CTA in patients with acute subarachnoid haemorrhage. A comparative study with selective, digital angiography and blinded, independent review.

PURPOSE: Minimal- or non-invasive methods replacing intra-arterial digital subtraction angiography (IA-DSA) would be of great importance in patients suffering from acute subarachnoid haemorrhage (SAH). The aims of this study were to compare CTA with IA-DSA in patients with acute SAH, to compare CTA interpretations with those of blinded, independent reviewers and to evaluate improvement in CTA diagnostics after 1 year of experience with CTA. MATERIAL AND METHOD: During 2 years 162 patients with SAH underwent CTA as well as IA-DSA. Independent blinded review of 77 patients was performed for 1 year. RESULTS: Totally 144 aneurysms were demonstrated in 119 patients at IA-DSA, while 43 patients had normal intracranial arteries. Initially 131 aneurysms were detected at CTA while 2 normal, tortuous arteries were misinterpreted as aneurysms, giving a sensitivity of 91% and a specificity of 95%. At independent blinded review the observer agreement was 87% and the kappa value 0.68. CONCLUSION: CTA in SAH is of great value in demonstrating vascular anatomy and the exact size of an aneurysm. However, IA-DSA is still needed for diagnostic evaluation in aneurysms smaller than 5 mm in diameter, especially in those located near bony structures.

[Leakage of cerebrospinal fluid. Diagnosis and treatment]. / Lekkasje av cerebrospinalvaeske. Diagnostikk og behandling.

Leakage of cerebrospinal fluid may occur after fracture of the skull base or after surgery on the skull base, nose, or paranasal sinuses. Further causes of cerebrospinal fluid leakage are tumours and malformations. It may also occur spontaneously. We describe four case reports illustrating diagnostic and surgical problems. Cerebrospinal fluid oto- and rhinorrhoea should be suspected in cases of recurring purulent meningitis. Immunologic demonstration of beta(2)-transferrin in secretions from the nose and ear is a diagnostic sign of cerebrospinal fluid or perilymph. Digital subtraction cisternography, CT cisternography, and flow-sensitive magnetic resonance imaging are sensitive methods for localising dural leakage. Frontal craniotomy has been the traditional surgical approach. The recent involvement of transnasal endoscopic sinus surgery and microsurgery has made it possible to treat cerebrospinal fluid oto- and rhinorrhoea with a high degree of success and less operative morbidity.

[Minor head injuries. May early CT-scanning replace in-hospital observation?]. / Lette hodeskader. Kan tidling CT-undersøkelse erstatte observasjon i sykehus?

A one-year prospective study was undertaken to judge whether in-hospital observation after minor head injury could be partly replaced by early computerized tomography (CT), and if such a practice would save hospital resources. All 146 patients had a Glasgow Coma Score (GCS) > or = 14 and no neurological deficits. 128 had suffered loss of consciousness. CT of 97 (67%) patients revealed intracranial lesions in eight (contusions six, oedema one and epidural haematoma in one). Mean duration of hospitalization was 9.4 days in patients with intracranial lesions and 1.6 days in patients without such lesions. We observed no complications to the head injury in patients with normal CT. There is no need for hospitalization after minor head injury in patients with GCS > or = 14 with no neurological deficits and normal CT. We advocated wide use of early CT in cases of minor head injury, to allow early detection of intracranial haematomas, diagnoses of brain contusions and avoidance of unnecessary hospitalization.

Modified Robinson-Smith procedure for the treatment of cervical radiculopathy.

In the present study, a modified Robinson-Smith procedure was used surgery for cervical radiculopathy in 52 patients. Thirty-one one-level and 21 two-level operations were performed. All patients were followed up between 1 and 3 years (mean 23 months) after surgery with a clinical evaluation by an independent investigator including a radiological examination. In 26 patients the postoperative result was classified as excellent, in 23 the result was good, in 2 satisfactory, while one patient was unchanged compared to the preoperative examination. No patient developed worsening of symptoms after surgery. Of 18 patients with duration of symptoms of more than 4 years, 16 demonstrated markedly improvement. No permanent postoperative complications were seen. A modified Robinson-Smith procedure appears to be safe and reliable and can be recommended in surgery for cervical radiculopathy.

