Neumoencéfalo como complicación de bloqueo regional epidural por radiculopatía lumbosacra / Pneumocephalus as a Complication of Regional Epidural Block Due to Lumbosacral Radiculopathy

Introducción: El neumoencéfalo (sinonimia: aerocele o neumatocele intracerebral), se define como la presencia de gas dentro de cualquiera de los compartimentos intracraneales (intraventricular, intraparenquimatosa, subaracnoidea, subdural y epidural). Objetivo: Describir los hallazgos clínicos, estudios complementarios, conducta terapéutica y evolución de un caso con neumoencéfalo como complicación de bloqueo regional epidural por radiculopatía lumbosacra. Presentación de caso: Se presentó un paciente masculino de 57 años de edad que comenzó con un cuadro súbito de desorientación, excitabilidad psicomotriz y convulsiones tónico-clónicas, a partir de una inyección epidural de metilprednisolona como método analgésico. Conclusiones: El caso presentado exhibió manifestaciones neurológicas inespecíficas, la aparición súbita posterior al proceder invasivo hizo sospechar en un evento neurológico agudo o fenómeno tromboembólico. Los estudios complementarios como la tomografía axial computarizada craneal simple, permitió su diagnóstico para tener una conducta consecuente. El manejo conservador del neumoencéfalo como complicación del uso de anestesia epidural, constituyó una conducta terapéutica eficaz y repercutió en la satisfactoria evolución del paciente(AU)

Introduction: Pneumocephalus (synonym: aerocele or intracerebral pneumatocele), is defined as the presence of gas within any of the intracranial compartments (intraventricular, intraparenchymal, subarachnoid, subdural and epidural). Objective: To describe the clinical findings, complementary studies, therapeutic conduct and evolution of a case with pneumocephalus as a complication of regional epidural block due to lumbosacral radiculopathy Case presentation: A 57-year-old male patient was presented who began with a sudden episode of disorientation, psychomotor excitability and tonic-clonic seizures, following an epidural injection of methylprednisolone as an analgesic method. Conclusions: The case presented exhibited non-specific neurological manifestations, the sudden appearance after the invasive procedure raised suspicion of an acute neurological event or thromboembolic phenomenon. Complementary studies such as simple cranial computed axial tomography, allowed its diagnosis to have a consistent conduct. The conservative management of pneumocephalus as a complication of the use of epidural anesthesia constituted an effective therapeutic approach and had an impact on the patient's satisfactory evolution(AU)

Cisternografía radioisotópica con 99Tc-DTPA para confirmación diagnóstica de la hidrocefalia oculta normotensa / 99 Tc-DTPA radionuclide cisternography to confirm the diagnosis of normal pressure hydrocephalus

Se presenta el caso clínico de una paciente que ingresó en el Hospital Clinicoquirúrgico Hermanos Ameijeiras con antecedentes de etilismo crónico y cuadro clínico progresivo de deterioro cognitivo-conductual, trastornos de la marcha y esfinterianos, a quien se le realizó una cisternografía radioisotópica con el objetivo de comprobar su eficacia en el estudio de la dinámica del líquido cefalorraquídeo para diagnosticar la hidrocefalia oculta normotensa. La resonancia magnética de cráneo evolutiva evidenció hidrocefalia y la cisternografía radioisotópica confirmó el diagnóstico de hidrocefalia oculta normotensa. A la paciente se le realizó una derivación ventrículo peritoneal con la que se obtuvo una respuesta clínica evolutiva favorable. Se concluye que la cisternografía radioisotópica continúa siendo una herramienta útil para confirmar este diagnóstico y predecir la respuesta al tratamiento derivativo(AU)

A female patient who was admitted to Hermanos Ameijeiras Clinical and Surgical Hospital is presented here. She had a history of chronic alcohol abuse and progressive clinical deterioration of cognitive behavioral, abnormal gait and sphincter disorders. This patient had a radioisotope cisternography in order to test its effectiveness in the study of the dynamics of cerebrospinal fluid, and to diagnose normotensive hidden hydrocephalus. This MRI revealed hydrocephalus and skull evolutionary radioisotope cisternography confirmed the diagnosis of normal pressure hidden hydrocephalus. This patient received a shunt with a favorable evolutionary clinical response. It is concluded that cisternography radioisotope remains a useful tool to confirm this diagnosis and predict response to derivative treatment(AU)

Retained foreign body in ethmoid with bilateral pneumoencephaly.

Intracranial penetrating injury through the nose is rare. We present a case of a 79 year-old patient who had intracranial penetrating injury with a wooden object accompanied by massive bilateral pneumoencephaly with the presence of a foreign body in the ethmoid bone with fracture and displacement of crista galli. This is a hitherto unreported retained foreign body with fractured ethmoid resulting in bilateral pneumoencephaly.

