Trans-radial cerebral angiography for stereotactic radiosurgery treatment of arteriovenous malformations.

OBJECTIVES: The popularity of trans-radial access (TRA) for cerebral angiography is growing. Potential benefits of TRA over traditional trans-femoral access (TFA) are multitude. This study aimed to evaluate discharge outcomes and patient opinion of TRA compared to TFA in patients undergoing cerebral angiography prior to stereotactic radiosurgery (SRS) treatment for cerebral arteriovenous malformations. METHODS: Consecutive patients treated at the National Centre for Stereotactic Radiosurgery (Sheffield, United Kingdom) over a 22-month period were included. All patients underwent cerebral angiography with either TRA or TFA as part of treatment planning prior to SRS. TRA patients who had previously undergone TFA in other centres were surveyed for their experience of cerebral angiography using a questionnaire. SRS staff at our centre was approached for their opinion. RESULTS: 492 patients were included (median age = 43 years, 57.5% male, median lesions treated = 1). More patients underwent angiography with TFA (75.2%) than TRA (24.8%). No difference was found in accumulated dose for angiography between the groups (p>0.05). There was 17.6% reduction in overnight stay between TRA and TRF, the proportion of patients requiring overnight admission was higher for the TFA (35.2%) than TRA (17.6%, p<0.05). 101 patients were surveyed, with a response rate of 47%. Most respondents (79%) indicated preference for TRA over TFA. CONCLUSIONS: Use of TRA in pre-SRS cerebral angiography is feasible and improves both patient and staff experience. The adoption of TRA could have important implications for department resources and costs by reducing the proportion of overnight admissions.

Spontaneous subarachnoid hemorrhage and negative initial vascular imaging--should further investigation depend upon the pattern of hemorrhage on the presenting CT?

BACKGROUND: Multiple investigations are usually performed in patients with spontaneous SAH who have negative initial angiography. This study aimed to evaluate the most appropriate use of additional imaging studies and how this may be influenced by the findings of the initial CT. METHODS: A retrospective analysis was performed on a prospectively collected cohort of patients referred with spontaneous SAH and negative initial angiography. The patients were divided into four categories based upon the distribution of blood on the initial CT: perimesencephalic (pSAH), diffuse (dSAH), sulcal (sSAH) and CT negative (CSF positive for xanthochromia) (nCT-pLP). The number and nature of the subsequent imaging investigations were reviewed, and the results were correlated with the findings of the presenting CT. RESULTS: One hundred fourteen patients were included in the study. Repeat imaging found five relevant abnormalities. Three cases of vasculitis were diagnosed on the first DSA following a negative CTA. A case of dissecting aneurysm was revealed on the third neurovascular study. A hemorrhagic spinal tumor presented with xanthochromia. No subsequent abnormality was found on the third DSA or MRI head. No case of pSAH had a subsequent positive finding if the initial CTA was negative. CONCLUSIONS: Certain patterns of SAH are associated with a low yield of abnormalities on repeat imaging if the initial angiography is normal. The authors believe that the pattern of hemorrhage on the presenting CT should be used to guide the most appropriate use of further imaging modalities and present a diagnostic algorithm for this purpose.

Multisensory determinants of orientation perception: task-specific sex differences.

Females have been reported to be more 'visually dependent' than males. When aligning a rod in a tilted frame to vertical, females are more influenced by the frame than are males, who align the rod closer to gravity. Do females rely more on visual information at the cost of other sensory information? We compared the subjective visual vertical and the perceptual upright in 29 females and 24 males. The orientation of visual cues presented on a shrouded laptop screen and of the observer's posture were varied. When upright, females' subjective visual vertical was more influenced by visual cues and their responses were more variable than were males'. However, there were no differences between the sexes in the perceptual upright task. Individual variance in subjective visual vertical judgments and in the perceptual upright predicted the level of visual dependence across both sexes. When lying right-side down, there were no reliable differences between the sexes in either measure. We conclude that heightened 'visual dependence' in females does not generalize to all aspects of spatial processing but is probably attributable to task-specific differences in the mechanisms of sensory processing in the brains of females and males. The higher variability and lower accuracy in females for some spatial tasks is not due to their having qualitatively worse access to information concerning either the gravity axis or corporeal representation: it is only when gravity and the long body axis align that females have a performance disadvantage.

Where's the Floor?

