Radio-frequency thrombosis of vascular malformations with a transvascular magnetic catheter.

A tiny magnetic electrode catheter introduced into the human carotid artery has been mechanically and magnetically propelled, with fluoroscopic control, to cranial arteriovenous malformations. Radio-frequency heating of the catheter tip in successive positions occludes abnormal blood vessels.

Lumbar myelography with iohexol and metrizamide. A comparative multicenter prospective study.

Diagnostic quality and adverse reactions associated with metrizamide and iohexol as contrast agents for lumbar myelography were compared in a prospective randomized double-blind study in 350 patients at seven centers. Both contrast media were administered in comparable volumes at a concentration of 180 mg I/ml. Overall quality of radiographic visualization was graded as "good" or "excellent" in 95% of 175 metrizamide studies and in 98% of 175 iohexol myelograms. Ninety-three patients examined with metrizamide (53%) and 130 patients studied with iohexol (74%) experienced no discomfort during or after myelography. The incidence of postmyelographic headache was 38% with metrizamide and 21% with iohexol. Nausea and vomiting were also more common with metrizamide. Five patients examined with metrizamide (3%) experienced transient confusion and disorientation after lumbar myelography. No such reactions were observed after iohexol myelography.

Imaging findings in schwannomas of the jugular foramen.

BACKGROUND AND PURPOSE: Tumors of the cranial nerve sheath constitute 5% to 10% of all intracranial neoplasms, yet few articles have described their CT and MR characteristics. We report the imaging findings in a relatively large series of schwannomas of the jugular foramen, contrasting them with other disease entities, especially vestibular schwannomas and tumors of the glomus jugulare. METHODS: CT and/or MR studies of eight patients who underwent surgery for histologically proved schwannomas were reviewed retrospectively. One additional patient with an assumed schwannoma of the jugular foramen, who did not have surgery, was also included. RESULTS: Surgical findings showed schwannomas of the glossopharyngeal nerve in seven patients and tumor involvement of both the glossopharyngeal and vagal nerves in one patient. All tumors were partially located within the jugular foramen. Growth extending within the temporal bone was typical. Tumor extended into the posterior cranial fossa in all nine patients and produced mass effect on the brain stem and/or cerebellum in seven patients; in five patients, tumor extended below the skull base. On unenhanced CT scans, tumors were isodense with brain in six patients and hypodense in two. In seven patients, CT scans with bone algorithm showed an enlarged jugular foramen with sharply rounded bone borders and a sclerotic rim. On MR images, T1 signal from tumor was low and T2 signal was high relative to white matter in all patients. Contrast enhancement on CT and/or MR studies was strong in eight patients and moderate in one. CONCLUSION: Schwannoma of the jugular foramen is characteristically a sharply demarcated, contrast-enhancing tumor, typically centered on or based in an enlarged jugular foramen with sharply rounded bone borders and a sclerotic rim. Intraosseous extension may be marked.

Carotid-cavernous sinus fistulas and venous thrombosis.

Radiographic signs of cavernous sinus thrombosis were found in eight consecutive patients with an angiographic diagnosis of carotid-cavernous sinus fistula; six were of the dural type and the ninth case was of a shunt from a cerebral hemisphere vascular malformation. Diagnostic features consisted of filling defects within the cavernous sinus and its tributaries, an abnormal shape of the cavernous sinus, an atypical pattern of venous drainage, and venous stasis. Progression of thrombosis was demonstrated in five patients who underwent follow-up angiography. Because of a high incidence of spontaneous resolution, patients with dural-cavernous sinus fistulas who show signs of venous thrombosis at angiography should be followed conservatively.

CT demonstration of cavernous sinus fat.

CT demonstration of cavernous sinus fat deposits has been described as abnormal and potentially a specific sign of Cushing disease. CT scans of 100 patients without biochemical or clinical evidence of Cushing disease and of 10 patients with Cushing disease were studied retrospectively. Twenty-seven percent of the non-Cushing patients demonstrated fat in one or both cavernous sinuses. Forty percent of Cushing disease patients had detectable cavernous sinus fat. While fat deposits were more frequent in the Cushing disease group, this was not statistically significant (p = greater than .6). CT demonstration of cavernous sinus fat ordinarily should be regarded as a normal finding.