Predicting the outcome of shunt surgery in normal pressure hydrocephalus.

We studied retrospectively the effectiveness of the repeated lumbar CSF tap test (RTT), lumbar external CSF drainage (LED) and radioisotope cisternography (RIC) in predicting the outcome of shunt surgery, as well as the diagnostic and prognostic value of periventricular hyperintensity (PVH) and of the classic clinical triad in normal pressure hydrocephalus. Two hundred and seventy patients were referred to the Departments of Neurosurgery, in Nancy, France and in Istanbul, Turkey. The decision to perform surgery was based on the clinical presentation (all patients had at least two symptoms of the classic clinical triad), neuroimaging examinations and the results of the RTT (taps were performed on three consecutive days and at each tap a minimum of 30 to 40 cc of CSF was removed), the LED (drainage was performed for 3 days and the volume of CSF drained daily was a minimum of 150 to 250 cc) or the RIC. After all shunt procedures, postoperative assessments verified improvements in 88% of the RTT group, 91% of the LED group and 66% of the RIC group. Gait disturbance had improved in 90% at the end of the second and twelfth month follow-up. Cognitive dysfunction had improved in 79% at the second and in 77% at the twelfth month follow-up. Urinary incontinence had improved in 66% at the second and in 62% at the twelfth month follow-up. From the surgical point of view, the greatest difficulty is not to make the diagnosis, but rather to identify the appropriate patients to operate on. The decision to perform shunt surgery should be based on strict clinical findings associated with CT and MRI criteria and especially with positive RTT or LED test results.

MR cisternography: initial experience in 41 cases.

PURPOSE: To present our initial experience with MR cisternography, an application of fast spin-echo MR with fat suppression, and compare it with routine MR cranial studies in the evaluation of the subarachnoid cisterns and their contents. METHODS: MR cisternography is a heavily T2-weighted fast spin-echo technique with high spatial resolution; it uses fat suppression and video reversal of the images. A small number of individual sections (two to four) are compressed into a composite image by a maximum-intensity projection algorithm, providing better depiction of anatomy in three dimensions. MR cisternography enhances the signal intensity of the cerebrospinal fluid (CSF) with suppression and subtraction of the background. A total of 41 patients were examined during a period of 6 months. MR cisternography was performed as an additional one (n = 31) or two (n = 10) sequences after conventional MR study. RESULTS: Twenty-one cases of disease were examined by MR cisternography, including 8 neoplasms, 4 CSF fistulas, and 3 large intracranial aneurysms. MR cisternography provided information unavailable by conventional MR studies in 17 cases. These included visualization of fistulous tracks in patients with CSF rhinorrhea, origin of a large suprasellar aneurysm, an additional loculus of a posterior fossa aneurysm and its relation to surrounding structures, and proper location of three tumors (intraaxial versus extraaxial). Clear depiction of the pituitary gland separate from the cavernous sinus was noted in 60% of the cases, and a new observation of a CSF sleeve around the third nerve in the posterior cavernous sinus was made in 85% of the cases. CONCLUSION: MR cisternography is superior to conventional MR studies in depicting anatomic structures within the subarachnoid spaces. This technique is recommended in the evaluation of cranial CSF fistulas and suprasellar and posterior fossa masses and in diagnosis of intraaxial versus extraaxial location of intracranial tumors.

Hidrocéfalo normotensivo comunicante del adulto: correlación cisternográfico-terapéutica / Normal-pressure communicant hydrocephalus of adult: cisternorgraphic and therapeutic correlation

El hidrocéfalo del adulto se inserta con frecuencia en el diagnóstico diferencial de las demencias de diversa etiología. La precisión de este diagnóstico es de especial importancia dado el eventual buen resultado que tiene su tratamiento quirúrgico a través de la derivativa del LCR. El progreso de los procedimientos diagnósticos como ser TAC, RNM y FSC ha permitido una aproximación cada vez más exacta al estudio de estos pacientes. Sin embargo, creemos que la información que proporciona la radiocisternografía, especialmente en el hidrocéfalo comunicante, es de importancia fundamental para consolidar el diagnóstico. En este trabajo se expone el esquema en uso actualmente entre nosotros para el análisis de los pacientes con síndromes demenciales asociados a dilatación ventricular. Se señala la introducción en éste del estudio de FSC mediante SPECT. Una vez que se muestra como muy probable el diagnóstico de hidrocéfalo normotensivo comunicante, estos pacientes son sometidos a intervención derivativa del LCR. Se analiza aquí la correlación existente entre los hallazgos radiocisternográficos y los resultados del tratamiento quirúrgico en 83 pacientes, con observación de los casos de un año como mínimo. Se destaca que el grupo más beneficiado corresponde a pacientes con bloqueo de la circulación de LCR y con evolución de su enfermedad inferior a un año. La edad avanzada no parece como contraindicación, dado los resultados observados en pacientes mayores de 60 años. De todos modos, los resultados globales, que muestran una mejoría neta en el 44,6 por ciento de los enfermos, no difieren de aquellos comunicados por otros autores. Este hacho, que inclina al pesimismo, acentúa aún más la necesidad de afinar la tipificación preoperatoria. En efecto, los resultados buenos suben al 69,6 por ciento en el grupo de pacientes con bloqueo subaracnoideo epicortical total