Visual and balance cues concerning the relative orientation of ourselves and our environment combine to direct our steps to select a secure footing. How are visual cues used to select the best support surface? Here we show that, when exposed to tilted, rectangular rooms of various aspect ratios, subjects do not necessarily choose the surface with its normal oriented closest to the gravity-defined vertical. Rather their decision is also strongly biased by the visual area subtended by each candidate surface.

Multisensory determinants of orientation perception in Parkinson's disease.

Perception of the relative orientation of the self and objects in the environment requires integration of visual and vestibular sensory information, and an internal representation of the body's orientation. Parkinson's disease (PD) patients are more visually dependent than controls, implicating the basal ganglia in using visual orientation cues. We examined the relative roles of visual and non-visual cues to orientation in PD using two different measures: the subjective visual vertical (SVV) and the perceptual upright (PU). We tested twelve PD patients (nine both on- and off-medication), and thirteen age-matched controls. Visual, vestibular and body cues were manipulated using a polarized visual room presented in various orientations while observers were upright or lying right-side-down. Relative to age-matched controls, patients with PD showed more influence of visual cues for the SVV but were more influenced by the direction of gravity for the PU. Increased SVV visual dependence corresponded with equal decreases of the contributions of body sense and gravity. Increased PU gravitational dependence corresponded mainly with a decreased contribution of body sense. Curiously however, both of these effects were significant only when patients were medicated. Increased SVV visual dependence was highest for PD patients with left-side initial motor symptoms. PD patients when on and off medication were more variable than controls when making judgments. Our results suggest that (i) PD patients are not more visually dependent in general, rather increased visual dependence is task specific and varies with initial onset side, (ii) PD patients may rely more on vestibular information for some perceptual tasks which is reflected in relying less on the internal representation of the body, and (iii) these effects are only present when PD patients are taking dopaminergic medication.

Precautions to be taken by radiologists and radiographers when prescribing hyoscine-N-butylbromide.

Hyoscine-N-butylbromide (Buscopan, Boehringer Ingelheim) is a widely used antispasmodic in radiological practice. There seems to be no consensus as to best practice within radiology regarding the precautions that need to be taken when prescribing Buscopan. We have performed a thorough review of the available literature and make the following recommendations to those administering Buscopan: (1) enquire whether there is an allergic history; (2) ensure patient literature warns that "in the rare event that following the examination you develop painful, blurred vision in one or both eyes, you must attend hospital immediately for assessment"; (3) warn patients to expect blurred vision and not to drive until this has worn off; (4) remind clinicians that special consideration needs to be given as to the method of investigating patients with cardiac instability, such as those recently admitted with acute coronary syndrome, recurrent cardiac pain at rest, uncontrolled left ventricular failure and recent ventricular arrhythmias.

The relative role of visual and non-visual cues in determining the perceived direction of "up": experiments in parabolic flight.

In order to measure the perceived direction of "up", subjects judged the three-dimensional shape of disks shaded to be compatible with illumination from particular directions. By finding which shaded disk appeared most convex, we were able to infer the perceived direction of illumination. This provides an indirect measure of the subject's perception of the direction of "up". The different cues contributing to this percept were separated by varying the orientation of the subject and the orientation of the visual background relative to gravity. We also measured the effect of decreasing or increasing gravity by making these shape judgements throughout all the phases of parabolic flight (0 g, 2 g and 1 g during level flight). The perceived up direction was modeled by a simple vector sum of "up" defined by vision, the body and gravity. In this model, the weighting of the visual cue became negligible under microgravity and hypergravity conditions.

Relative role of visual and non-visual cues in determining the direction of "up": experiments in the York tilted room facility.

Perceiving a direction as "up" is fundamental to human performance and perception. Astronauts in microgravity frequently experience reorientation illusions in which they, or their world, appear to flip and 'up' becomes arbitrarily redefined. This paper assesses the relative importance of visual cues in determining the perceived up direction. In the absence of information about the origin of illumination, people interpret surface structure by assuming that the direction of illumination is from above. Here we exploit this phenomenon to measure the influence of head and body orientation, gravity and visual cues on the perceived up direction. Fifteen subjects judged the shape of shaded circles presented in various orientations. The circles were shaded in such a way that when the shading was compatible with light coming from above, the circle appeared as a convex hemisphere. Therefore, by finding which shaded circle appeared most convex, we can deduce the direction regarded as "up". The different cues contributing to this percept were separated by varying both the orientation of the subject and the surrounding room relative to gravity. The relative significance of each cue may be of use in spacecraft interior design to help reduce the incidence of visual reorientation illusions.