Erdheim-chester disease.

Erdheim-Chester disease (ECD) is a rare histiocytic infiltrative disease, characterized by long bone sclerosis. We describe two confirmed cases of ECD, both of which demonstrate non-malignant retroperitoneal and peri-renal infiltration causing dilatation of the upper renal tracts. The cases are illustrated with contrast studies, computed tomography (CT) and magnetic resonance imaging (MRI). Typical sclerosis of the long bones was apparent on radiography. Both cases have been treated conservatively to date.A brief review of the literature regarding the manifestations of ECD is included. In cases of non-malignant retroperitoneal infiltration, ECD should be considered as a diagnosis and radiographs of the long bones performed.

Paravertebral extravasation of contrast medium during lumbar myelography.

We report on paravertebral extravasation of water soluble contrast medium seen during lumbar myelography and/or subsequent post myelogram CT in 10 patients. This is an uncommon feature of lumbar myelography occurring in less than 1% of cases in our experience and which has not been previously documented.

Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study.

Evaluation of the relative efficacy of three screening instruments for depression and anxiety in a group of stroke patients was undertaken as part of the Perth community stroke study. Data are presented on the sensitivity and specificity of the Hospital Anxiety and Depression Scale (HAPS), the Geriatric Depression Scale and the General Health Questionnaire (GHQ) (28-item version) in screening patients 4 months after stroke for depressive and anxiety disorders diagnosed according to DSM-III criteria. The GHQ-28 and GDS but not the HADS depression, were shown to be satisfactory screening instruments for depression, with the GHQ-28 having an overall superiority. The performance of all 3 scales for screening post-stroke anxiety disorders was less satisfactory. The HADS anxiety had the best level of sensitivity, but the specificity and positive predictive values were low and the misclassification rate high.

An overview of medical imaging in the Röentgen centenary year.

This article reviews briefly current opinion regarding optimal imaging in a number of clinical situations presenting in family practice. The choice of imaging procedure, of course, depends upon availability, particularly in country areas. Nuclear medicine especially has not yet become as widely disseminated outside the large cities. To exclude repetition, topics that are the subject of more extensive review later in this issue have been excluded from this article.

Radiology and low back pain.

An outline of radiological investigations for patients with low back pain is presented. The article emphasises the need for thorough clinical evaluation of patients before any radiological investigations are undertaken. The types of radiological tests best suited to particular clinical problems are highlighted.

Prevalence of depression after stroke: the Perth Community Stroke Study.

BACKGROUND: The Perth Community Stroke Study (PCSS) was a population-based study of the incidence, cause, and outcome of acute stroke. METHOD: Subjects from the study were assessed initially, by examination and interview, and at four- and 12-month follow-ups to determine differences in prevalence of depression between the sexes and between patients with first-ever and recurrent strokes. RESULTS: The prevalence of depressive illness four months after stroke in 294 patients from the PCSS was 23% (18-28%), 15% (11-19%) major depression and 8% (5-11%) minor depression. There were no significant differences between the sexes or between patients with first-ever and recurrent strokes. With a non-hierarchic approach to diagnosis of those with depression, 26% of men and 39% of women had an associated anxiety disorder, mainly agoraphobia. Nine per cent of male and 13% of female patients interviewed had evidence of depression at the time of the stroke. Twelve months after stroke 56% of the men were still depressed (40% major and 16% minor), as were 30% of the women (12% major and 18% minor). CONCLUSION: The prevalence of depression after stroke was comparable with that reported from other studies, and considerably less than that reported from in-patient and rehabilitation units.

Anxiety disorders after stroke: results from the Perth Community Stroke Study.

BACKGROUND: The prevalence of anxiety disorders in 294 patients who survived to four months in the Perth Community Stroke Study (Perth, Australia), and a follow-up of these patients at 12 months, are presented. METHOD: Diagnoses are described both in the usual DSM hierarchic format and by a non-hierarchic approach. Adoption of the hierarchic approach alone greatly underestimates the prevalence of anxiety disorders. RESULTS: Most cases were of agoraphobia, and the remainder were generalised anxiety disorder. The prevalence of anxiety disorders alone was 5% in men and 19% in women; in community controls, it was 5% in men and 8% in women. Adopting a non-hierarchic approach to diagnosis gave a prevalence of 12% in men and 28% in women. When those who showed evidence of anxiety disorder before stroke were subtracted, the latter prevalence was 9% in men and 20% in women. CONCLUSION: One-third of the men and half of the women with post-stroke anxiety disorders showed evidence of either depression or an anxiety disorder at the time of the stroke. At 12 month follow-up of 49 patients with agoraphobia by a non-hierarchic approach, 51% had recovered, and equal proportions of the remainder had died or still had agoraphobia. The only major difference in outcome between those with anxiety disorder alone and those with comorbid depression was the greater mortality in the latter.

