Rupture of a large ophthalmic segment saccular aneurysm associated with closed head injury: case report.

OBJECTIVE AND IMPORTANCE: Although each year approximately 30,000 to 50,000 cases of subarachnoid hemorrhage in the United States are caused by the rupture of intracranial saccular aneurysms, there is little information in the literature documenting the association of aneurysmal rupture with closed head injury. CLINICAL PRESENTATION: A 61-year-old woman presented after a motor vehicle accident with multiple injuries, including a severe closed head injury. Computed tomography revealed a diffuse basal subarachnoid hemorrhage. Angiography revealed the source as a large aneurysm arising from the ophthalmic segment of the left carotid artery. INTERVENTION: After the patient was stabilized for her multiple injuries, she underwent craniotomy and clipping of the aneurysm. She recovered without developing new neurological deficits. CONCLUSION: Although the association of head trauma and aneurysmal subarachnoid hemorrhage is rare, the presence of significant basal subarachnoid blood on a computed tomographic scan should alert the physician to the possibility of a ruptured aneurysm.

Type IV spinal arteriovenous malformation in association with familial pulmonary vascular malformations: case report.

OBJECTIVE AND IMPORTANCE: Type IVc arteriovenous malformations (AVMs) of the spinal cord consist of multiple high-flow feeding vessels, and they often present a challenging management situation. Their location is intradural and extramedullary, and they are rare malformations that are difficult to treat owing to the risk of thrombosis of the anterior spinal artery. The authors report a case of Type IVc spinal AVM in a patient with a family history of three siblings with pulmonary AVMs. Spinal AVMs have been reported to be associated with inherited syndromes such as familial cutaneous hemangiomas and Kartagener's syndrome, but an association with pulmonary AVMs has not previously been described. CLINICAL PRESENTATION: A 27-year-old man presented with sudden onset of occipital headache with cervical radiation while weightlifting. Results of computed tomography of the brain were normal, but lumbar puncture revealed a subarachnoid hemorrhage. The patient had a 1-year history of a neurogenic bladder and exhibited marked left calf muscle wasting. INTERVENTION: The patient underwent spinal magnetic resonance imaging, which revealed the AVM in the conus region. Selective spinal angiography was performed for diagnostic purposes. A laminectomy was performed, and the vessels feeding the AVM were clipped, as was the fistula. CONCLUSION: The patient remained neurologically stable, and angiography confirmed obliteration of the AVM. This is the first case report of a patient with a spinal AVM who had multiple siblings with pulmonary malformations or AVMs.

Neurovascular complications of cocaine.

Use of cocaine in the USA, has reached epidemic proportions since 1983, when "crack" was introduced, its higher potency compared with cocaine HCl has been associated with a tremendous increase in the incidence of strokes. This study reports our experience with 55 cases of neurovascular events (25 ischemic and 30 hemorrhagic) related to cocaine use in 54 patients. Only 15 patients had other risk factors for stroke. Twenty six patients smoked "crack", 10 snorted cocaine and 12 injected it intravenously. Strokes occurred within 3 h of cocaine use in 15 patients with infarcts and 17 with hemorrhages. Ten infarcts occurred after an overnight binge. Of the hemorrhage group 9 were subarachnoid, 16 intracerebral (8 basal ganglia, 7 hemispheric and one brain stem) and 5 intraventricular. Computerized tomography (CT) showed an aneurysm of the anterior communicating artery, as well as one of the vein of Galen. Four aneurysms and 3 AVMs were identified on angiography. CT revealed 15 infarcts; it was normal in 7 patients with pure motor hemiparesis and in 3 with findings consistent with anterior spinal artery infarction. Several mechanisms may be responsible for the cerebrovascular complications. A sudden rise in systemic arterial pressure may cause hemorrhages, frequently in association with an underlying aneurysm or AVM. Vasospasm, arteritis, myocardial infarction with cardiac arrhythmias and increased platelet aggregation may provoke infarcts.

MR Imaging of the cervical cord in juvenile amyotrophy of distal upper extremity.

We report the MR studies of the cervical cord in seven patients presenting juvenile muscular atrophy of distal upper extremity. This illness, also known as monomelic amyotrophy or benign focal amyotrophy, is distinct from the other motor neuron diseases. Seen in young males, it is characterized by muscular atrophy of the hand, and usually of the forearm, most often unilateral. The underlying process, of unknown origin, affects the anterior horn cells in the lower cervical cord. The gradual onset of purely motor disturbances may mimic early amyotrophic lateral sclerosis. This latter diagnosis may be excluded because of clinical stabilization and lack of pyramidal tract involvement. In our series, five MR studies were positive. In three cases we were able to demonstrate focal and unilateral atrophy in the lower cervical cord limited to the anterior horn region. Morphologic MR findings correlated with clinical and electromyographic features. In two other cases the MR-clinical correlation was more complex. No pathologic MR signal was detected on either T1- or T2-weighted images. Although the diagnosis of monomelic muscular atrophy is based on neurologic and neurophysiologic data, MR provides confirmatory evidence as well as useful information contributing to an understanding of this disease.