RISA cisternography in the option of ventriculocisternal shunt for infantile non-tumoural aqueductal stenosis.

Twenty cases of infantile triventricular hydrocephalus from non-tumoural aqueductal stenosis were treated by ventriculocisternal shunt following RISA cisternography. In 11 cases RISA cisternography showed a normal pattern of CSF circulation. One patient was lost to follow-up. Two had their intrathecal shunt converted into an extrathecal one because of postoperative meningeal infection. Of the remaining 8 patients, 7 had good and 1 fair long term results. In 9 cases RISA cisternography presented an abnormal pattern without indicating a definite impairment of CSF absorption. Slow flow of the tracer leading to its complete disappearance from 36 to 48 hours and 48 to 72 hours was observed respectively in 7 and 2 patients. In both the latter as well in two of the other seven an extrathecal shunt had to be employed (44%). A retrospective analysis to assess the predictive value of CSF absorption test by RISA in the selection of this kind of intrathecal shunt is made.

[Vascular compression neuropathy of the optic nerve by sclerotic internal carotid artery].

Although mechanical compression of the optic nerve by a dilated and/or tortuous sclerotic intracranial internal carotid artery is occasionally reported as an etiology for impairment of vision and visual field, early diagnosis of such condition has been hampered by the lack of characteristic neuro-ophthalmological and neuroradiological findings. The review of 35 previously reported cases (60 eyes) including ours showed that 41% out of the 34 operated eyes were improved neurologically by the decompressive procedure, while it was in 27% out of the 26 undecompressed or non-operated eyes. These unsatisfactory operative results are considered mainly due to the failure of early diagnosis. In order to investigate the relationship between the carotid artery and optic nerve, we proposed a method of angiographical projection consisting of the straight view along the long axis of the optic canal. By this projection, it is possible to detect a supero-medial enlargement and/or dislocation of the cisternal portion of the internal carotid artery. The addition of metrizamide CT cisternography which clarifies the relationship of the optic nerve, chiasm and internal carotid artery in the supersellar cistern may further provide an useful clue for the diagnosis of this condition.

Computed tomography of the cerebellopontine cistern in normal and acoustic tumor patients.

Air computed tomography of the cerebellopontine cistern was performed in 15 consecutive patients. The series comprised 7 patients with a normal cistern and 8 patients with tumor, including one with bilateral tumors. Two tumors were of small size (less than 10 mm i diameter), 3 were medium sized (10-20 mm in diameter), and 4 were large (greater than 20 mm in diameter). In the normal group, the jugular foramen nerve bundle (the 9th, 10th and 11th nerves), the trigeminal nerve, or the brain stem margin were clearly defined by air. In the tumor group, the possible extension of the tumor to these structures could be defined. Differentiation between a compression or attachment of the trigeminal nerve to the tumor was not always possible. The importance of using reconstruction views is stressed.

False diagnosis of acoustic neuroma due to subdural injection during gas CT cisternogram.

Gas CT cisternography is a reliable examination for the detection of small acoustic neuromas. False-positive or equivocal findings do result, however, from a small number of these examinations. In this case report inadvertent subdural injection of gas caused diagnostic difficulties.

[Experiences with the radiologic diagnosis of small acoustic neuromas]. / Erfahrungen in der radiologischen Diagnostik kleiner Akustikusneurinome.

The authors report on their experience with air-CT cisternography in diagnosing small neurinomas of the auditory nerve. Although this examination method has been very successful, false-positive findings are possible. Recent experiments with RM tomography are described and the ranking of this new method is discussed.

[Radiologic diagnosis of acoustic neurinoma. Apropos of 130 patients]. / Le diagnostic radiologique du neurinome de l'acoustique. A propos de 130 patients.