Spectrum of primary intracerebral haemorrhage in Perth, Western Australia, 1989-90: incidence and outcome.

In a population based register of stroke (n = 536) compiled in Perth, Western Australia during an 18 month period in 1989-90, 60 cases (11%) of primary intracerebral haemorrhage were identified among 56 persons (52% men). The mean age of these patients was 68 (range 23-93) and 46 (77%) events were first ever strokes. The crude annual incidence was 35 per 100,000, with a peak in the eighth decade, and a male predominance. Deep and lobar haemorrhages each accounted for almost one third of all cases. The clinical presentations included sudden coma (12%), headache (8%), seizures (8%), and pure sensory-motor stroke (3%). Primary intracerebral haemorrhage was the first presentation of leukaemia in two cases (both fatal) and it followed an alcoholic binge in four cases. 55% had a history of hypertension. 16 (27%) patients, half of whom had a history of hypertension, were taking antiplatelet agents, and one patient was taking warfarin. There were only two confirmed cases of amyloid angiopathy. The overall 28 day case fatality was 35%, but this varied from 100% for haemorrhages in the brainstem to 22% for those in the basal ganglionic or thalamic region. Other predictors of early death were intraventricular extension of blood, volume of haematoma, mass effect, and coma and severe paresis at onset. Although based on small numbers, these data confirm the heterogeneous nature of primary intracerebral haemorrhage, but they also suggest a different clinical spectrum of this type of stroke in the community compared with the experience of specialist neurological units.

Ascertaining the true incidence of stroke: experience from the Perth Community Stroke Study, 1989-1990.

OBJECTIVE: To determine the age and sex specific incidence, and case fatality of stroke in Perth, Western Australia. DESIGN AND SETTING: A population-based descriptive epidemiological study. SUBJECTS: All residents of a geographically defined segment of the Perth metropolitan area (population 138,708) who had a stroke or transient ischaemic attack between 20 February 1989 and 19 August 1990, inclusive. MAIN OUTCOME MEASURES: Definite acute "first-ever-in-a-lifetime" (first-ever) and recurrent stroke classified according to standard definitions and criteria. RESULTS: During the 18-month study period, 536 stroke events occurred among 492 patients, 69% of which were first-ever strokes. The crude annual event rate for all strokes was 258 (95% confidence interval 231-285) per 100,000, and the overall case fatality at 28 days was 24% (95% CI, 20%-28%). The crude annual incidence for first-ever strokes was 178 (95% CI, 156-200) per 100,000; 189 (95% CI, 157-221) per 100,000 in males and 166 (95% CI, 136-196) per 100,000 in females. The corresponding rates, age-adjusted to the "world" population, were 132 (95% CI, 109-155) for males and 77 (95% CI, 60-94) for females. CONCLUSIONS: In contrast to mortality rates for ischaemic heart disease, the incidence of stroke in Australia appears little different from that for several other Western countries. For both males and females the incidence of stroke rises exponentially with increasing age. Although the sex-dependent difference in the risk of stroke is greatest in middle age, males are at greater risk of stroke even among the most elderly. To determine the incidence of stroke accurately, population-based studies of stroke need exhaustive and overlapping sources of case ascertainment. If only cases admitted to hospital had been used, we would have underestimated the rate of stroke among the most elderly by almost 40%. We estimate that approximately 37,000 people, about 50% of whom are over the age of 75, suffer a stroke each year in Australia.

Determining the incidence of different subtypes of stroke: results from the Perth Community Stroke Study, 1989-1990.

OBJECTIVE: To determine the incidence and case fatality of seven distinct subtypes of stroke in Perth, Western Australia. DESIGN AND SETTING: A population-based descriptive epidemiological study. SUBJECTS: All residents of a geographically defined segment of the Perth metropolitan area (estimated population 138,708 persons) who had a stroke or transient ischaemic attack between 20 February 1989 and 19 August 1990, inclusive. MAIN OUTCOME MEASURES: The following subtypes of stroke were classified according to standard clinical, radiological and pathological criteria: types of cerebral infarction, namely, large artery (thrombotic) occlusive infarction (LAOI), cerebral embolic infarction (EMBI), lacunar infarction (LACI) and boundary zone infarction (BZI); primary intracerebral haemorrhage (PICH); subarachnoid haemorrhage (SAH); and stroke of undetermined cause. RESULTS: Over the 18-month study period 536 stroke events were registered, of which 86% (95% confidence interval, 83%-89%) had a defined "pathological" diagnosis on the basis of computed tomographic scanning, magnetic resonance imaging or necropsy. Cerebral infarction accounted for 71% of cases (95% CI, 68%-75%), PICH 11% (95% CI, 9%-14%) and SAH 4% (95% CI, 2%-5%). The 382 cases of cerebral infarction included LAOI (in approximately 71%), EMBI (15%), LACI (10%) and BZI (5%). While the incidence of all subtypes of stroke increased with age, there were age and sex differences in their proportional frequency, management and prognosis: patients with PICH, SAH and EMBI were more likely to be admitted to hospital, and these conditions carried the highest early case fatality. Over all, the 28-day case fatality was 24% (95% CI, 20%-28%), but varied from 0 for LACI and BZI, to 37% (95% CI, 15%-59%) for SAH and 35% (CI, 23%-47%) for PICH. CONCLUSIONS: In this study, we found considerable differences in incidence rates, the effect of age and sex on incidence rates, and prognosis for the different subtypes of stroke. Hospital-based studies are likely to be selectively biased by emphasising strokes that are severe and require admission to hospital. These data have important implications in the design and evaluation of clinical trials of therapy for stroke.