Congenital arteriovenous fistulas supplied by a single branch of the maxillary artery.

We report four cases (two children, two adults) of congenital arteriovenous fistula supplied by a single large (pterygoid) branch of the second part of the maxillary artery deep to the parotid gland and mandible, with emphasis on the angiographic findings, therapeutic implications, and cause, with a review of the literature. Awareness of a predilection of congenital arteriovenous fistulas for this site, excellent-quality selective angiography, and careful attention to flow patterns help make the correct diagnosis. Endovascular balloon occlusion is the preferred treatment.

Craniopharyngioma: radiologic and histologic findings and recurrence.

PURPOSE: To identify the CT and MR characteristics of craniopharyngiomas, to evaluate the histologic types of craniopharyngioma, and to compare the radiologic/histologic appearance and type of therapy with tumor recurrence. METHODS: We reviewed the records of 45 patients with craniopharyngiomas for which surgical specimens (n = 45), preoperative MR or CT studies (n = 27), or other MR or CT studies or reports (n = 18) were available. Radiologic appearance, histologic morphology, treatment, and tumor recurrence were studied. RESULTS: Adamantinomatous epithelium was found in 40 of 45 surgical specimens, keratin in 34 of 45, and squamous epithelium in 11 of 45. A continuum of mixed morphology rather than distinct subtypes of tumors was found. The radiologic appearance did not correlate with the histologic features. No statistically significant difference was found between children and adults with respect to tumor size, calcification, histology, or tumor recurrence. Patients treated with radiation after subtotal resection had far fewer tumor recurrences (n = 3) than patients treated with surgery alone (n = 18). CONCLUSION: Craniopharyngiomas could not be divided into distinct histologic types. No differentiating radiologic or histologic characteristics could be established for craniopharyngiomas in children versus adults. Radiation treatment was strongly associated with tumor regression or lack of recurrence.

Esophageal carcinoma metastatic to the brain: clinical value and cost-effectiveness of routine enhanced head CT before esophagectomy.

PURPOSE: To assess the value of screening enhanced head CT before esophagectomy for carcinoma, identify increased risk factor(s) for brain metastases, and determine metastasis incidence. METHODS: Thoracic surgery files of patients undergoing esophagectomies for squamous carcinomas, adenocarcinomas, and undifferentiated carcinomas between January 1984 and March 1993 were reviewed regarding sex, size (length) of neoplasm, and brain metastases. Surgical pathology and tumor registry files also were reviewed. Records of patients with brain metastases were reviewed in detail. RESULTS: Three hundred thirty-four esophagectomies were performed for 230 adenocarcinomas (202 male, 28 female) and 104 squamous carcinomas (61 male, 43 female). In 9 males and 1 female with adenocarcinomas and 1 male and 1 female with squamous carcinomas, brain metastases developed. Surgical pathology files identified 293 additional esophageal carcinomas, including 2 males with adenocarcinomas metastatic to brain. Tumor registry files identified I additional male with brain metastasis from an undifferentiated esophageal neoplasm. No statistically significant preoperative characteristic of esophageal carcinomas with proneness to brain metastases was found, except large size of primary neoplasm. Preoperative screening head CT done on approximately 240 patients who underwent esophagectomies showed no metastases. CONCLUSIONS: Brain metastases from carcinomas of the esophagus are relatively uncommon (3.6% in the esophagectomy cohort). They tend to occur in patients with large primary neoplasm, probably especially adenocarcinomas involving the esophagogastric junction, and with findings of local invasion and lymph node metastases by CT and/or microscopically. It may be reasonable to obtain head CT as a last preoperative staging procedure in such patients. Routine preoperative head CT for staging is not cost effective.

Effect of head turning on blood flow in lateral sinuses of nonhuman primates.

The pattern of blood flow leaving the cranium via the lateral sinuses and internal jugular veins is significantly altered by head rotation. This effect is documented in the baboon and macaque monkey by Doppler flow recording and by angiography. This phenomenon may affect the validity of cerebral blood flow data determined by venous sampling and may have significance in angiographic interpretation and in the clinical course of patients with a hypoplastic or occluded lateral sinus or internal jugular vein.