Diagnostic value of radiologic examinations was assessed in a homogeneous series of 130 cases of neurinoma of acoustic nerve seen over the last 10 years. Radiologic exploration is conceived and used at the present time for two purposes. Firstly, it enables selection of patients with suspected acoustic nerve neurinoma. Radiotomography appears to be currently an accessory examination because of the discriminative performance of early auditory evoked potentials tests on the brain stem. Secondly, radiology is necessary for confirmation of diagnosis. Visualization of the tumoral syndrome can be obtained only by a scan or possibly opaque or gas meatocisternography.

Meckel's cave epidermoid with trigeminal neuralgia: CT findings.

An epidermoid tumor of Meckel's cave was found in a middle-aged woman with trigeminal neuralgia. On CT the lesion had negative attenuation numbers of fat and extended from an expanded Meckel's cave through the porous trigeminus into the ambient and cerebellopontine angle cisterns. Surgical excision provided relief of the patient's trigeminal neuralgia.

[Current status of the neuroradiologic diagnosis of cerebellopontile angle tumors]. / Gegenwärtiger Stand der neuroradiologischen Diagnostik von Kleinhirnbrückenwinkel-Tumoren.

By means of 124 tumors of the cerebellopontine angle (CPA) the diagnostic results of the neuroradiological investigative methods computed tomography (CT), CT-air-cisternography, magnetic resonance tomography (MRT) and selective angiography are critically analysed with regard to their differential diagnostic significance and from this their order of employment. The histologically proven CPA-tumors consisted of 68 neurinomas, 8 meningeomas, 2 epidermoids, 29 tumors of the glomus tympano-jugulare, 2 metastases, 2 hemangioblastomas, 1 ectopic neuroepithelial cyst, 4 arachnoidal cysts, 6 cases with adhesive arachnitis and 2 abscesses. CT-findings were present in all cases; additional MRT-findings existed in 8 patients, and selective angiographies were done in further 103 patients. The description of the normal CPA-anatomy and its pathological findings in CT-air-cisternography is based on 250 examinations, 35 of which were done on both sides and further 38 simultaneously with an enhanced CT. For early diagnosis of CPA-tumors with less than 10 mm size and preponderantly otologic symptoms and signs CT-air-cisternography is recommended as examination method of choice; the same is true for native CT with subsequent enhancement in advanced stages with further neurologic signs. MRT-examinations should be done only in the second place. At present, the advantage of non-invasive, qualitative tumor detection is reduced by the deficient specifity of MRT-findings. However, because of distinct MRT-representations of intrameatal tumor-parts in acoustic neurinomas this method is already now likely to be qualified for early diagnosis, possibly replacing then CT-air-cisternography.(ABSTRACT TRUNCATED AT 250 WORDS)

Gas computed tomographic cisternography: evaluation of small and intracanalicular acoustic neuromas.

With improvements in microsurgical techniques, early evaluation of small and intracanalicular acoustic neuromas has taken on added importance. Since its introduction in 1979 by Sortland, several authors have demonstrated the accuracy and safety of computed tomography combined with gas cerebellopontine angle cisternography in the early diagnosis of acoustic neuromas. We present our experience with 32 patients referred for gas computed tomographic cisternography yielding five surgically proved acoustic neuromas, three of which were less than 1 cm in size. This procedure can be performed on an outpatient basis, has a low morbidity, and is highly accurate in diagnosing even purely intracanalicular tumors. Gas computed tomography cisternography offers several advantages over positive contrast cisternography, and is the procedure of choice in the radiologic diagnosis of acoustic neuromas after contrast-enhanced computed tomography has excluded the presence of a large tumor.

Air cisternography of the cerebellopontine angle using high-resolution computed tomography.

While high-resolution CT/air cisternography is considered the preferred method of investigating non-enhancing or small acoustic neuromas, it is not without pitfalls. Eighty such studies were reviewed, emphasizing procedural problems and sources of interpretive error. Two patients presented difficulty in transporting the air bolus due to a spinal cord tumor coexisting with bilateral acoustic neuromas; spinal cord decompression was required in one case. Three potential false positives were avoided by persistent efforts to fill the internal auditory canal. Of 4 patients thought to have a tiny acoustic neuroma, elective vestibular nerve section in 2 revealed no evidence of tumor. One unilateral Mondini malformation was diagnosed. Four patients required a blood patch for persistent headaches.

Neuro-otological findings in patients with small acoustic neuromas.

The method of choice for the diagnosis of even the smallest acoustic neuromas is CT gas cisternography. Lumbar puncture and gas insufflation, however, is an intervention demanding strict indication. Neuro-otological examinations should lead to this indication. The aim of this paper is to demonstrate neuro-otological findings on 19 patients presenting small acoustic neuromas. These neuro-otological findings are not necessarily comparable to earlier reports in the literature dealing with mainly larger tumours at a time when early diagnosis was not so advanced.