Spontaneous intracranial hypotension (SIH) is a rarely reported syndrome of spontaneously occurring postural cephalalgia associated with low CSF pressure. We report a case of SIH in which MRI of the brain revealed diffuse symmetric pachymeningeal enhancement that resolved without specific therapy.

Summary: An 81‐year‐old woman with rotatory seizures and a right frontal lobe malignant brain tumor is described. This association has not been previously reported, to our knowledge. Evidence for a possible dopamine receptor‐mediated pathway of body rotation during rotatory seizures is discussed. RÉSUMÉ Les auteurs décrivent le cas D'une femme ágée de 81 ans qui a des crises rotatoires et une tumeur cérébrale maligne du lobe frontal droit. A leur con‐naissance cette association n'a jamais été rapportée auparavant. Ils discutent la possibilité de L';intervention D'une voie dopaminergique dans la rotation du corps au cours des crises rotatoires. RESUMEN Se describe a una enferma de 81 anos de edad con ataques rotatorios y tin tumor cerebral maligno localizado en el lóbulo frontal derecho. Que sepamos esta asociación no ha sido descrita previamente. Se discute la existencia de una posible via, mediada por receptores de dopamina, a través de la cual se pro‐ducirfa la rotación corporal durante los ataques rotatorios. ZUSAMMENFASSUNG Eine 81 jährige Frau mit rotatorischen Anfällen und einem malignen Hirntumor im rechten Frontallappen wird beschrieben. Dieses Zusammentreffen ist bisher nicht dargestellt worden. Es wird diskutiert, welche Hinweise daftir existieren, daß die Körperrotation während rotatorischer Anfälle die Frage einer Er‐regunsübertragung durch Dopaminrezeptoreinwirkung erlaubt.

The authors report two elderly men with diffuse meningeal enhancement 13 and 21 years following insertion of ventriculojugular shunts. Lumber puncture documenting low CSF pressures suggests that diffuse meningeal enhancement in patients with long-standing ventricular shunts may be secondary to dural venous dilatation rather than meningeal fibrosis. The authors theorize that these elderly patients, neither of whom had postural headache, may be less subject to brain "sag" because of decreased brain weight.

Kaiko and colleagues [l] are to be congratulated on their clinical investigation of the neuroexcitatory effects of meperidine in cancer patients. Unfortunately, the neurotoxicity associated with this drug is not well appreciated in the medical community, as is illustrated by the following cases of neurotoxicity in two patients with chronic renal failure who were on hemodialysis. To my knowledge, only a single renal failure patient with such neurotoxiciry has been previously reported [2].A 61-year-old man had a history of recurring grand ma1 seizures for one year despite therapeutic blood levels of phenytoin sodium and phenobarbital; he also experienced light-sensitive, movement-precipitated multifocal myoclonus for several years, which was refractory to 2 mg of clonazepam. This patient had become addicted to oral meperidine, initially prescribed because of pain associated with Pager's disease. It became apparent that seizures and myoclonus would occur when the patient increased his dosage of meperidine to fifty to sixty, and sometimes as many as one hundred, 100-mg tablets per week. Meperidine was withdrawn and the anticonvulsants were stopped. In the two subsequent years, neither seizures nor myoclonus have recurred.A 58-year-old woman with severe abdominal pain was also seen in 1981. The patient had received a total of 1,875 mg of rneperidine within one week prior to the occurrence of a single grand ma1 seizure, which had been preceded by an increasing frequency of myoclonic jerks over several days. The electroencephalogram, computed tomographic scan of the brain, and magnesium level were normal. Meperidine was discontinued. No further seizures occurred, even after phenytoin sodium was stopped. Myoclonus gradually disappeared over several days.In patients with chronic renal failure, Kaiko and colleagues [l] point up the possible dilemma of distinguishing between multifocal myoclonus and seizures that are secondary to uremia and those that result from meperidine administration. In these two patients with chronic renal failure, differential diagnosis was not difficult. The myoclonus of both patients was painful, induced by movement of the extremities, and also (in the first case) stimulus-sensitive to bright light directed at the eyes. In contrast, the myoclonus in uremics, while also multifocal, occurs spontaneously at rest and is usually painless. Furthermore, both patients with chronic renal failure were alert and oriented during myoclonic periods, unlike patients with myoclonus secondary to uremia, who are usually obtunded or stuporous, and unlike the eight cancer patients with rnyoclonus, whose mental status was described by Kaiko and colleagues as "agitated delirium" 111.Grand ma1 seizures in both of the patients with chronic renal failure could not be distinguished from uremic convulsions. The association of the seizures with the distinctive myoclonus described here should suggest the correct diagnosis.Caution should be exercised in giving meperidine at frequent intervals for several days, because of the...

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