Intraoperative sonography in the nonstereotaxic biopsy and aspiration of subcortical brain lesions.

Deep-seated brain lesions, especially small ones, present a neurosurgical challenge to achieve tissue diagnosis with minimal damage to intervening normal brain. Needle biopsy is often indicated but has been a relatively arduous procedure using stereotaxic frame methods. Tissue sampling is greatly simplified by the use of intraoperative real-time sonography for needle guidance. The technique is also applicable to cyst or abscess drainage and ventricular decompression. Of 37 cases in which intraoperative brain sonography was used, 19 included sonographic guidance of a needle, probe, or wire-stiffened catheter into the lesion. Sonography is an easy and accurate substitute for stereotaxic guidance procedures. It is also useful for reexamination of the brain after interventions such as biopsy, resection, and drainage.

Cerebral CT findings in methylmalonic acid propionic acidemias.

The cerebral computed tomographic findings in two infants with methylmalonic acidemia and one infant and one adult with propionic acidemia are presented. Pertinent metabolic, clinical, and pathologic features of these genetic disorders of vitamin B12 (cobalamin) and biotin metabolism are reviewed briefly. Computed tomographic abnormalities consist of focal or diffuse deep cerebral hemisphere lucencies and diffuse loss of brain substance. These findings correlated well with the clinical and pathologic findings. The leukoencephalopathy in these uncommon autosomal recessive conditions appears to be due to ketoacidosis, which in some cases may be managed by vitamin supplementation.

Orbital angiographic changes after intracarotid BCNU chemotherapy.

Seven patients treated with intraarterial internal carotid 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) chemotherapy for malignant gliomas of the brain had postinjection angiographic demonstration of increased orbital vascularity and vasodilatation, sometimes associated with arteriovenous shunting. Subjective orbital discomfort reported by the patients during chemotherapy correlated with this orbital hyperemia. Some therapeutic suggestions for managing this undesirable effect of BCNU chemotherapy are discussed.

Iohexol versus metrizamide for cervical myelography: double-blind trial.

Cervical myelography was performed by lateral C1-C2 puncture in 60 patients. Thirty patients received iohexol (an investigational aqueous contrast agent) and 30 received metrizamide in order to provide a prospective, randomized, double-blind trial comparing these contrast media. The two media produced radiographs of equal quality. Contrast-related morbidity was suffered by four patients (13%) in the iohexol group and by 11 patients (37%) in the metrizamide group. These features indicate that iohexol is superior to metrizamide as a contrast agent for cervical myelography.

Intraoperative sonography of intraspinal tumors: initial experience.

Real-time sonography during surgery for intraspinal tumors is capable of demonstrating the extent of the tumor, its relation to the spinal cord, and the internal morphology of both the tumor and the cord. Such information is not obtainable intraoperatively by any other imaging method. It is especially valuable when all or a part of the tumor is anterior to the cord and therefore not visible to the surgeon without exploration and the attendant risk of spinal cord injury. Direct contact with the spinal cord is not necessary for sonographic imaging.

Iohexol versus metrizamide for lumbar myelography: preliminary report of double-blind trial.

Lumbar myelography was performed in 38 patients; 19 received iohexol (an investigational aqueous contrast agent) and 19 received metrizamide. Iohexol is stable in solution, which is not the case with metrizamide. There was no other significant difference in diagnostic utility or quality between the two media. However, there was considerable postmyelography morbidity in the metrizamide group, but no postmyelography morbidity in the iohexol group. Preliminary clinical evidence suggests that iohexol is significantly superior to metrizamide as a contrast agent for lumbar myelography.

Angiographic demonstration of brain injury without significant mass lesion.

Evidence of brain damage was demonstrated in two patients without significant mass lesions by the presence of early venous filling and abnormal contrast staining. The vascular changes were most prominent on subtraction films. It is likely that these angiograms demonstrated the "luxury perfusion" phenomenon described previously in areas of damaged brain.

