieve has presented evidence that mercaptans (methanethiol, methionine), which are also generated in the gastrointestinal tract and removed by the liver, act in conjunction with.

The deformity of deafferented Charcot joints occurs in less than 10 percent of tabetics (the most common cause nowadays is diabetic neuropathy) Most often the hips, knees, and ankles are affected but occasionally also the lumbar spine or upper limbs The process generally begins as an osteoarthritis, which, with repeated injury to the insensitive joint, progresses to destruction of the articular surfaces Osseous architecture disintegrates, with fractures, dislocations, and subluxations, only some of which occasion discomfort The arthropathy has been observed to occur as frequently in the burned-out as in the active phase of tabes; hence it is only indirectly related to the syphilitic process Although the basic abnormality appears to be repeated injury to an anesthetic joint, the process need not be painless Presumably a deep and incomplete hypalgesia and loss of autonomic function are enough to interfere with protective mechanisms.

Often edema alone is evident on imaging studies until the administration of contrast exposes small tumor nodules (Fig 3110) Metastases from melanoma and chorioepithelioma are often hemorrhagic, but some from the lung, thyroid, and kidney exhibit this characteristic as well In a number of these cases, one-quarter in some series, the rst manifestation of the metastasis is an intratumoral hemorrhage The relative frequency of lung cancer makes.

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