CT features of primary cerebral lymphoma in AIDS and non-AIDS patients.

Computed tomographic study of six cases with primary cerebral non-Hodgkin lymphoma are reviewed. Three had a history of intravenous drug abuse and were diagnosed as having acquired immunodeficiency syndrome (AIDS). All cases presented with space occupying lesions in the frontal lobe with the exception of Case 4. Computed tomography demonstrated multiple lesions in AIDS cases whereas non-AIDS lesions were invariably single. The AIDS patients died within 1 year despite radiotherapy as compared with the non-AIDS patients.

Epidural spinal infection in intravenous drug abusers.

The incidence of spinal epidural abscess and disk space infection appears to be rising in intravenous drug-using patients. We report 18 cases seen over three years in two municipal hospitals. Staphylococcus aureus was the most common infective agent, but two patients had Mycobacterium tuberculosis infection. Computed tomography of the spine facilitates diagnosis. Early treatment improves outcome but host factors play a role in recovery.

Third ventricular primary cerebral neuroblastoma. Electron-microscopic and immunohistochemical study.

A case of third ventricular primary cerebral neuroblastoma with secondary hydrocephalus is reported. Light microscopy showed a cell pattern that resembled either ependymoma or oligodendroglioma. The tumor was confirmed to be neuroblastoma by electron microscopy and immunohistochemistry. Immunoperoxidase staining was positive for neuron-specific enolase and negative for glial fibrillary acidic protein.

Cocaine-related intracranial hemorrhage. Report of nine cases and review.

Nine cases of intracranial hemorrhages related to cocaine usage are presented. Another 5 cases from the literature are reviewed. The relationship between severe cocaine-induced hypertension, and the development of subarachnoid or intracerebral hemorrhages is noted, and apparently is related to sudden transient increases of blood pressure related to cocaine use.

Treatment of a recurrent traumatic carotid-cavernous fistula: vertebro-basilar approach after surgical occlusion of the internal carotid artery.

A case of a post-traumatic carotid-cavernous fistula treated by endovascular approach through the vertebrobasilar system is reported. The 16 year old female patient was hurt in a car accident. The instantly-occurring carotid-cavernous fistula was treated with a Fogarty catheter, the internal carotid artery being occluded during this procedure. Ten years later the fistula recurred with a predominantly cortical venous drainage. The fistula was closed with two detachable balloons by an endovascular approach from the vertebrobasilar system via the posterior communicating artery. The small residual fistula, fed by the external artery was occluded by a venous approach via the internal jugular.

Traumatic intraspinal pneumocele.

Traumatic intraspinal pneumocele (TIP) is a radiologic finding in which air is visualized within the spinal canal on routine cervical spine x-rays following a head injury. TIP may be the initial radiologic evidence of a severe central nervous system injury. The presence of TIP will alert a physician to the severity of the head injury, as well as the need for further radiologic investigations.

Acute intervertebral gas following vertebral fracture: CT demonstration.

The occurrence of intervertebral gas secondary to the vacuum phenomenon has been previously described and is thought to be pathognomonic of degenerative disk disease. The case reported here illustrates that the intervertebral vacuum phenomenon may occur following trauma, suggesting that it is not exclusive to degenerative disk disease.

Dural arteriovenous malformation of the major venous sinuses: an acquired lesion.

Arteriovenous malformations of the dura are thought to be congenital. However, arteriographic investigations of four patients who, after a head injury, developed dural arteriovenous fistulae with features of congenital malformations suggest that these abnormal communications may also be acquired. Thrombosis or thrombophlebitis in the dural sinus or vein may be the primary event in their formation. The pathogenesis is probably "growth" of the dural arteries normally present in the walls of the sinuses during the organization of an intraluminal thrombus. This may result in a direct communication between artery and vein or sinus, establishing an abnormal shunt. Ultimate fibrosis of the sinus wall and intraluminal thrombus may be the factors responsible for the spontaneous disappearance of such malformations.

Pitfalls in the diagnosis of erosive changes in expanding lesions of the pituitary fossa.

Tomographic findings were reviewed in 47 cases of transsphenoidal hypophysectomy for expanding intrasellar mass. Changes caused by factors other than the presence of a mass were classified into five groups. These were: (a) patterns of aeration of the sphenoid sinus, (b) sites of attachment of the sphenoid sinus septum, (c) thickening of the mucous membrane of the sphenoid sinus, (d) extensive thinning of the sellar cortex, and (e) sloping floors. These were the most common sites for causes of error in interpreting expanding lesions. An increased awareness of these pitfalls should decrease interpretive error.