Selective thrombolysis of central retinal artery occlusion without long-term systemic heparinization.

BACKGROUND: A central retinal artery occlusion is a potentially blinding retinal vascular event with no effective treatment regimen available. Recently, a few reports have described improved vision in eyes with central retinal artery occlusions after selective fibrinolytic therapy followed by long-term systemic anticoagulation. Acceptance of this treatment, however, has been hampered by a paucity of confirmatory reports and its potential for producing serious hemorrhagic complications. Our report independently confirms the beneficial effects of selective thrombolysis, even with the use of only short-term, post-procedure systemic heparinization. METHODS: A case report of selective fibrinolysis of an occluded central retinal artery using urokinase infusion into the ophthalmic artery followed with only 12 h of systemic heparinization is described. RESULTS: A 65-year-old man presenting with a central retinal artery occlusion of less than 4-h duration enjoyed an improvement of vision from counting-fingers acuity to 20/20 after selective fibrinolysis with urokinase and only 12 h of systemic heparinization. No hemorrhagic or thrombotic complications occurred. CONCLUSIONS: Selective thrombolysis with urokinase followed by short-term systemic heparinization can effectively treat a central retinal artery occlusion. Whereas the authors acknowledge that a single case does not prove that short-term heparinization is better than long-term heparinization, it does show that the latter is not always required.

Multiple myeloma with hairy cell-like features.

Hairy cell leukemia (HCL) and multiple myeloma (MM) are well-described disease entities with characteristic clinical and pathologic features. We describe two patients initially treated for MM in whom atypical clinical and morphologic features subsequently developed that raised the possibility of HCL. Although the cytologic appearance and immunophenotype were not diagnostic of HCL, these cases challenge the criteria used to diagnose MM, HCL, and other recently described villous neoplasms.

Cirsoid aneurysm treatment by percutaneous injection of sodium tetradecyl sulfate.

BACKGROUND: Cirsoid aneurysms are uncommon arteriovenous fistulas of the scalp. Surgery for these lesions can be difficult; transarterial embolization is rarely curative, while embolization of the venous pouch with permanent agents usually necessitates subsequent surgical removal of the embolic material. The ideal embolic agent would be one that is safe and effective, commercially available, and would not require subsequent removal. METHODS: We treated an arteriovenous fistula of the scalp with direct puncture and injection of sodium tetradecyl sulfate, a commercially available sclerosing agent. RESULTS: Control angiography immediately following percutaneous injection of sotradecol into the fistula showed decreased flow but not complete closure of the lesion. However, within several days of the embolization, the patient's scalp pain and mass resolved. Four months after embolization, MRA demonstrated no evidence of residual or recurrent fistula. Color doppler flow imaging demonstrated only slightly decreased vascular resistance in the distal superficial temporal artery, possibly indirect evidence of persistent micro-fistulae. Twenty-three months after the procedure, the patient continued to be asymptomatic and had no palpable lesion. CONCLUSIONS: Percutaneous injection of sotradecol can be considered as one of the treatment options for arteriovenous fistula of the scalp. Further experience is needed to compare the safety and effectiveness of sotradecol with other agents currently used in the treatment of scalp arteriovenous fistulae.

Papaverine-induced mydriasis.

Five cases of ipsilateral pupillary dilatation that developed during local intraarterial infusion of papaverine are reported. All patients were being treated for symptomatic vasospasm secondary to subarachnoid hemorrhage. In each case, the tip of the infusion catheter was positioned in the internal carotid artery in close proximity to the ostium of the ophthalmic artery. Pupillary dilatation in all patients readily resolved after termination of the infusion.

Three-dimensional time-of-flight MR angiography with a surface coil: evaluation in 12 subjects.

We compared three-dimensional time-of-flight MR angiograms obtained with head coils and then with surface coils in five patients with intracranial vascular lesions and in seven normal volunteers to determine if imaging of intracranial vascular anatomy could be improved with the use of a surface coil. Visualization of small peripheral vessels was consistently better with a surface coil than with a head coil at identical small fields of view (FOVs). The surface-coil technique allowed small-FOV imaging of peripheral vascular lesions with higher spatial resolution and signal-to-noise ratio similar to that of large-FOV head-coil images. The use of a surface coil introduced the problem of signal falloff; centrally located vessels were visualized as well or better when a standard head coil was used. We conclude that surface-coil MR angiography can serve as a useful adjunct to routine head-coil MR angiography in the evaluation of peripheral vascular abnormalities.

High-signal foci on MR images of the brain: observer variability in their quantification.