Large peripheral cystic schwannomas. Two case reports and a review.

Two patients presented with benign cystic schwannomas, which originated from the brachial plexus and the sciatic nerve, respectively. The tumours were single, egg-shaped growths that were excised completely without damage to the nerve. Histopathological examination confirmed the diagnosis of encapsulated, cystic, benign schwannomas. Preoperative magnetic resonance imaging provided useful information and is recommended in the evaluation of peripheral nerve tumours.

Hypothalamic hamartoma causing precocious puberty treated by surgery: case report.

A 6-year-old girl was treated for precocious puberty secondary to a hypothalamic hamartoma by resection of the tumor. When she was six months old, her parents noticed incipient pubic hair and menses accompanied by breast development. Computed tomography was judged as normal. The girl was treated with monthly gonadotropin-releasing hormone analogue injections until 6 years of age, when magnetic resonance imaging (MRI) demonstrated a pedunculated isodense mass below the tuber cinereum. The hamartoma was totally removed using microsurgery. The symptoms and signs of precocious puberty disappeared after surgery. Follow-up MRI 1 year later showed no remaining tumor.

Acute orbit from ethmoiditis drained by endoscopic sinus surgery.

Orbital complications from sinusitis are briefly reviewed. Acute orbit is suggested as the common term for all stages in the development. Four patients with acute orbit and ethmoiditis are presented. All had transnasal ethmoidectomy and drainage of the orbit performed by functional endoscopic sinus surgery (FES). Surgical indications are discussed based on clinical signs and CT examination. The operation can easily be staged according to the needs of the individual patient, starting with drainage of the primary cause, the sinusitis. Orbital skin incisions are avoided. Postoperative regression of clinical symptoms has been rapid.

[Sphenoidal sinus mucocele. Diagnosis and endoscopic surgery]. / Mucocele i sinus sphenoidalis. Diagnostikk og endoskopisk kirurgi.

Two cases of sphenoid sinus mucocele are described. Diagnosis was based on insidious orbital symptoms, apex orbital syndrome, followed by CT and MRI examinations. In one case the mucocele was preceded by seven years of a successfully treated undifferentiated nasopharyngeal carcinoma. Simple transnasal endoscopic drainage of the mucoceles gave good results, although a monocular blindness of long standing was irreversible. A high level of suspicion, combined with modern imaging techniques and prompt surgical intervention, are the prerequisites for avoiding persisting sequelae.

[Neurofibromatosis and development of cancer in childhood]. / Neurofibromatose og kreftutvikling i barnealderen.

Neurofibromatosis takes two major forms; classical or peripheral neurofibromatosis as described by von Recklinghausen, which accounts for more than 90% of the cases, and central or bilateral acoustic neurofibromatosis. The diagnosis is often postponed until adulthood, since the classical signs gradually appear during childhood and adolescence. It is a relatively common autosomal dominant disorder affecting about one in 3,000. At least 20% of patients will develop one or more complications associated with neurofibromatosis. One of the complications is the development of malignancies. Four children at our hospital developed different forms of malignant tumours arising from neurofibromatosis. We recommend that all patients suffering from this disease are evaluated in detail after the diagnosis has been confirmed and are followed up every six to 12 months. In this way complications may be discovered early and the necessary steps taken.

[Experiences with ambulatory radiculography]. / Erfaringer med poliklinisk radikulografi.

54 outpatients who were referred with the clinical diagnosis lumbar disk herniation, underwent lumbar myelography with iohexol. After the examination the patient returned to the ward where he was observed for about 2 hours while resting in a chair. He was then allowed to leave the hospital with the recommendation to avoid hard physical exercise for the next 24 hours. No serious complications occurred. Severe headache was reported by 20% of the patients and 22% experienced transient minor discomfort. It is concluded that lumbar iohexol myelography can be performed safely on ambulatory patients.

Screening for retrocochlear pathology.

