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The special features of congenital hydrocephalus associated with the Chiari malformation, aqueductal atresia and stenosis, and the Dandy-Walker syndrome are discussed in Chap 38 Occult Tension Hydrocephalus Here the hydrocephalus becomes evident only after the cranial sutures have closed (Fig 302) The causes of obstruction to the ow of CSF are diverse, and although some are clearly congenital, symptoms may be delayed as late as adolescence or early adult life or even later In some instances the condition gives rise to a normal-pressure hydrocephalus, as discussed below and in Chap 7 The clinical features of occult hydrocephalus and the course of the illness are quite variable Some instances of arrested hydrocephalus are truly occult in that the disease is unrecognized during life or is discovered only by chance imaging of the brain or on postmortem examination In other cases, the symptoms are intermittent and relatively mild; in still others, they are slowly or rapidly progressive, in the latter instance giving the clinical impression of a subacute disease The patient may complain of bifrontal or bioccipital headaches, but often these are not present Other symptoms and signs are predominantly those of a frontal lobe disorder of mentation or of gait Slowness of mental response (abulia), inattentiveness, distractibility, perseveration, and inability to plan activity or to sustain any type of complex cognitive function are characteristic The immediate responses to verbal and other stimuli are normal, though memory may be slightly impaired Conspicuous by their absence are apraxia, agnosia, or aphasia Gait deteriorates early in the course of hydrocephalus; such deterioration may be present for years before other symptoms become manifest The features of gait deterioration are hard to characterize, but the main aspects are discussed below, under Normal-Pressure Hydrocephalus We have seen a few cases in adults in which the gait disturbance appeared abruptly.

One of the primary conventions that helps you separate C# code from SQL commands is the convention of writing SQL commands in all caps, just like a constant For example, the following code segment from C# distinguishes the C# from the SQL:

(T, d, 15 )

Figure 30-2 MRI of adult tension hydrocephalus from a congenital stenosis of the cerebral aqueduct There is transependymal movement of water that appears as a T2 signal rimming the lateral ventricles The third ventricle, but not the fourth, was enlarged

sqlCmd = new SqlCommand("SELECT LastName, Donation FROM Supporters", hookUp);

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Looking at that line of code, you can see the following language breakdown:

As the nomenclature implies, the f ('r)andt valuesin most interpolationcontextsarethe dependentand independent variables,respectively a consequence, valuesof the As the r's are typically unilbrmly spaced simple exampleis a table of valuesderivedfor the A tunction(r): l/x: f

enough to give the impression of a cerebellar stroke A suck re ex and grasp re exes of the hands and feet are variably present; plantar re exes are sometimes extensor Last, there may be sphincteric incontinence, often without the patient s awareness Occult hydrocephalus due to tumor growth is discussed in Chap 31 Clinical Picture of Acute Hydrocephalus Surprisingly little has been written about this syndrome despite its frequency in clinical practice It is seen most often following subarachnoid hemorrhage from a ruptured aneurysm, less often with bleeding from an arteriovenous malformation or from deep hemispheral hemorrhage that dissects into the ventricles; it may also occur as the result of obstruction of the CSF pathways in the fourth ventricle by a tumor or cerebellar-brainstem hemorrhage or within the basal cisterns by neoplastic in ltration of the meninges, although this last process tends to evolve more subacutely The patient complains of a headache of varying severity and often of visual obscuration, may vomit, and then becomes drowsy or stuporous over a period of minutes or hours Bilateral Babinski signs are the rule, and in the advanced stages, which are associated with coma, there is increased tone in the lower limbs and extensor posturing Early in the process, the pupils are normal in size and the eyes may rove horizontally; as the ventricles continue to enlarge, the pupils become miotic, the eyes then cease roving and assume an orthotopic position, or there may be bilateral abducens palsies and limitation of upward gaze The speed with which hydrocephalus develops determines whether there is accompanying papilledema If this condition is left untreated, the pupils eventually dilate symmetrically, the eyes no longer respond to oculocephalic maneuvers, and the limbs become accid Rarely, there is an unanticipated cardiac arrest, even at an early stage of evolution of the hydrocephalus; this complication is seen particularly in children and may be presaged by brain compression at the level of the perimesencephalic cisterns, detectable by imaging studies Treatment is by drainage of CSF, usually effected by a ventricular catheter or, if there is undoubted communication between all the CSF compartments, by lumbar puncture The latter may pose some risk if spinal uid is withdrawn rapidly, thereby creating a pressure gradient between the cerebral and spinal regions Neuropathologic Effects of Tension Hydrocephalus Ventricular expansion tends to be maximal in the frontal horns, explaining the hydrocephalic impairment of frontal lobe functions and of basal ganglionic frontal motor activity in all forms of hydrocephalus The central white matter yields to pressure, while the cortical gray matter, thalami, basal ganglia, and brainstem structures remain relatively unaffected There is an increase in the content of interstitial uid in the tissue adjacent to the lateral ventricles, readily detected by magnetic resonance imaging (MRI) (Fig 30-2) Myelinated bers and axons are injured, but not to the extent that one might expect from the degree of compression; minor degrees of astrocytic gliosis and loss of oligodendrocytes in the affected tissue are present to a decreasing extent away from the ventricles and represent a hydrocephalic atrophy of the brain The ventricles are characteristically denuded of ependyma and the choroid plexuses are attened and brotic The lumens of cerebral capillaries in biopsy preparations are said to be narrowed a nding that is dif cult to evaluate.

sqlCmd = new SqlCommand(); This is a C# statement "SELECT LastName, Donation FROM Supporters" Terms in all caps are SQL keywords; others are labels for either fields or the name of the table hookUp This is a C# SqlConnection instance name

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Figure 11-1 shows the precise breakdown you re likely to see in a SQL query The SQL keywords can easily be distinguished from the C# code because the SQL keywords are written in all caps The other clue that code is SQL is if it is set as a string literal The C# SqlCommand object s constructor accepts two parameters The first is a string with all of the SQL commands, and a second parameter specifies the SqlConnection instance