Pars interarticularis stress and disc degeneration in cricket's potent strike force: the fast bowler.

Cricket fast bowlers are the potent strike force in a multidiscipline team. They subject their spines to repetitive sagittal plane and rotatory movements over many years. The effect of this repetitive stress has not previously been analysed. This study examined 20 former fast bowlers to determine the incidence of spondylolysis, spondylolisthesis and degenerative change. Fast bowlers are noted to have an increased incidence of spondylolysis. A mixed front/side bowling style involving more lumbar hyperextension or rotation has significant association with spondylolysis when compared with side-on bowling styles. There was a high incidence of radiological thoracolumbar degenerative facet joint and disc disease in former fast bowlers.

Spinal abnormalities in young fast bowlers.

The action of fast bowling in the game of cricket is known to cause injuries to the lumbar spine. We studied a group of 16- to 18-year-old fast bowlers, selected for special training in Western Australia. All 24 had MR scans of the spine, 22 had radiographs and CT scans; in 20 the bowling technique was analysed biomechanically. There was a high incidence of back pain and this was always associated with a radiological abnormality. Pars interarticularis defects were diagnosed in 54% and intervertebral disc degeneration in 63%. Bowling actions which involved counter-rotation were associated with a higher incidence of both injuries.

Radiological investigations in stroke and transient ischaemic attacks.

This article covers the radiological investigations of CT scanning, Doppler ultrasound, digital subtraction angiography and magnetic resonance imaging in relationship to diagnosis and management of stroke and transient ischaemic attacks. The author discusses what each technique can and cannot do.

Necrobacillosis.

Necrobacillosis is a severe septicaemic illness caused by the gram negative anaerobe, Fusobacterium necrophorum, that typically occurs in previously healthy young adults following a mild sore throat. Radiological changes in the chest are prominent and include rapidly developing empyema, pneumonic consolidation, cavitation and pneumatocele formation. Metastatic abscesses in other sites are also seen. The clinical setting and time course are in marked contrast to the presentation of most anaerobic pleuro-pulmonary infections. Two cases are described, in one of which the outcome was fatal. Both displayed marked chest disease as an early manifestation of their illness. As the condition is relatively uncommon, radiological diagnosis demands a high index of suspicion in order to facilitate early treatment.

Spontaneous resolution of spinal canal deformity after burst-dispersion fracture.

We reviewed the records of 28 patients with 30 burst-dispersion spinal fractures treated since the introduction of CT facilities in Western Australia. Twenty-five patients showed spinal canal deformity and stenosis with bone fragments protruding into the canal on the initial scan. Of these, 22 patients were treated nonsurgically. Fifteen of the conservatively treated patients were available for follow-up, and they form the basis of this report. Thirteen of the 15 patients who had repeat CT at follow-up showed correction of the previously measured spinal canal stenosis by spontaneous resorption of intraspinal bone fragments. In view of this previously unreported finding, it is suggested that the role of surgical correction of spinal canal stenosis resulting from displaced bone fragments after trauma be more clearly defined.

Degenerative joint abnormalities in patients with paraplegia of duration greater than 20 years.

Radiographs and medical and surgical records of 51 patients following spinal injury have been reviewed. All the patients had been paraplegic for 20 years or more at the time of the survey. The reason for the survey was to assess the incidence of degenerative change of the hips, sacroiliac and shoulder joints in patients following spinal injury. Our review indicates that the number of paraplegic patients who develop degeneration of hip and sacroiliac joint changes is less significant than has been previously reported. Analysis of our figures has revealed certain important associations which predispose these patients to joint degeneration. The associations (anatomical level of injury, urinary tract infections, and the level of the patients' activity) with joint degeneration are described.

Intracerebral haematoma mimicking intracranial neoplasm at computed tomography.

The diagnosis of a typical acute intracerebral haematoma is comparatively specific with computed tomography. Three cases are presented to illustrate computed tomographic similarities between intracerebral haematomas and intracranial neoplasms. In the appropriate clinical setting, an incorrect diagnosis may be reached unless these similarities are borne in mind.