In 1982, 135 patients were screened for possible retrocochlear pathology, by means of an investigation protocol consisting of caloric test, impedance audiometry and brainstem response audiometry (BRA). A combination of the first two of these procedures had an unacceptably low prognostic accuracy. BRA indicated retrocochlear pathology in 8 and was inconclusive in 4 cases. Enhanced computer tomography revealed an intracranial tumour in 4 of the former, while no space-occupying lesion could be demonstrated in the remainder nor in the 4 patients with inconclusive BRA. BRA is the best single test for screening of this patient category.

A comparison between middle and inferior meatal antrostomy in the treatment of chronic maxillary sinus infection.

Intranasal antrostomy has been performed in a series of 38 adult patients with either bilateral chronic or recurrent acute maxillary sinusitis which had failed to respond to medical treatment. In each patient, the antrostomy opening was made in the middle meatus of one side and in the inferior meatus of the opposite nasal cavity, laterality being randomised. A points' system was employed for comparing the pre- and post-operative symptoms, clinical and roentgenological findings. Symptoms and clinical findings were significantly improved following both types of antrostomy, while the roentgenological findings were essentially unchanged. Comparison of middle and inferior meatal antrostomies revealed no significant difference.

Complications in cerebral angiography. A comparison between the non-ionic contrast medium iohexol and meglumine metrizoate (Isopaque Cerebral).

Cerebral angiography was performed in 100 patients in order to study the frequency of adverse effects and complications with a new non-ionic contrast medium, iohexol, compared with an ionic medium, meglumine metrizoate. The study was performed as a double blind clinical trial. Iohexol was better tolerated than meglumine metrizoate, since more patients experienced the injections as painful and unpleasant with metrizoate than with iohexol. However, the subjective adverse effects were minor with both contrast media. There was no statistically significant difference in the frequency of more serious side effects. Transient hemiparesis was seen in two patients who prior to the angiography had suffered from numerous similar attacks per day and in one patient in whom a nearly occluded internal carotid artery was occluded during the examination. These complications occurred in the iohexol group, but are more likely to be due to thromboembolism than to contrast medium toxicity.

Metrizamide cisternography of the cerebello-pontine angle by lateral C1-C2 puncture.

Cisternography of the cerebello-pontine angle was performed with metrizamide using pluridirectional motion tomography on the Polytome. Lateral puncture between C1-C2 with a low pressure technique was used with the patient in lateral decubitus position. In a series of 20 patients all examinations were conclusive and small acoustic neuromas were seen in three patients. The investigation is easy to perform and sufficient contrast-medium-filling of the cerebello-pontine cistern and the internal auditory canal was obtained with 2 ml metrizamide (300 mg I/ml).

Complex partial status epilepticus following myelography with metrizamide.

Complex partial status epilepticus developed in two patients following myelography with metrizamide. The status epilepticus was manifested by confusion and complex motor symptoms, and electroencephalograms (EEGs) showed ictal activity alternating independently over both hemisphere. Immediate clinical improvement occurred with antiepileptic treatment, and to date no sequelae have been observed. Neither patient had a previous history of epileptic seizures, but both had preexisting EEG abnormalities.

Computed tomographic findings of the brain in children with acute lymphocytic leukemia after central nervous system prophylaxis without cranial irradiation.

Nineteen children in primary remission of acute lymphocytic leukemia (ALL) were investigated by computed tomographic (CT) scans of the brain 2 to 64 (mean 19) months after the central nervous system (CNS) prophylaxis was finished. The CNS prophylaxis consisted of high dose Methotrexate (HDM) intravenously combined with 6--8 doses of Methotrexate intrathecally. Two children received only Methotrexate intrathecally as CNS prophylaxis. In addition three children with ALL who had CNS leukemia were investigated by CT scans of the brain. Only one abnormal CT scan was found among the nineteen asymptomatic children, and one of the three patients with CNS relapse had slightly dilatated subarachnoidal spaces. These results compared with other reports in literature in which the CNS prophylaxis has consisted of intrathecal Methotrexate and cranial irradiation, suggest that there are fewer abnormal CT findings of the brain in patients not receiving cranial irradiation as part of CNS prophylaxis.