Cardiac surgery and distribution of the leukocyte L1 protein-calprotectin.

Activated polymorphonuclear leukocytes (PMN) secrete lysosomal enzymes, eicosanoids and toxic oxygen metabolites. In cardiac surgery patients, we measured arterial plasma levels of PMN and L1 (calprotectin), a prominent granulocyte protein, during cardiopulmonary bypass (CPB). The myocardial arterio-venous gradients were evaluated during reperfusion after cold cardioplegic arrest (n = 10). The arterial plasma concentration of L1 increased during CPB from 344 +/- 71 micrograms/l (mean +/- SD) preoperatively to 5221 +/- 1267 micrograms/l at the end of CPB (P less than 0.001). Simultaneously, the number of circulating PMN also increased (from 4.4 +/- 0.4 x 10(9)/l to 9.1 +/- 1.2 x 10(9)/l (P less than 0.05)). There was a positive correlation between the mean number of circulating PMN and the plasma level of L1 at all sampling times during CPB (r = 0.93, P less than 0.05). A coronary sequestration of both L1 (P less than 0.006) and PMN (P less than 0.002) was found after 5 min reperfusion. This was not present at 15 and 30 min reperfusion. The coronary entrapment of L1 and PMN did not covary significantly, and was unrelated to both the time of cardioplegic arrest and the arterial levels of L1 and PMN. In conclusion, the increased plasma concentrations of PMN and L1 during CPB and the coronary sequestration of both PMN and L1 may be factors in the pathogenesis of reperfusion injury of the myocardium.

The leucocyte protein L1 (calprotectin): a putative nonspecific defence factor at epithelial surfaces.

The L1 protein occurs at high concentrations in neutrophils, monocytes, certain reactive tissue macrophages, squamous mucosal epithelia, and reactive epidermis. It constitutes in fact about 60% of the neutrophilic cytosol protein fraction. The two L1 chains (L1H and L1L) are referred to by a bewildering collection of names, various authors having different preferences (MRP-8 and MRP-14; CFA or calgranulin A and B). The most recent proposal is calprotectin because of its calcium-binding properties and antimicrobial effect shown in vitro. L1 belongs to the S-100 protein family and may be involved in the regulation of keratinocyte proliferation and differentiation. It exists at high levels in blood and interstitial tissue fluid in several infectious, inflammatory, and malignant disorders, and it is released abundantly in foci of granulocytes and macrophages. The C-terminal sequence of the L1H chain has been shown to be identical to the N-terminus of peptides known as neutrophil immobilizing factors. Such an activity of L1 could be important for the accumulation of vital granulocytes, while L1 released from neutrophils, macrophages and epithelial cells might exert antimicrobial activity, perhaps by depriving microorganisms of zinc. The minimum inhibitory concentrations of L1 in vitro were found to be 4-32 mg/l for Candida albicans, 64 mg/l for Staphylococcus aureus, 64-256 mg/l for S. epidermidis, and 256 mg/ml for Escherichia coli and Klebsiella spp. Killing was observed at 2-4 times higher concentrations. In patients with HIV infection, those who developed oral candidiasis had significantly lower parotid L1 levels than those who did not (67 micrograms/l vs. 216 micrograms/l).

Enzyme-linked immunosorbent assay (ELISA) for isotype-specific quantitation of antibodies to Staphylococcus aureus in patients with atopic dermatitis.

An enzyme-linked immunosorbent assay (ELISA) was developed to study the serum antibody response against Staphylococcus aureus within four immunoglobulin classes (IgG, IgA, IgM and IgE) in patients with atopic dermatitis (AD) and in normal controls. Soluble antigens released from S. aureus Wood 46 (protein A deficient) were partially purified by gel filtration of supernatant culture fluid. Median ELISA activity against S. aureus antigens within the IgG and IgE classes was significantly higher in patients than in controls (IgG, p less than 0.005; IgE, p less than 0.05). Patients with severe disease had significantly higher (p less than 0.05) IgG antibody levels than those with mild AD. No such clinical association was found for IgE activity. The antibody levels showed no relation to the serum concentrations of total IgE.