Foci of high signal in the cerebral white matter are common incidental findings on MR images of the brain of control subjects or patients with a variety of diseases. Although the number of foci has been reported to correlate with age and several risk factors, the degree of observer variability in quantifying foci has not been reported. We used kappa statistics to determine radiologists' agreement in counting high-signal-intensity foci on MR images obtained in healthy volunteers and in patients with hypertension. Before interpreting the images, one pair of radiologists studied 30 routine MR images and reached consensus on differentiating high-signal foci from other foci of high intensity caused by normal structures (e.g., deep gyri or Virchow-Robin spaces). These two observers than independently determined the number of foci in the study group. Using their own criteria, other radiologists independently counted the foci. Agreement between observers was determined with the kappa statistic. The results showed fair agreement between the radiologists who first reached a consensus in counting foci of hyperintensity and poor agreement between the other observers. We conclude that in order to compare the frequency of foci of hyperintensity in different groups of patients, observer variability must be controlled. Studies without proper control subjects may lead to incorrect conclusions regarding the correlation of focal hyperintensities and various risk factors.

Visualization of the distal intratemporal facial nerve with MR imaging: use of an oblique plane.

Although magnetic resonance (MR) imaging routinely is used to evaluate the facial nerve, the conventional axial, coronal, and sagittal planes are not optimal for demonstrating the tympanic and mastoid portions of the nerve. A vertical oblique plane for MR imaging of these portions of the facial nerve was evaluated. With this plane, the course of the nerve was effectively demonstrated on MR images and corresponding cryosections. The oblique plane can be used to supplant or supplement conventional planes in imaging of the facial nerve.

Non-Hodgkin's lymphomas in patients with human immunodeficiency virus infection. Presence of Epstein-Barr virus by in situ hybridization, clinical presentation, and follow-up.

The authors studied all patients with serologic evidence of human immunodeficiency virus (HIV) infection and malignant non-Hodgkin's lymphoma (NHL) that presented at a single hospital from 1982 to 1989. Sixteen patients were identified, all white homosexual men with a mean age of 38.2 years. Lymphoma was the initial presentation of HIV infection in 37.5%. Sixty-two percent of the cases had a high-grade NHL, 31% had intermediate-grade, and 6% (one patient) had a low-grade lymphoplasmacytoid lymphoma. Extranodal involvement was present in 43.7%, with the gastrointestinal tract and liver being the most common sites. Actuarial survival was increased by treatment with methotrexate, doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin (MACOP-B). Colorimetric in situ hybridization identified Epstein-Barr virus (EBV) in nine of the 14 cases hybridized. A statistically significant association of EBV with diffuse small noncleaved type (i.e., Burkitt's-like) (six of six) compared with other morphologic types (three of eight) was found (P = 0.025).

High-intensity signals within the posterior pituitary fossa: a study with fat-suppression MR techniques.

Five different theories have been proposed to explain the high-intensity signals within the posterior pituitary fossa seen on MR: (1) a paramagnetic effect of phospholipids in the posterior lobe, (2) lipid in pituicytes in the posterior lobe of the pituitary, (3) neurosecretory granules in the posterior lobe, (4) fat within the sella but outside the pituitary gland, and (5) fat in bone marrow in the dorsum sellae. Previous reports have contained conflicting evidence on which of these structures is the cause of the high-intensity signals within the posterior sella. The purpose of this study was to examine the high-intensity signals of the normal posterior sella with fat-suppression MR techniques to reevaluate the contribution of fat to those signals. The sellae of 19 normal volunteers and two cadavers were imaged with MR with a commercially available unit and a research fat- water-suppression technique. High-intensity signals in the posterior sella were observed in all 21 subjects on conventional T1-weighted MR images. In two volunteers, the high-intensity signals in the posterior sella were suppressed with fat-suppression techniques; in 17 subjects the signals were suppressed with water-suppression techniques. In two volunteers the results were indeterminate. The high-intensity signals in the posterior sella do not behave like lipid in the majority of cases. Our study supports the conclusion that high-intensity signals in the posterior sella may have more than one source. It appears that most of these sources do not suppress with fat-suppression techniques.

Serous papillary adenocarcinoma of the tunica vaginalis of the testis with metastasis.

Testicular or paratesticular neoplasms that resemble the common epithelial type of ovarian tumor are quite rare. The authors report the case of a 29-year-old man with a metastatic serous papillary adenocarcinoma arising from the tunica vaginalis. To the authors' knowledge, this is the first reported case of a serous carcinoma of the tunica vaginalis behaving in a malignant fashion. The fact that clinically apparent metastatic disease occurred 4 years after initial presentation suggests that development of metastases is a late event. Unfortunately, the tumor has been refractory to therapy with chemotherapeutic agents with activity against ovarian malignancies.

MR imaging of optic nerve lesions: value of gadopentetate dimeglumine and fat-suppression technique.

Eleven patients with known or suspected optic nerve lesions and eight normal subjects were examined with spin-echo technique at 1.5 T with unenhanced T1-weighted imaging, IV gadopentetate-dimeglumine-enhanced T1-weighted imaging, and enhanced T1-weighted imaging with fat suppression. Two pathologically proved and four presumed optic nerve meningiomas demonstrated significant enhancement and were best seen with the fat-suppression technique. None of the three presumed optic nerve gliomas nor the optic nerves of normal subjects demonstrated qualitative enhancement. We conclude that the use of a fat-suppression technique with gadopentetate dimeglumine enhancement improves delineation of enhancing optic nerve lesions. This technique should be useful for evaluating other anatomic regions where enhancing tissue marginates fat.

MR imaging of optic nerve lesions: value of gadopentetate dimeglumine and fat-suppression technique.

Eleven patients with known or suspected optic nerve lesions and eight normal subjects were examined with spin-echo technique at 1.5 T with unenhanced T1-weighted imaging, IV gadopentetate-dimeglumine-enhanced T1-weighted imaging, and enhanced T1-weighted imaging with fat suppression. Two pathologically proved and four presumed optic nerve meningiomas demonstrated significant enhancement and were best seen with the fat-suppression technique. None of the three presumed optic nerve gliomas nor the optic nerves of normal subjects demonstrated qualitative enhancement. We conclude that the use of a fat-suppression technique with gadopentetate dimeglumine enhancement improves delineation of enhancing optic nerve lesions. This technique should be useful for evaluating other anatomic regions where enhancing tissue marginates fat.

Color Doppler flow imaging of the normal and abnormal orbit.

Twenty-six normal orbits (16 subjects) and seven patients with suspected orbital disease were studied with color Doppler flow imaging CDFI). Arterial structures consistently identified included the ophthalmic artery, central retinal artery, and posterior ciliary branches. The terminal lacrimal branch was seen in the majority of orbits (n = 19). Venous structures consistently seen included the central retinal vein and venae vorticosae; the superior ophthalmic vein was identified in the majority of normal orbits (n = 22). Response of the superior ophthalmic vein to the Valsalva maneuver was assessed in six of the normal subjects (12 orbits). Retrograde flow was typically seen during the maneuver and accentuated antegrade flow after cessation of the maneuver. Pathologic entities correctly diagnosed with CDFI included a dural arteriovenous malformation (AVM) with spontaneous carotid-cavernous fistula, an orbital AVM, and superior ophthalmic vein thrombosis. Vascular lesions were excluded in two patients with orbital masses. Bilaterally enlarged superior ophthalmic veins were identified in a patient with unilateral symptoms suggestive of a varix; CDFI results were confirmed with computed tomography, but orbital venograms were interpreted as normal. These findings suggest that CDFI may be helpful in the evaluation of suspected vascular orbital disease.

MR imaging of facial nerve enhancement in Bell palsy or after temporal bone surgery.

The authors evaluated magnetic resonance (MR) images obtained with intravenously administered gadolinium in ten patients who had facial paralysis and no facial nerve tumor. In patients with either Bell palsy (four patients) or facial paralysis after temporal bone surgery (six patients), intratemporal facial nerve enhancement was seen. Facial nerve enhancement on MR images proved to be a nonspecific finding.

Gradient recalled echo MR imaging of superior sagittal sinus occlusion.

With T1-weighted gradient recalled echo (GRE) MR images and flow compensation, we studied the superior sagittal sinus in 3 normal volunteers and 3 patients with sinus occlusion. In these images, sites of patency of the superior sagittal sinus were identified due to the high signal intensity of the normal sinus. Tumor invading the sinus was nearly isointense with cerebral gray matter. T1-weighted GRE imaging proves to be an effective technique to evaluate sinus blood flow.

Magnetic susceptibility artifacts in gradient-recalled echo MR imaging.

Artifacts related to magnetic susceptibility differences between bone and soft tissue are prevalent on gradient-recalled echo images, particularly when long echo delay times are used. These susceptibility artifacts spatially distort and artifactually enlarge bone contours. This can alter the apparent shape of the spinal canal and exaggerate the degree of spinal stenosis seen in patients with cervical spondylosis. The effects of magnetic susceptibility artifacts in gradient echo imaging were studied in a phantom model and the results were correlated with MR images obtained in patients with cervical spondylosis.

MR imaging of the cavernous sinus: value of spin echo and gradient recalled echo images.

A detailed evaluation of the MR appearance of the pituitary gland-cavernous sinus junction has not been described. In a series of coronal T1-weighted spin echo images without and with IV gadolinium, we noted the variable size and signal intensity of cavernous venous spaces adjacent to the pituitary gland and the inconsistent visualization of the dural membrane just lateral to the gland. Correlation of coronal T1-weighted spin echo and gradient recalled echo images (the latter with high-signal-intensity vascular structures) proved to be an effective means of identifying cavernous venous spaces, connective tissue and cranial nerves, and the lateral margins of the pituitary gland, and of differentiating tumor tissue from cavernous venous spaces. Further work is needed to develop criteria to distinguish cavernous sinus compression from actual tumor invasion.